HPMI for print April.11

Federal Ministry of Health
Health Services Quality Directorate
Hospital Performance Monitoring and

Improvement Manual
Second Edition
October, 2017
Addis Ababa, Ethiopia
Hospital Performance Monitoring and Improvement Manual – October, 2017 1

MESSAGE OF THE DIRECTORATE
Since its launch in the 1990s, the Health Sector Development Program (HSDP) has led to
considerable expansion of the health services through rapid expansion of infrastructure,
increased availability of the health workforce; increased budget allocation and improved
financial management. However, improvement in Quality of health services at every location
is still not perceived, generally.
The Hospital Performance and Monitoring improvement (HPMI) manual was launched in
2011 G.C and revised in 2017 G.C with the aim of providing quality and equitable access to
all segment of Ethiopian population. Hospitals are central to these reform efforts and a
number of recent initiatives have specifically sought to improve hospital performance and
quality of health services. Such initiatives include: Ethiopian Hospital Services
Transformation Guidelines (EHSTG), Health Sector transformation in quality (HSTQ),
Saving Life through Safe Surgery (SaLTS), Clean and Safe Hospitals (CASH) and the revised
Health Management Information System (HMIS) are among others.
HPMI manual has been prepared comprehensively beginning with areas of administrative
concerns and disease of high priority. Twenty-Six (26) Key Performance Indicators (KPI)
described in this manual are organized into 11 categories under hospital management,
outpatient services, emergency services, inpatient services, maternity services, pharmacy
services, laboratory service, productivity, human resources, finance and clinical governance.
In addition, the HPMI manual in accompany with the HSTQ and EHSTG guidelines, are
going to be the main tools to transform the administrative and clinical process of hospital
functions. Using these tools, the ministry of Health has revised the manual and launched it
nationwide which is going to be implemented and catalyzed through the EHIAQ platform.
It is, therefore, hoped that all hospitals will take advantage of these guidelines and quick and
time bound actions as per the road map placed in HPMI guideline.
I must appreciate the efforts of all experts and partners involved in the preparation and
finalization of these manual.
I also deeply appreciate the commitments of all staffs of Health Service Quality Directorate of
the ministry for finalizing this manual after a series of consultative meetings and workshops.

Hassen Mohammed (MD, MPH)
Director, Health Service Quality Directorate
Federal Democratic Republic of Ethiopia Ministry of Health

ACKNOWLEDGMENTS
The development of the Manual for the Performance of Monitoring and Improvement (HPMI) in
the Health Sector is a culmination of the efforts of all health sector stakeholders that were
spearheaded by the Health Service Quality Directorate (HSQD) in the Ministry of Health. A
national taskforce was appointed by the director to oversee and coordinate the technical and
consultative processes in the development of the manual through the HPMI technical working
group. The standards and procedures outlined in this document are aimed at operationalizing the
Hospital’s Performance Monitoring framework, as well as setting the minimum threshold for
establishing enduring Monitoring and improvement functions in health institutions at the national
level.
Invaluable efforts and commitments went into this endeavor. I wish to appreciate the constructive
input and oversight exercised by members of the health sector’s HPMI technical working group
(HPMI TWG). Working together with the national taskforce, their incisive contributions, expertise
and direct engagement have shaped this document. My sincere gratitude also goes to the 11
Regional health Bureaus, Hospitals and Harvard PGSSC team who participated in, interrogated
and validated this document.
FMOH Led Core Team

We, recognize and would also like to sincerely thank the support of the FMOH led core team
members, whose support was central to the preparation, coordination and facilitation of HPMI
guidelines development workshop briefs, consultation documents, review of drafts and
stakeholder contributions, addressing the comments and recommendations and enrichment of
the manuals.
Members of the FMOH Led Core Team are:
Dr. Hassen Mohammed…………………..FMOH/HSQD
Dr.Ayele Teshome………………….…….St.Peter Specialized Hospital
Mr. Bedri Ahmed………………….….…FMOH/HSQD
Mr.Kasu Tola……………………….…...FMOH/HSQD
Mr.Abiy Dawit…………………….…….FMOH/HSQD
Dr.Hilina Tadesse………………….…….FMOH/HSQD
Mr.Markos Paulos……………………….FMOH/HSQD
Sr.Gezashegn Denekew…………….……FMOH/HSQD

Review Workshop participants
We would also like to extend our deepest gratitude for the valuable input, contribution and
comments of the following individuals whose active participation and efforts during the final
review and revision process of these documents has been elemental.
Dr. Hassen Mohammed………………………..FMOH/HSQD
Mr. Bedri Ahmed………………………...……FMOH/HSQD
Mr.Kasu Tola…………………………..……...FMOH/HSQD
Mr.Abiy Dawit…………………………..…….FMOH/HSQD
Dr.Ayele Teshome………...…….St.Peter Specialized Hospital
Dr.Hilina Tadesse………………………….……FMOH/HSQD
Mr.Markos Paulos……………………………….FMOH/HSQD
Dr.Samuel Z/Menfeskidus………………………FMOH/HSQD
Dr.Atlibachew Teshome…………………..…….FMOH/HSQD
Dr.Samson Esseye……………….……………..FMOH/Jhpiego
Dr.Eyob Gebrehawariat…………………….…….FMOH/WHO
Sr.Gezashegn Denekew…………………….……FMOH/HSQD
Mr.Molla Godif…………………………………FMOH/HSQD
Sr.Ayinalem Legesse…………………………….FMOH/HSQD
Mr. Andergachew Abebe…………………….….FMOH/HSQD
Mahlet Asayhegn…………………………...……FMOH/HSQD
Mr.Deneke Ayele………………………………..FMOH/HSQD
Mr.Getachew Yimam……………………………FMOH/HSQD
Dr.Yibeltal Mekonin………………….…………….FMOH/CSD
Mr.Naod Wendrad…………….……………………FMOH/CSD
Mr.Semi Daniel…………………….………………..FMOH/CSD
Kidist W/Senbet.…………………………………..FMOH/ECCD
Anbesaw Tekle………………………………..………AACAHB
Dereje Abdissa………………………….………….Oromia RHB
Ayanaw Takele……………………….……………Amhara RHB
Berihun Mesfin ……………………………………..Tigray RHB
Tebeje Mamo………………………………………SNNPR RHB
Biresa Chali………………..………………….Benishangul RHB
Thomas Tut………………………………………Gambella RHB
Shimelis Aweke………………………………………..Afar RHB
Yared Hailu ……………………………………….Diredawa RHB

TABLE OF CONTENT
Contents
ABBREVIATIONS/ACRONYMS............................................................................................3
Section 1: Introduction...............................................................................................................5
1.1 Background......................................................................................................................5
1.2 Rational for Revision of the HPMI Manual.....................................................................6
1.3 Purpose of this Manual.....................................................................................................7
1.4 Target Audience for the Manual......................................................................................7
Section 2: A Framework for Hospital Performance Monitoring and Improvement..................8
Section 3: Hospital Key Performance Indicators (KPIs)............................................................9
3.1: What are Key Performance Indicators?..........................................................................9
3.2 KPIs for Ethiopian hospitals........................................................................................10
KPI 4: Outpatients not seen on same day.........................................................................10
KPI 5: Emergency room patients triaged within 5 minutes of arrival..............................10
KPI 26: Patient satisfaction.............................................................................................11
3.3 KPIs Relationship with HMIS........................................................................................11
3.4. Collecting Hospital KPI data.........................................................................................12
3.4.1KPI Data Owners.....................................................................................................12
3.4.2. KPI focal person.....................................................................................................12
3.5 Analyzing and reporting Hospital KPI data...................................................................13
3.5.1 Analysis and reporting at Hospital level.................................................................13
3.5.2 Analysis and reporting at regional level..................................................................14
3.6. How should KPI reports be used?.................................................................................14
3.6.1 Use of KPIs by Hospital management and staff......................................................14
3.6.2 Use of KPIs by a Hospital Governing Board..........................................................16
3.6.3 Use of KPIs by Regional Health Bureaus...............................................................16
3.6.4 Use of KPIs by HSQD.............................................................................................17
3.7 KPI Data Elements.........................................................................................................17
3.8. Detailed guide to each KPI............................................................................................20
Hospital Management KPIs..............................................................................................21
OUTPATIENT SERVICES.............................................................................................23
EMERGENCY SERVICES.............................................................................................25

INPATIENT SERVICES.................................................................................................27
MATERNITY SERVICE.................................................................................................35
PHARMACY SERVICE..................................................................................................37
LABORATORY SERVICE.............................................................................................38
PRODUCTIVITY............................................................................................................40
HUMAN RESOURCE.....................................................................................................43
HEALTH FINANCEING................................................................................................44
CLINICAL GOVERNANCE...........................................................................................45
Section 4: Hospital Supportive Supervision Site Visits...........................................................46
4.1 Purpose of hospital supportive supervision site visits...............................................46
4.2 Overview of the supportive supervision site visit process........................................47
4.3 Selection of the site visit team...................................................................................49
4.4 Pre-visit preparation for a site visit...........................................................................50
4.4.1 Preparation by the site visit team............................................................................50
4.4.2 Preparation by the Hospital....................................................................................52
4.5 Conducting the site visit............................................................................................52
4.5.1 Opening meeting.....................................................................................................52
4.5.2 Information gathering..............................................................................................52
4.5.3 Collation of evidence...............................................................................................52
4.5.4 Closing meeting.......................................................................................................53
4.6 Post Visit Follow Up.................................................................................................53
Section 5: Regional Review Meetings.....................................................................................55
5.1 Purpose......................................................................................................................55
5.2 Frequency of meetings..............................................................................................55
5.3 Length of meeting......................................................................................................55
5.4 Participants................................................................................................................55
5.5 Pre -Meeting Preparation...........................................................................................56
5.6 Conducting the meeting.............................................................................................56
5.7 Post meeting follow up..............................................................................................56
Section 6: FMOH and RHB Meetings.....................................................................................57
6.1 Purpose......................................................................................................................57
6.2 Frequency of meetings.............................................................................................57
6.3 Length of meeting......................................................................................................57
6.4 Participants................................................................................................................57
6.5 Pre- Meeting Preparation...........................................................................................58
6.6 Conducting the meeting.............................................................................................58
6.7 Post meeting activities...............................................................................................58
7. Glossary................................................................................................................................59
8. Appendices...........................................................................................................................62
Appendix 1 HOSPITAL CASH AUDIT TOOL..................................................................62
Appendix 2 Survey Protocol: Outpatient Waiting Time to Treatment.............................76
Appendix 3 Survey Protocol: Emergency Patients Triaged Within 5 Minutes of Arrival81
Appendix 4: Completeness of Inpatient Medical Records...................................................84
Appendix 5: new pressure ulcers reporting format.............................................................86
Appendix 6: Surgical Site Infection Report Form...............................................................87
Appendix 7: WHO Safe surgical check list..........................................................................88
Appendix 8: Patient Satisfaction..........................................................................................89
Appendix 9: Essential lab tests availability.........................................................................97
Appendix 10: STAFF SATISFACTION SURVEY TOOL...............................................105
Section 2: Site visit briefing notes......................................................................................110
List of Tables
Table 1: KPIs reporting hierarchy of public health facilities, 2017.........................................16

Table 2: Summary of KPI Data Elements................................................................................20
Table 3: Sample Site Visit Schedule........................................................................................54
List of Figures
Figure 1: Framework for Hospital Performance Monitoring and Improvement……………8
Figure 1: Overview of the supportive supervision site visit process........................................51

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
CRCPTs Curative and Rehabilitative Core Process Teams

CG&QMU Clinical Governance and Quality Management Unit
DOTS Directly Observed Therapy (Short Course)
EHSTG Ethiopian Hospital Services Transformation Guidelines
EHMI Ethiopian Hospital Management Initiative
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
HSDP Health Sector Development Plan
HSQD Health service Quality Directorate
HSTQ Health sector transformation in Quality
I-PAHC Inpatient Assessment of Health Care
KPI Key Performance Indicator

MHA Masters in Hospital and Healthcare Administration
MCH Maternal and Child Health
NHS National Health Service (UK)
NGO Non-Governmental Organization
OPD Outpatient Department
O-PAHC Outpatient Assessment of Health Care
PNC Post Natal Care
RHB Regional Health Bureau
SMT Senior Management Team (Hospitals)
SEHC Satisfaction of Employees in Health Care
TB Tuberculosis
Voluntary Counseling and Testing
VCT

Section 1: Introduction
1.1 Background
Federal Ministry of Health through the Health Sector Transformation Plan (HSTP-I) envisions
all of its citizens to enjoy quality and equitable access to all types of health services. To
realize this, the FMOH and RHBs are leading a sector wide reform to strengthen and improve
the quality of health services in Ethiopia. Hospitals are central to these reform efforts and a
number of recent initiatives have specifically sought to improve hospital performance and
quality of services. Such initiatives include: Ethiopian Hospital Services Transformation
Guidelines (EHSTG), Health Sector transformation in quality (HSTQ),Saving Life through
Safe Surgery (SaLTS) and Clean and Safe Hospitals (CaSH) and the revised Health
Management Information System (HMIS) and Demographic and health information system
two (DHIS2) are among others.
Measurement is central to the concept of quality improvement; it provides a means to define

what hospitals actually do, and to compare that with the original targets in order to identify
opportunities for improvement. This is addressed through the monitoring and evaluation of
health sectors which consists of routine data collection, aggregation and dissemination,
performance monitoring and quality improvement, integrated supportive supervision,
inspection and operational research/evaluation components. The M&E framework of the
HSTP is using multiple data sources including routine administrative sources (such as the
Health Management Information System), household surveys (such as the Demographic
Health Survey, MIS, EPI coverage survey), health-facility surveys(such as the Service
Provision Assessment (SPA) and the Service Availability and Readiness Assessment (SARA),
disease and behavioral surveillance, civil registration and vital statistics, financial and
management information, censuses, and research studies.
Since its publication in 2010, Ethiopian Hospital Reform Implementation Guideline (EHRIG)
and Hospital performance monitoring and improvement manual (HPMI) has played a pivotal
role in improving the services provided in Hospitals. The manual provides detailed guidance
to ensure that hospitals collect and analyze accurate KPIs data and provides guidance on

performance improvement methods that will assist hospital management and staff to act upon
the findings of the KPIs. The manual also provides guidance for the Federal Ministry of
Health (FMOH) and Regional Health Bureaus (RHBs) to receive, review and analyze KPI
information, and to conduct site visits and facilitate review meetings that aim to strengthen
hospital performance.
Currently, different structures to lead and coordinate hospital performance monitoring and
Quality improvement activities are formed at different levels across the sector. At Federal
Ministry of Health the Health Service Quality Directorate (HSQD) is leading the coordination
and harmonization of all quality improvement efforts within the sector and is being guided
and overseen by the National Health care Quality Steering Committee (NHQSC). On the other
hand Quality Unit (QU) at the Regional Health Bureau is being led by CRCPO and supported
by a Regional Health Care Quality Steering Committee to oversee hospital performance and
quality improvement activities within the region. All Hospitals have established Clinical
Governance and Quality Improvement Unit (CG/QIU) that lead by a full time physician
assigned to work in the unit with regular responsibility of coordinating and mainstreaming
Quality improvement concepts and activities in all departments in the Health facility. The
Quality Unit is being assisted by a Quality committee represented by those heads of both
clinical and selected supportive departments and experts working in the health facility. To
achieve their functions, these stakeholders (Governing Board, SMT, RHB, QU, FMOH and
others) require accurate and timely information about hospital performance to ensure that
expectations are being met and to take timely action to address any problems identified.
1.2 Rational for Revision of the HPMI Manual
Hospital performance monitoring and improvement can be defined as a process by which

hospitals practices strategic use of performance standards, measures, progress reports, and
ongoing quality improvement efforts to ensure their desired results are being achieved.
The existing HPMI (2011) is revised in 2017 due to a number of driving forces have resulted
in the need for KPI revision. Some of the driving forces for revision include: the need to have
more quality and equity indicators that will provide details required to operationalize the
monitoring and evaluation framework of the HSTP. 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. The requirements to integrate the newly introduced

health initiatives and alignment with international indicators are some of the factors that drive
the manual revision.
1.3 Purpose of the Manual
The purpose of this manual is to standardize the approach in hospital performance monitoring
and improvement process and activities across the sector. It aims to provide hospital senior
management teams (SMTs), Governing Boards (GBs), health service providers and higher
health sector offices with information to assist in measuring and monitoring hospital
performance focusing on a core set of Key Performance Indicators and, conduct site visits and
facilitate review meetings to ensure the effectiveness, efficiency and quality of services
provided. The manual also provides detailed guidance’s which are:
 To ensure that hospitals collect and analyze accurate KPI data and enhance continuous use
of information for evidence based decision making.
 Provide guidance on how to gather, analyze, interpret and use performance information’s.
 Provide a standardized definition of Hospital performance monitoring and Improvement;
 To identify areas for further improvements within hospitals where targeted support, by the
Community, Government offices and other partners is deemed necessary.
 Provide guidance on planning and implementation of comprehensive hospital Performance
monitoring and improvement activities.
 Create a culture of learning based on utilizing M&E information as a basis for decision
making and accountability in management and governance
 To identify and disseminate best practice
1.4 Target Audience for the Manual
These manual is intended to assist actors in the health sector to gather, synthesize and analyze
data and use this information 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 etc

Section 2: A Framework for Hospital Performance Monitoring and
Improvement
The principal methods of monitoring hospital performance used nationwide are regulatory
inspection, client satisfaction surveys, supportive supervisions, regular hospital review
meetings and summits, operational research/evaluation, internal assessments and statistical
indicators, most of which have never been tested rigorously.
Current Hospital Performance Monitoring and Improvement has three principal
methods:
1. The establishment, reporting and review of a core set of hospital KPIs;

2. Supportive supervision to hospitals,
3. Regular Review meetings
Performance Performance
Qualityimprovement monitoring
improvementchampion(s) team
Unit (guidanceteam)
Performance standards Performance measurement Performance reporting
 Identify relevant  Collection, aggregation  Regular KPI reporting

&analysis of data  Review & analyze KPI report
standards  Provide feedback results
 Select indicators  Data quality assurance  Regular Supportive supervision
 Set goals and targets  Performance assessment  Summit
 Communicate  Enhance data systems  Performance review meeting
expectations
Performance
) management
database
Continuous Quality improvement process

Apply Kaizen and Model for improvement
Implement the improvement
Share lessons learned
Public health stakeholders
Figure 1: Framework for Hospital Performance Monitoring and Improvement (adapted from the Turning
Point National Excellence Collaborative, 2003

Section 3: Hospital Key Performance Indicators (KPIs)
3.1 What are Key Performance Indicators?

An indicator is a variable that measures key elements of a health intervention, program,
service, or project. Performance indicators are a popular mechanism for measuring the quality
of healthcare to facilitate both quality improvement and systems management. 1Indicators are
used to track progress and evaluate change initiatives towards meeting an aim or objective.
Indicators are vital in health interventions because, when collected and used regularly, they
can: provide a reference point for health intervention planning, management, and reporting,
allow managers of health interventions to assess trends and identify problems and act as early
warning signals for corrective action.
Different types of indicators are used for different purposes. For example indicators could be
used to monitor implementation of a specific program, to monitor the financial performance of
a hospital, to monitor the quality of care provided by each clinical team or to monitor hospital
performance against its plan.
Instead of trying to monitor everything, SMT, Governing Board and other stakeholders need a
core set of indicators that provide all the information they need to ensure that hospitals
provide effective, efficient and quality services. These KPIs should describe the minimum
information needed to effectively govern and manage hospital performance. KPs are a set of
core hospital indicators that are used to identify whether Hospital performance is meeting
desired standards and /or requires improvement. A common set of KPIs allow hospital
performance to be tracked over time, and comparisons between hospitals and among regions.
The ZHD/RHB and FMOH should conduct regular review of Hospitals, Zonal and regional
KPI’s performance respectively, and identify areas where additional support is needed and
should give timely feedback.
3.2 KPIs for Ethiopian hospitals

Currently there are total of 41 National KPIs (15 KPIs are integrated in Revised HMIS
indicators reference guide) that were developed through series of consultation among the RHBs,
FMOH and partners as the core set of indictors that form the foundation of the Hospital
Performance Monitoring and Improvement Framework for Ethiopia.
1 NHS Institute for Innovation and Improvement, 2008

Twenty-Six (26) KPIs described in this manual are organized into11 categories under hospital
management, outpatient services, emergency services, inpatient services, maternity services,
pharmacy services, laboratory service, productivity, human resources, finance and clinical
governance.
Hospital Management
KPI 1: % of Non-functional model medical equipment
KPI 2: CASH Audit score
Outpatient Services
KPI 3: Outpatient waiting time to Consultation
KPI 4: Outpatients not seen on same day
Emergency Services
KPI 5: Emergency room patients triaged within 5 minutes of arrival
KPI 6: Emergency room attendances with length of stay > 24hours
Inpatient Services
KPI 7: Delay for elective surgical admission
KPI 8: Pressure ulcer incidence
KPI 9: Surgical site infection rate
KPI 10: Completeness of inpatient medical records
KPI 11: Peri-operative Morality rate
KPI 12: Rate of safe surgery checklist utilization
KPI 13: Mean duration of in-hospital pre-elective operative stay
KPI 14: Surgical volume
KPI 15: Anesthetic adverse outcome
Maternity Service
KPI 16: Proportion of women Survived from PPH
KPI 17: Births by surgical, instrumental or assisted vaginal delivery
Pharmacy Services
KPI 18: Percentage of clients with 100% prescribed drugs filled
Laboratory Services
KPI 19: Essential Lab tests availability
KPI 20: Proportion of SLIPTA standard met
KPI 21: Blood unavailability ratio for surgical patients
Productivity
KPI 22: Outpatient clinical care productivity for physicians
KPI 23: Major surgeries per surgeon
Human resources
KPI 24: Staff satisfaction
Finance
KPI 25: Raised revenue spending as a proportion of total operating spending

Clinical governance
KPI 26: Patient satisfaction
Key Performance Indicator (KPI) which is incorporated to revised HMIS (15 KPI)
KPI 27: Institutional maternal deaths
KPI 28: Still birth rate
KPI 29: Early Institutional neonatal death rate
KPI 30: Inpatient mortality rate
KPI 31: Viral load suppression
KPI 32: Health budget utilization
KPI 33: Outpatient attendance per capita
KPI34: Admission rate
KPI 35: Bed occupancy rate
KPI 36: Average length of stay
KPI 37: Mortality rate in intensive care unit (ICU)
KPI 38: Emergency unit/department mortality
KPI 39: Referral rate
KPI 40: Proportion of patient attendances for insurance beneficiaries
KPI 41: Reimbursement ratio
3.3 KPIs Relationship with HMIS

The Health Management Information System (HMIS) draws its data from routine services and
administrative records and it is primarily designed to monitor and refine implementation of the
Health Sector Transformation Plans2. Additionally, the indicators are based on the priorities of
the Plan for Accelerated and Sustained Development to End Poverty, the needs and priorities of
local authorities and the requirements of international agreements, such as the Sustainable
Development Goals.
On the other hand, the hospital KPIs are a small set of 43 indicators with the primary function
of assisting hospital SMTs, Governing Boards, RHBs and FMOH to oversee hospital
operations. The hospital KPIs and HMIS indicators should be reviewed together as some of
KPIs are already integrated with existing HMIS and both HMIS and KPIs are already included
in DHIS2 as separate modules.
3.4. Collecting Hospital KPI data

Hospitals should develop suitable mechanisms for collecting KPI /EHSTG/HSTQ data. These
mechanisms should ensure that the information is accurate and that it has been properly
checked prior to submission to next level. To achieve this, The Hospital should assign KPI
focal person and respective data owner for each KPI for proper collection, analysis and
reporting of KPI /EHSTG/HSTQ data.
2 FMOH (2015) HMIS/M&EIndicator Definitions: HMIS / M&E Technical Standards: Area 1.

3.4.1KPI Data Owners
The data owner should be an individual who is responsible for the primary data source (e.g.
register, record or database) from which the KPI /EHSTG/HSTQ is drawn and who has
responsibility for the service area that is being measured.
Each KPI data owner is responsible for:
Maintenance of the primary data source(s) for KPI information

Calculating the KPI, at the end of each reporting period
Timely submit the KPI /EHSTG/HSTQ data to the KPI focal person
Reviewing the KPI& selected standards and identify any action that is
needed as a result (i.e. performance improvement plan)
For example, the Head of Human Resources (HR) department could be the KPI data
owner for KPI24: Staff satisfaction
3.4.2. KPI focal person

A focal person should be assigned to collect all KPIs and the data elements from the data
owners and prepare the hospital KPI /EHSTG/HSTQ report. The KPI focal person should be a
member of the hospital quality committee and accountable to Quality unit head together with
HMIS team. The KPI focal person should be the member of hospital performance review team.
Any of HMIS team members who trained on KPI should also be assigned to act in the absence
of the KPI focal person.
The KPI focal person is responsible for:
 Collecting KPI data from every KPI data owner at the end of the reporting period
 Checking the accuracy of the KPI /EHSTG/HSTQ data, by reviewing data sources and
conducting spot checks for accuracy on the data sources and the KPIs submitted by data
owners
 Entering the KPI/EHSTG/HSTQ data into the electronic Hospital KPI Database/DHIS2
 Preparing the KPI report (including data elements and KPI results) from the KPI
Database
 Submit the KPI report to the hospital Clinical Governance and Quality Management
Unit (CG&QMU) and CEO during the specified reporting period.
 Train and support the KPI data owners and other relevant staffs
 Ensuring the availability of all required computer hardware and software, stationery and
formats for the collection and submission of KPIs.
3.5Analyzing and reporting Hospital KPI data
3.5.1Analysis and reporting at Hospital level
An electronic DHIS2 or Hospital KPI Database has been created (in Microsoft Excel
spreadsheet) into which the KPI focal person should enter all KPI data elements. The KPI
Database will automatically generate KPI results and related tables and charts. KPI reports can
be printed from this Database.

After entering and checking the data quality, the KPI focal person should print the KPI report
and submit this to their CG&QMU and the CEO. The hospital CEO should review, check and
sign the KPIs before submitting them to the Governing Board and next levels.
Additionally, KPI data should be submitted to the RHB. Ideally, the KPI focal person should
regularly email the electronic KPI Database to the RHB. If this is not possible, the KPI focal
person should print a copy of the data elements and a copy of the KPI results directly from the
KPI Database and should fax these to the RHB.
Hospitals should also keep track of progress towards attainment of EHSTG standards. To assist
with this, a Hospital EHSTG Database has been created into which the KPI focal person should
enter all EHSTG self-assessment results. The EHSTG Database will automatically generate
tables and charts from the entered data.
The KPI focal person should email an electronic copy of the EHSTG Database to
the RHB every quarter. If this is not possible then a hard copy of the EHSTG self-
assessment tool should be faxed to the RHB.
Table 1: KPIs reporting hierarchy of public health facilities, 2017
Reporting Report Frequency of Comm

From level arrival date reporting ent
Primary
ZHD 26th of the month Monthly, Quarterly & Annual
Hospitals
General
RHB 2nd of the month Monthly, Quarterly & Annual
hospitals/ZHD
RHB FMOH 7th of the month Monthly, Quarterly & Annual
3.5.2 Analysis and reporting at regional level
Each RHB should assign a focal person to receive KPI and EHSTG reports from all hospitals,
and regional data should be aggregated and analyzed using electronic Regional KPI
Database/DHIS2that it will automatically generate results and related tables and charts,
including regional averages. Regional team should review the quality and regional performance
before sending their KPI and EHSTG reports.
Every quarter, the RHB should email electronic copies of the Regional KPI Database and
Regional EHSTG Database to FMOH. If it is not possible to send electronically then hard
copies of the KPI Data Elements and KPI Data Results and EHSTG together with a hard copy
of the average attainment within the Region.

3.6. How should KPI reports be used?
Hospital KPI data should be used as information for action to guide decision making and
planning for performance improvement at all levels. The performance improvement methods &
tools presented in Section-2 above can be used, alongside KPI results, to determine actions to
be taken to improve performance. Particular considerations for hospital management, staffs,
Governing Boards, RHBs and the FMOH are outlined below.
3.6.1Use of KPIs by Hospital management and staff

The data owner of each KPI is responsible not just for reporting the KPI data, but also for
reflecting on the information and collaborating with colleagues to improve performance.
Useful questions to consider when reviewing KPI data include:
- How does this KPI result compare to the last reporting period?
- Is there improvement or change?
- How and why has the change in performance happened?
- How does the KPI compare to the target for the reporting period?
- Has the target been reached? If the target has not been reached and why?
- Is there a need for further improvement on this KPI?
- Is additional information required?
- Is further support (e.g. trainings, supervision) required from the RHB or other partners to
support the hospital to make improvements?
The KPI data owner, together with case team and other relevant colleagues should analyze the
performance and develop actions that need to be taken to improve performance. Each hospital
should have a performance review team or Quality Unit and Quality Committee (QC) to
oversee performance monitoring and improvement functions across the hospital. The Quality
committee should be multidisciplinary, with members appointed from different clinical,
administrative and supportive units within the hospital. The chair of the committee or Quality
unit head should be a full time in their role and should be accountable to CEO as a member of
the hospital senior management team and.
Roles of the Quality Unit include:

a) To develop hospital performance and/ quality management strategy and present to the
Senior Management Team for approval,
b) To develop an implementation plan for the overall improvement of hospital performance
and monitor its execution,
c) To ensure that performance management activities relate to the vision and mission of the
hospital, and are aligned with the hospital strategic and annual plans,
d) To co-ordinate all hospital performance improvement activities,

e) To promote and support the participation of all staff in hospital performance improvement
activities,
f) To receive and analyze feedback information from patients, staff and visitors,
g) To receive clinical audit reports and maintain a record of all clinical audit activities,
h) To review selected hospital deaths
i) To monitor KPIs and HMIS indicators
j) To conduct peer review in response to specific quality and safety concerns and to take
appropriate action and follow-up when deficiencies are identified, and
k) To update hospital staff on hospital performance improvement activities and
findings including:
a) Comparisons across time
b) Comparisons between case teams/departments

c) Comparisons with other health facilities.
3.6.2 Use of KPIs by a Hospital Governing Board
Hospital Performance Reports should be presented to the Governing Board by the hospital
CEO. The report should be circulated at least ones a week in advance of the Governing Board
meeting, together with the agenda and any other discussion papers for the board meeting.
The Governing Board should discuss the report, identifying areas of improvement or weakness
and set direction and specific follow up actions.
For example, if the Patient Satisfaction Score is low or is decreasing, the Governing Board
could ask the CEO to present the full results of the Patient Satisfaction Survey to see if there
are any particular areas of concern, and could also ask to describe actions that the hospital is
going to take to improve patient satisfaction. Or, if inpatient mortality is high or increasing, the
Governing Board could ask the CEO if there are any factors to explain this (perhaps a
communicable disease outbreak) or to provide additional information on the mortality rate for
each ward or specialty (e.g. surgical mortality rate, pediatric mortality rate etc) to identify if
there is a particular problem area.

When reviewing the hospital KPI data and discussing with the CEO, questions that
Governing Board members should consider include:
- How does each KPI compare to the last reporting period?
o If there is improvement, how did this take place? Should special recognition be
given to any staff members or case teams who are responsible for the
improvement?
o If performance is worse why has this taken place?
o How does each KPI compare to the target for the reporting period?
Has the target been reached? If not, why not?
- What action should be taken by the CEO/hospital in response to the KPI results?
- What support (e.g. trainings, supervision) is required from the RHB or other partners to
support the hospital to make improvements?
3.6.3 Use of KPIs by Regional Health Bureaus
After receiving hospital KPI and EHSTG reports and entering these into the Regional KPI and
EHSTG/DHIS2 Databases, the RHBs should compare hospitals, monitor changes over time
and calculate regional averages. The RHB should give feedback to each hospital on the KPI
reports, asking for clarification or further information where required. The RHB should also
use the hospital KPI reports to identify areas for action by the RHB. In particular, KPI reports
should be used as input for hospital site visits and regional review meetings. When reviewing
individual hospital KPI reports, the RHB should consider the same questions as outlined above
for Governing Boards. In addition, the RHB should compare performance between hospitals,
in particular:
- Which hospitals are showing the best and/or poor performance?
- What are the particular strengths and/or the weaknesses in the region?
3.6.4 Use of KPIs by HSQD

The HSQD assigned regional focal person to receive reports from all RHBs, review and
send timely feedback to regions. Regional reports should be used nationally to monitor
changes over time and to calculate national averages using electronic national KPI/EHSTG
database or eDHIS2.
When reviewing regional KPI reports, HSQD should consider the same questions as RHBs. In
addition, HSQD should compare performance between regions, in particular:

- Which regions are showing the best performance overall? Which are showing poor
performance?
- Which regions are improving? Which regions show slow or no improvement?
- What are the common strengths in all regions, what are the common weaknesses?
HSQD should give feedback to each RHB on the KPI reports, asking for clarification or
further information where required. HSQD should not contact hospitals directly in response
to the KPI reports, but instead should discuss first with the RHB so that a joint response can
be made to the hospital and any follow up action can be agreed jointly between FMOH and
the RHB.
In particular, KPI reports should be used as input for hospital site visits and regional and
national review meetings.
3.7KPI Data Elements

The KPIs are calculated from individual data elements numbered Q1 to Q 60, which
are listed below (Table 2). These data elements form the numerators and
denominators of each KPI and, using the formulae, are used to calculate the 26
national KPIs.
Table 2: Summary of KPI Data Elements
Category Code Data Element

Q1 Total number of Non-Functional Medical Equipment from the
actual available list in the reporting period(Q1)
Q2 Total number of Medical Equipment actually available in the
Hospital reporting period(Q2)
Management
Q3 The total number of CASH audit tool standards met with
Green
Q4 The total number of CASH Audit tool standards
Q5 Sum total of outpatient waiting time (in minutes)

Q6 Number of outpatient “waiting time cards “completed
Outpatient Services
Q7 Number of outpatients not seen on same day as registration
in OPD during the reporting period
Q8 Number of new and repeat outpatient attendances at public
facility
Emergency Q9 Number of surveyed patients who undergo triage within 5

minutes of arrival in emergency room
Number of patients included in emergency room during
Q10
triage time survey
Services
Total number of admissions who remain in emergency room
Q11
for more than 24 hrs
Q12 Total number of emergency room admissions
Q13 Sum total of number of days between date added to surgical
waiting list to date of admission for surgery
Number of patients who were admitted for elective (non-
Q14
emergency) surgery during the reporting period
Number of inpatients who develop a new pressure ulcer during
Q15
the reporting period
Q16 Number of patients discharged alive (including transfers out)
Q17 Number of deaths among admitted inpatients
Inpatient Number of inpatients with new surgical site infection arising

Services Q18 during the reporting period
Number of major surgeries (both elective & non-elective)

Q19
performed during the reporting period on public patients
Number of major surgeries (both elective & non-elective)
Q20
performed during the reporting period on private wing patients
Q21 Sum total of medical record checklist scores Yes (Q21)
Q22 Number of discharged inpatient medical records surveyed x

7 (i.e. the number of items in checklist)
Q23 Total number of deaths within 24 hour after surgery among
patients who underwent a major surgical procedure in an OR
Q24 Total number of deaths above 24 Hour prior to discharge among
patients who underwent a major surgical procedure in an OR
Q25 Total number of patients who received major surgery(both
elective and non electives) in the reporting period
Number of surgical patient charts in which the WHO
Q26
Surgical Safety Checklist was completed per chart
Q27 Total number of patient charts reviewed
Q28 Total sum of pre-operative length of stay
Q29 Total number of elective surgical procedures during the

reporting period

Q30 Number of surgical cases with anesthetic adverse outcome
(high spinal anesthesia, failed intubation, cardio-respiratory
arrest) during reporting period
Number of Women who gave birth in the health facility or
Q31 referred in who had any bleeding with hypotension or requiring
blood transfusion and survived
Maternity Total number of women who gave birth in the health facility or
Services Q32 referred in or on arrival who had any bleeding with hypotension
or requiring blood transfusion (survived or died)
Q33 Number of Caesarean sections
Q34 Number of abdominal surgical deliveries
Number of instrumental or assisted vaginal deliveries

Q35
Q36 Total deliveries (Number of live births attended in the hospital
Q 37 Number of stillbirths attended in the hospital)
Q38 Number of clients who received 100% of prescribed drugs

Pharmacy Services
Q39 Total number of clients who received prescriptions
Q40 Total number of days each essential laboratory tests are available
in the hospital during the reporting period
Laboratory Q 41 Total number of hospital specific essential tests
Services
Q42 Total number of days in the reporting period
Q43 Total SLIPTA audit standards met
Q44 275 (i.e. total number of SLIPTA audit standards)
Q45 Total number of referral plus Death plus cancelation of elective

surgery due to blood shortage
Q46 Total number of blood request to hospital mini blood bank
Productivity Q47 Total number of FTE physicians assigned in outpatient

department during the reporting period
Q48 Number of major surgeries (both elective & non-elective)

performed on public patients
Q49 Number of major surgeries (both elective & non-elective)
performed on private wing patients

Q50 Average number of FTE specialist surgeons (excluding
Ophthalmologists)
Q51 Total number of “Neutral” responses

Human
Resources
Q52 Total number of “satisfied” responses
Q 53 Total number of staff Satisfaction surveys completed
Q54 Total number of staff satisfaction criteria’s evaluated

Q55 Operating spending retained revenue during reporting period
Health Financing Q56 Total operating expenditures for reporting period, i.e. operating
budget spending from treasury for reporting period
Clinical Governance Q57 Total number of “Neutral” responses
Q58 Total number of “satisfied” responses
Q59 Total number of Patient Satisfaction surveys completed
Q60 Total number of patient satisfaction criteria’s evaluated
3.8. Detailed guide to each KPI

The following tables present a detailed guide to each KPI, outlining the importance of the
indicator, the data sources and formula for calculating the indicator.
(Please note: The detail about KPIs together with data entry formats for each KPI, are presented in
Appendix 5. To be used and/or shared with the data owner of each KPI to assist with collection of
the data elements and calculation of the KPI by the data owner).

Hospital Management KPIs
KPI 1: % of Non-Functional Model Medical Equipment
Why is this Hospitals need to know the proportion of Medical Equipment’s that are
important? non-functional at any given time from their Model Medical Equipment List,
MME they prepared. Model Medical Equipment List means, a list of
equipment that describe the ideal types and number of equipment required
by specific hospital that determined by multi-disciplinary team of the
hospital. The indicator measures the effectiveness of services without
interruption for diagnosis, therapeutics, prevention and investigation of the
patient in the hospital due to failure of M/Es. It also helps to plan for
maintenance or procurement of new essential medical equipment.
For the RHB and FMOH, knowledge of the proportion of Non-Functional

Medical Equipment in hospitals is necessary to plan and to take immediate
action to procure, Maintain, install, calibrate and train on Medical
equipment’s. It can also help conduct national or regional maintenance and
commissioning campaigns.
Definition The proportion of Non-Functional Medical Equipment among available
Medical Equipment in the hospital.
All Hospitals should prepare their ideal Model Medical Equipment
List as per the tier level as a strategy and they shall work to fulfill
according to the list on the basis of the hospital’s service packages as
stated in EHSTG (Chapter 15)
Medical Equipment defined as any instrument, apparatus, machine,
appliance, implant, in vitro reagent or calibrator and software
materials that are necessary to provide essential service in the
hospital.
Based on the definition and the prepared ideal list, hospitals should
decide which M/Es to be included and followed for its functionality.
As a new M/E procured, it will be included in the list and if a M/E
transferred or disposed due to different reasons, it will be excluded
from the denominator in a specific reporting period.
• Note: All Medical Equipment in the hospital should be functional all

the time.
Unit of
%
measurement
Numerator Total number of Non-Functional Medical Equipment from the actual
available list in the reporting period(Q1)
Denominator Total number of Medical Equipment actually available in the reporting
period(Q2)
Formula Total number of Non-Functional Medical Equipment (Q1)/ Total number of
Medical Equipment in the hospital (functional plus non-functional)
(Q2)*100
Data sources Hospital Medical Equipment inventory of the reporting period
Model Medical Equipment list
Medical equipment history file
Frequency of
Quarterly
reporting
Data entry
Q1
Calculation: KPI 1= X 100=¿ %
Q2
KPI 2: CASH Audit Score
Why it is Hospitals monitor their CASH performance regularly so as to identify

important? their gaps and then improve continuously.
Similarly regional health bureaus and federal ministry of health also
monitor and evaluate CASH progress and this KPI will be a good
monitoring indicator.
Definition The proportion of CASH Audit tool standards met (Green) in the
hospital.
Green-For each standard if all criterion are met.
Yellow-For each standard if >50% of the criteria are met.
Red-For each standard if <50% of the criteria are met.
Unit of %
Measurement
Numerator The total number of CASH audit tool standards met with Green(Q3)
Denominator The total number of CASH Audit tool standards(Q4)
Formula The total Number of CASH audit tool standards met with Green flag
The total Number of CASH audit tool standards
*100
Data sources CASH audit tools
Frequency of Quarterly
reporting
Data entry Q3: Total number of CASH audit tool standards met are available in
the hospital during the reporting period= ______________
Q4: Total number of CASH audit tool standards= _________
Calculation: The total Number of CASH audit tool standards met with
Green flag(Q3)

The total Number of CASH audit tool standards(Q4)
*100
KPI 2 = Q3 *100%
Q4
OUTPATIENT SERVICES
KPI 3: Outpatient waiting time to Consultation
Why is this The time that a patient waits from arrival to treatment is a measure
important? 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 times a hospital can assess if there is a need

 extra personnel and/or other resources in the outpatient
department,
 And/or a need to review patient flow processes to increase the
efficiency of service provision.
Definition Average time from arrival at the outpatient department to treatment
consultation with clinical staff member (minutes)
For patients who have an appointment and who go immediately to
the OPD waiting area (without attending registration or triage), the
time of arrival begins at the time when they reach the OPD waiting
area.
For patients who do not have an appointment, the time of arrival

means the time of arrival at triage
EXCLUDE:
Patients not seen on the same day
Unit of
Minutes
measurement
Numerator Sum total of outpatient waiting time (in minutes) (Q5)
Denominator Number of outpatient “waiting time cards “completed (Q6)
Formula Sum total of outpatient waiting time (in minutes) (Q5) ÷ Number of
outpatient “waiting time cards” completed (Q6)

Data sources Survey – see protocol for survey to measure OPD wait time in
Appendix 7
The survey should be conducted on Monday and Thursday of the
first week of the last month of each quarter
Frequency of
Quarterly
reporting
Data entry Q5 = Sum total of outpatient waiting time (in minutes) = ___________
Q6 = Number of outpatient waiting time cards completed =_______
Q5
Calculation: KPI 3= minutes
Q6
KPI 4: Outpatients not seen on same day
Why is this All patients should be seen in the OPD on the same day that they
important? register for treatment. By measuring the number and proportion of
patients that do not receive a same day service, 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.
Definition The proportion of all outpatients that do not receive treatment on
the same day as the day of registration in the outpatient department
Unit of
%
measurement
Numerator
Number of outpatients not seen on same day as registration in OPD
during the reporting period (Q7)
Denominator Number of new and repeat outpatient attendances at public facility

(Q8)
(No private wing ,public facility only)
Formula Number of outpatients not seen on same day as registration during
the reporting period (Q7) ÷Number of new and repeat outpatient
attendances at public facility (Q8) x 100
Data sources OPD registration book/ central triage book

Frequency of
Quarterly
reporting
Data entry Q8 = Number of new and repeat outpatient attendances at public
facility = __________
Q7 = Number of outpatients not seen on same day as registration in

OPD during the reporting period =__________

Q7
Q8
EMERGENCY SERVICES
KPI 5: Emergency room patients triaged within 5 minutes of arrival
Why is this Triage is a process of sorting patients into priority groups according
important? 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 additional staff and/or resources and/or service
redesign to reduce waiting times in ER.
Definition Proportion of all patients presenting to the emergency room who
were seen by the triage officer within 5 minutes of arrival at the
emergency room
Unit of
%
measurement
Numerator Number of surveyed patients who undergo triage within 5 minutes
of arrival in emergency room (Q9)
Denominator Number of patients included in emergency room during triage time
survey (Q10)
Formula Number of surveyed patients who undergo triage within 5 minutes
of arrival in emergency room (Q9) ÷ Number of patients included
in emergency room triage time survey (Q10) x 100
Data sources Survey – see Appendix 8 : Protocol for survey to measure % of
patients triaged within 5 minutes of arrival in ER .
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
Saturday: 5pm to 8am
Frequency Quarterly
Data entry Q9 = Number of surveyed patients who undergo triage within 5
minutes of arrival in emergency room =__________
Q10 = Number of patients included in emergency room during
triage time survey =___________
Q9
Q 10
KPI 6: Emergency room attendances with length of stay > 24 hours
Why is this important? Hospitals have emergency room beds where patients can
stay for a short period of time to receive emergency
treatment. However, the length of stay in the emergency
room should always be less than 24 hours. If a patient
requires treatment for longer than 24 hours then he/she
should be transferred to a ward. If emergency room beds
are occupied by patients 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 for any NEW emergency attendances.
Definition The proportion of all emergency room admissions who

remain in the emergency room for > 24 hours
INCLUDE:
All patients registered in the emergency room (all
ages)
EXCLUDE:
Patients who were already dead (i.e. no vital signs
present) on arrival
Unit of measurement %
Numerator Total number of admissions who remain in emergency
room for more than 24 hrs (Q11)
Denominator
Total number of emergency room admissions (Q12)
Formula
Total number of admissions who remain in emergency
room for more than 24 hrs (Q11) ÷ Total number of
emergency room admissions(Q12) x 100
Data sources
Emergency room registration book

Frequency of reporting Monthly
Data entry Q12= Total number of emergency room admissions= _____
Q11= Total number of emergency room admissions who

remain in emergency room for more than 24 hrs=________
Q 11
Q 12
INPATIENT SERVICES
KPI 7: Delay for elective surgical admission
Why is this Delays in surgery for different conditions are associated with a
important? 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.
Definition The average number of days that patients who underwent elective
surgery during the reporting period waited for admission (i.e. the
average number of days between the date each patient was added
to the waiting list to their date of admission for surgery
Unit of measurement Days
Numerator Sum total of number of days between date added to surgical
waiting list to date of admission for surgery (Q13)
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.
Denominator Number of patients who were admitted for elective (non-
emergency) surgery during the reporting period (Q14)
Formula Sum total of number of days between date added to surgical
waiting list to date of admission for surgery (Q13) ÷ Number of
patients who were admitted for elective (non-emergency) surgery

during the reporting period (Q14)
Data sources Liaison registration book,
Data entry Q13 = Sum total of number of days between date added to surgical
waiting list to date of admission for surgery = _____________
Q14 = Number of patients who were admitted for elective (non-
emergency) surgery during the reporting period =
______________
Q 13
Calculation: KPI 7= = days
Q 14 ¿
KPI 8: Pressure ulcer incidence
Why is this important? This is an indicator of the quality of care performed by nursing
staff in a hospital. Poor nursing care, with inadequate turning of
patients in their bed can lead to the development of a pressure
ulcer (also called bed ulcer or decubitus ulcer). Pressure ulcers can
be fatal when allowed to progress without treatment.
By measuring the pressure ulcer rate hospitals can assess the

quality of nursing care provided and take action to address any
problems identified.
Definition Proportion of inpatients that develop a pressure ulcer during their

hospital stay.
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
INCLUDE:
 New pressure ulcers that arise during the patients 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
Numerator Number of inpatients who develop a new pressure ulcer during the
reporting period (Q15)
Denominator Number of patients discharged alive (including transfers out)
(Q16) + Number of deaths among admitted inpatients (Q17)
Data sources IPD register **
Data entry Q17= Total number of patients discharged alive (including
transfers out = ___________
Q16= Total number of patients discharged alive (including
transfers out) = ____________
Q15= Total number of inpatients who develop a new pressure
ulcer during the reporting period = _________
Q15
Q 17+Q 16
**NB. The PRESUR ULCER data always recorded on IPD registry at the remark part.
KPI 9: Surgical site infection rate
Why is this Infection at the site of surgery may be caused by poor infection prevention
important? practices in the operating room or on the ward after completion of surgery.
The surgical site infection rate is an indicator of the quality of medical care
received by surgical patients and an indirect measure of infection prevention
practices in the hospital. By monitoring surgical site infection hospitals can
assess the adequacy of infection prevention practices in the hospital and take
action to address any problems identified.
Definition Proportion of all major surgeries with an infection occurring at the site of the
surgical wound prior to discharge. 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
 Spontaneous wound dehiscence or deliberate wound
revision/opening by the surgeon in the presence of: pyrexia > 38C
or localized pain or tenderness or redness/heat
 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
 A major surgical procedure is defined as any procedure conducted
in an OR under general, spinal or major regional anesthesia.
Unit %
Numerator Number of operated inpatient with new surgical site infection arising

before discharge (Record at discharge) (Q18)
INCLUDE:
Patients undergoing surgery in public facility
Private wing surgical cases
Denominator Number of operated inpatients discharged alive (including transfers out)
(Q19) + Number of operated inpatients discharged dead during the reporting
period (Q20)
Formula Number of operated inpatient with new surgical site infection arising
before discharge (Record at discharge) (Q18) ÷
[Number of operated inpatients discharged alive (including transfers out)
(Q19) + Number of operated inpatients discharged dead during the
reporting period (Q20)] x 100.
Data sources IPD registration
Frequency Monthly
Data entry Q18= Total number of inpatients with new surgical site infection arising during the
reporting period = _______
Q19= Total number of major surgeries (both elective & non-elective) performed during
the reporting period on public patients = ___________
Q20= Total number of major surgeries (both elective & non-elective) performed during
the reporting period on private wing patients = _____________
Q18
Q 19+Q 20
NB: The IPD nurses will record the SSI data on the remark column of the IPD Registry. The ward
physician is responsible for recording absence or presence of SSI on the discharge summary.
KPI 10: Completeness of inpatient medical records
Why is this Complete and accurate medical records are essential to maintain the
important? 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.
Definition Proportion of elements completed of the minimum elements of an inpatient
medical record.
The MINIMUM elements are*:
- Patient Card (Physician notes) – present and all entries signed
- Progress note – documented at least once a day throughout the hospital stay
- Order Sheet – Present and revised daily
- Nursing Care Plan – Present, revised at least daily; V/S taken at least QID
for all admitted patients
- Medication Administration Record – present and all medications given are
signed

- Discharge Summary – present and signed
- Clinical pharmacist record chart present and signed
* 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). However for standardization of this indicator,
only the items that are listed in the checklist should be included in the
survey.
Unit of %
measurement
Numerator Sum total of medical record checklist scores Yes (Q21)
Denominator Number of discharged inpatient medical records surveyed (Q22) x 7 (i.e.
the number of items in checklist)
Formula Sum total of medical records checklist scores Yes(Q21)/ Number of
discharged inpatient medical records surveyed (Q22) x 7 (i.e. the number of
items in checklist)*100
Data sources Audit of medical records against checklist
A full protocol for the audit is presented in Appendix 4
5% or 50 (whichever is greater) medical records should be audited
reporting
Data entry Q21 = Sum total of medical record checklist scores = _____________
Q22 = Number of discharged inpatient medical records surveyed =
_________
KPI 10 = Q21* 100%

Q22
KPI 11: Peri-operative Mortality
Why is this Surgical and anesthesia safety is an integral component of care delivery;
important? peri-operative morality encompasses deaths in the operating theatre and in
the hospital after the procedure. Informs policy and planning regarding
surgical and anesthesia safety, as well as surgical volume when number of
procedures is the denominator
Definition All-cause death rate prior to discharge among patients who underwent a
major surgical procedure in an operating theatre during the reporting period

in the reporting health facility. Stratified by emergent and elective major
surgical procedures.
Exclusion: exclude patients operated in another facility unless re-operated
in the reporting facility.
Unit of Percentage
measurement
Numerator Total number of deaths before discharge within 24 hour after surgery
among patients who underwent a major surgical procedure in an OR(Q23)+
Total number of deaths before discharge but more than 24 Hours post op
among patients who underwent a major surgical procedure in an OR(Q24)
Denominator Total number of patients who received major surgery(both elective and non
electives) in the reporting period(Q25)
Formula
Total number of deaths before discharge within 24 hour after surgery
among patients who underwent a major surgical procedure in an
OR( (Q23 ) )+ Total number of deaths before discharge but more than 24
Hours post op among patients who underwent a major surgical procedure in
an OR (Q24)/Total number of patients who received major surgery(both
elective and non electives) in the reporting period(Q25)
Data sources OR Registry and All IPD registers
Frequency of Monthly
reporting
Data entry KPI 11= Q23+ Q24 *100%
Q25
KPI 12: Rate of safe surgery checklist utilization
Why is this Safe surgery checklist a safety checks that could be performed in any
important? operating 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.
Definition Proportion of surgical cases where the WHO safe surgery check list was
fully implemented.
Unit of Percentage
measurement
Numerator Number of Major surgical patient charts in which the WHO Surgical Safety
Checklist was completed per chart(Q26)
Denominator Total number of patient charts reviewed (Q27)
 50 charts
Formula Number of surgical patient charts in which the WHO Surgical Safety
Checklist was completed patient chart (Q26) / Total number of patient charts
reviewed (Q27) x 100
Data sources Survey Patient Chart
reporting
Data entry
KPI 12= Q26 * 100%
Q27
Why is this A long in hospital pre op stay results in unnecessary bed occupancy as
well as increase the risk of colonization by antibiotic resistant hospital
Important? flora. It is indicative of insufficient pre admission preparation or
inefficient OT management resulting in cancellations. These will be
highlighted for intervention by monitoring this indicator
The average number of days patients waited in-hospital (after

Definition admission) to receive elective surgery during the reporting period.
Unit of Number
measurement
Numerator Total sum of pre-operative length of stay (Q28)
Denominator Total number of elective surgical procedures during the reporting
period (Q29)
Formula Total sum of pre-operative length of stay (Q28) / Total number of
elective surgical procedures during the reporting period (Q29) x 100
Data sources OR Registry
reporting
Data entry KPI 13= Q28
Q29

KPI 13: Mean duration of in-hospital pre-elective operative stay
KPI 14 ፡Surgical volume
Why is this The number of surgical procedures done is an indicator of met

important? need. With the high surgical need of the population, this
indicator will show progress across time. Informs policy and
planning regarding met and unmet need for surgical service.
Definition Total number of major surgical procedures performed in operating
theatre per month. Major surgery is defined as a procedure performed
under general anesthesia, regional anesthesia in an OR.
Unit of measurement Number
Numerator Total number of major surgical procedures performed in OR per
Denominator None
Formula Total number of major surgical procedures performed in OR per
Data sources OR Registry
reporting
Data entry
KPI 14 = Q25

KPI 15: Anesthetic adverse outcome
Why is this
important? 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.
Definition Percentage of surgical patients who developed any one of the following:
1. Cardio respiratory arrest
2. Inability to secure airway
3. High spinal anesthesia
Cardio-respiratory arrest as: cessation of cardiac activity as evidenced by:
▪ Chest compressions being performed
▪ Loss of femoral, carotid and apical pulse with ECG changes
High spinal defined as:
Within 15 minutes of administration of spinal anesthesia:
▪ Patient experiences loss of sensation in the shoulder
AND
▪ Need for positive pressure ventilation after administration of

spinal anesthesia
Includes any administration of spinal anesthesia extending above T4 level.
Inability to secure airway defined as:
 Having to awaken patient due to inability to intubate
 Cardio-respiratory arrest due to failure to intubate
Unit of Percentage
measurement
Numerator Number of surgical cases with anesthetic adverse outcome (high spinal
anesthesia, failed intubation, cardio-respiratory arrest) during reporting
period(Q30)
Denominator Total number of major surgical procedures performed in OR during reporting
period(Q25)
Formula Number of surgical cases with anesthetic adverse outcome (high spinal
anesthesia, failed intubation, cardio-respiratory arrest) during reporting
period(Q30)/ Total number of major surgical procedures performed in OR
during reporting period(Q25) x 100
Data sources Anesthesia Registry
reporting
Data entry
KPI 15= Q30 *100%
Q25
MATERNITY SERVICE
KPI 16: Proportion of women Survived from PPH
Why is this important? This indicator measures quality of care provided to women in the immediate
post-partum period and an indirect measure of timely response for early
identification and managing the incidence of PPH.
By monitoring the management of PPH hospitals can review all possible

causes and take action to address any problems identified.

Definition Women who gave birth in the health facility or referred in who had any
bleeding with hypotension or requiring blood transfusion
INCLUDE:
All PPH cases diagnosed in the health institution/ on arrival/ referred in
EXCLUDE:
Dead on arrival of PPH cases
Numerator Number of Women who gave birth in the health facility or referred in who
had any bleeding with hypotension or requiring blood transfusion and
survived (Q31)
Denominator Total number of women who gave birth in the health facility or referred in or
on arrival who had any bleeding with hypotension or requiring blood
transfusion or died (Q32) + Number of Women who gave birth in the health
facility or referred in who had any bleeding with hypotension or requiring
blood transfusion and survived (Q31)
Formula Total Number of Women who gave birth in the health facility or referred in
who had any bleeding with hypotension or requiring blood transfusion and
survived (Q31) ÷ Total Number of women who gave birth in the health
facility or referred in who had any bleeding with hypotension or requiring
blood transfusion (survived or died) during the month (Q32)x 100
Data sources Delivery register/ postnatal register/maternity register/ICU register/OR
register
Data entry Q31= Total Number of Women who gave birth in the health facility or
referred in or on arrival who had any bleeding with hypotension or requiring
blood transfusion and survived during the month) = ___________
Q32= Total Number of women who gave birth in the health facility or
referred in or on arrival who had any bleeding with hypotension or requiring
blood transfusion or died during the month = _______
Q 31
Q 31+Q32
KPI 17: Births by surgical, instrumental or assisted vaginal delivery
Why is this In the health care system of Ethiopia, it is expected that hospitals will manage
important? complicated maternity cases and that uncomplicated pregnancies and normal
deliveries should mainly be managed by Primary Health Care Units. By
monitoring the % of attended deliveries that are complicated, the hospital and
RHB can assess if hospital services are being used appropriately.
Definition Number of births by surgical, instrumental or assisted vaginal delivery per 100
deliveries attended in the hospital
Caesarean Section means delivery of the fetus (including live births and
stillbirths) by the abdominal route when the uterus is intact (Q33)
Abdominal Surgical Delivery means removal of the fetus, placenta and/or

membranes by the abdominal route (including live births and stillbirths) where
the uterus is not intact (i.e. ruptured uterus). (Q34)
Instrumental or assisted vaginal delivery (Q35) means any vaginal delivery

(including live births and stillbirths) using an instrument or manual
intervention of the health worker.
INCLUDE:
Forceps delivery
Rotational deliveries, e.g. internal podalic version
Assisted breech delivery
Vacuum extractions
Craniotomy
EXCLUDE: Episiotomy
Vaginal tears
Numerator Number of Caesarean sections (Q33) + Number of abdominal surgical
deliveries (Q34) + Number of instrumental or assisted vaginal deliveries (Q35)
Denominator Total deliveries (Number of live births attended in the hospital (Q36) +
Number of stillbirths attended in the hospital) (Q37)
Unit of %
measurement
Formula [Number of Caesarean sections (Q33) + Number of abdominal surgical
deliveries (Q34) + Number of instrumental or assisted vaginal deliveries
(Q35)] ÷ Total deliveries [Number of live births attended in the hospital (Q36)
+ Number of stillbirths attended in the hospital (Q37)] x 100
Data sources Delivery registration book
reporting
Data entry Q36 = Total number of live births attended in the hospital = _____
Q37 = Total number of stillbirths attended in the hospital = ______
Q33 = Number of Caesarean sections = __________________
Q34 = Number of abdominal surgical deliveries = ___________
Q35 = Number of instrumental or assisted vaginal deliveries = ____
KPI 17 =Q33+ Q34 + Q35 x 100 = --------%
Q36 + Q37
PHARMACY SERVICE
KPI 18: Percentage of Clients with 100% prescribed drugs filled
Why is this Percentage of clients who get all of the prescribed drugs (100%) from
important? dispensary is an indicator of access to quality and affordable medicines.
Proportion of clients who get all the prescribed drugs is one of the indicators
that tell about the continuous availability of drugs and quality
pharmaceutical care in country. Getting prescribed drugs within the facility

pharmacy improves patient satisfaction and overall trust and confidence in
the health sector. Percentages of clients who get all the prescribed drugs
(100%) from dispensary are expected to be 100 percent.
Definition Percentage of clients who get all of the prescribed drugs (100%) from
dispensary among all the clients who received prescriptions in a given
time period.
Unit of
%
measurement
Numerator Number of clients who received 100% of prescribed drugs(Q38)
Denominator Total number of clients who received prescriptions(Q39)
Formula Number of clients who received 100% of prescribed drugs(Q38)/Total

number of clients who received prescriptions(Q39)*100
Data sources Survey of patient chart and Rx of dispensed medicines
Frequency of
Quarterly
reporting
Data entry Q38 = Number of clients who received 100% of prescribed
drugs = ___________
Q39 = Total number of clients who received prescriptions =
Q 38
KPI 18= X 100=¿ %
Q 39
LABORATORY SERVICE
KPI 19: Essential laboratory tests availability
Why is this The availability of hospital specific essential laboratory tests is a

important? measure of service availability. Essential tests should ALWAYS be
available at the hospital. If one of these tests is unavailable at any time,
the hospital should take action to identify and address the cause.
For the RHB, knowledge of the availability of hospital specific essential

laboratory tests in hospitals helps to assess the adequacy of access to

laboratory tests and helps to address issues of good governance.
Definition The number of days in which all hospital specific essential laboratory
tests were available in the reporting period.
NB: Hospitals are required to avail the minimum laboratory tests

recommended by Food, Medicine and Healthcare Administration and
Control Authority standards at all times.
Unit of Percentage
measurement
Numerator Total number of days each essential laboratory tests are available in the
hospital during the reporting period (Q40)
Denominator Total number of hospital specific essential tests (Q41) X Total number
of days in the reporting period (Q42)
Formula ∑days available (Q40) ÷ [∑tests (Q41) x ∑total number of days in time period
(Q42) ] x 100
Data sources Hospitals should introduce and use as data source, Unavailable test log
sheet.
reporting
Data entry Q40: Total number of days each essential laboratory tests are available
in the hospital during the reporting period= ______________
Q41: Total number of hospital specific essential tests = ___________
Q42:Total number of days in the reporting period = 30
Q 40
Q 41 X Q 42
KPI 20: Proportion of SLIPTA standards met
Why is this The Stepwise Laboratory (Quality) Improvement Process Towards

important? Accreditation (SLIPTA) is a framework for improving quality of
Hospital laboratories to achieve ISO 15189 standards.
Laboratory audits are 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.

This quality improvement process towards accreditation further
provides a learning opportunity and pathway for continuous
improvement, a mechanism for identifying resource and training
needs, a measure of progress,
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:
Definition The percentage of SLIPTA audit scored

Unit of
%
measurement
Numerator
Total SLIPTA audit standards met (Q43)
Denominator
275 (i.e. total number of SLIPTA audit standards) (Q44)
Formula
Total SLIPTA audit standards scored (Q43) ÷ 275 (i.e. total
number of SLIPTA audit standards) (Q44)
Data sources Assessment tool for Stepwise Laboratory (Quality) Improvement

Process Towards Accreditation (SLIPTA)
Frequency of
Biannual
reporting
Data entry Q43 = Total SLIPTA audit standards met = ____________
Q44= 275 (i.e. total number of SLIPTA audit standards)
Q 43
Q 44 (275)
KPI 21: Blood unavailability ratio for surgical patients
PRODUCTIVITY
KPI 22: Outpatient clinical care productivity for physicians

Why is this Timely access to blood is a factor in surgical morbidity and mortality
important? especially in obstetric and trauma care where hemorrhage is a major
cause of mortality.

Definition The ratio of major surgical/obstetric cases which are referred or
cancelled because of unavailability of blood to major surgical
procedures in the reporting period.
Unit of Ratio
measurement
Numerator Total number of major surgical/obstetric procedures cancelled or
referred because of lack of blood for transfusion(Q45)
Denominator Total number of surgical patients for whom cross - match was done
(Q46)
Formula Report as a ratio(E.g. 1:2)

Data sources OR Registry, IPD register, Liaison office record
Frequency Monthly
Data entry KPI 21 = Q45 : Q46
This indicator relates to the productivity of physicians and helps the hospital to
determine whether physicians are underproductive, productive, or are overloaded.
Why this is
important? Accordingly, the indicator will be related with other indicators like OPD waiting
time to treatment and patients not seen on the same day, and if quality gaps are
identified the productivity will be analyzed in relation to other resource gaps
including planning to increase physician number if they are already overloaded or
planning for more clinic numbers or accountability systems if the physicians are
underproductive.
For teaching hospitals, the estimated allocation of time for clinical care, teaching
learning process and research activities is 40%, 40% and 20% respectively.
Accordingly, interpretation of productivity takes this in to consideration with due
consideration of specific period of the report. For instance, the clinical care
engagement should be adjusted more than 40% if the physicians are not engaged
in research activities in that particular reporting period. The same applies for
teaching learning activities if the actual number of consultants is in excess of the
need to run the regular schedule of academic activities.

Definition Clinical care productivity for physicians is the average number of patients
managed by full time equivalent (FTE) physicians. A FTE physician is the one
who worked for at least 8 hours a day (except Friday in which case it is 7 hours),
5 days a week and 4 weeks of the reporting period.
If a physician works only part of the reporting period then his/her regular work
hours should be converted to a FTE number by dividing the number of regular
working hours by 39. For instance, if he/she was productive only for 2 weeks,
then the FTE will be 0.5 and 0.75 if he/she was productive for 3 weeks.
Unit number
Numerator Total number of outpatients managed in the reporting period during regular
working hours (Q8). INCLUDES: all outpatient clinic visits (new and repeat) in
the reporting period during regular working hours. EXCLUDES: all outpatient
clinic visits (new and repeat) seen in the private wing and all emergency patients
Denominat Total number of FTE physicians assigned in outpatient department during the
or reporting period(Q47)
INCLUDES: all interns, GPs, all years of Residency, consultants who are
appointed by the government or are voluntary or funded by another source
EXCLUDES: Interns, GPs, Residents, Consultants who are assigned in the
outpatient department but not physically available during all days of the reporting
period for private or hospital related missions.
Formula Total number of outpatients managed in the reporting period during regular
working hours (Q8) ÷ Total number of FTE physicians assigned in outpatient
department during the reporting period(Q47)
Data Outpatient registration book/register, HR database or intern/resident assignment
source schedule
Frequency Monthly
Data entry Q 8:Total number of outpatients managed in the reporting period during regular
working hours
Q 47: Total number of FTE physicians assigned in outpatient department during
the reporting period.

Q8
Calculation: KPI 22=
Q 47
KPI 23: Major surgeries per surgeon
Why is this This indicator relates to the productivity of surgeons, and helps the
important? hospital to determine whether surgeons are working productively, or
are overloaded. The indicator is useful for planning future surgical
staff numbers. Definition
Definition The number of major surgical procedures per full time equivalent
(FTE) specialist surgeon.

Numerator Number of major surgeries (both elective & non-elective)
performed on public patients (Q48) + Number of major surgeries
(both elective & non-elective) performed on private wing patients
(Q49)
A major surgical procedure is defined as any procedure conducted

under general, spinal or major regional anesthesia.
INCLUDE:
 all major surgeries conducted on patients admitted to public
facility
 all surgeries conducted on private wing patients
EXCLUDE: all ophthalmic surgery
NB: Ophthalmologists and ophthalmic surgery should be excluded

because the case mix of ophthalmic surgeons is substantially
different from that of other surgeons. In particular, ophthalmic
surgery tends to be of shorter duration than other types of surgery
and hence inclusion of ophthalmic surgery in the calculation would
introduce bias when comparing hospitals that provide an ophthalmic
service with those that do not.
Denominator Average number of FTE specialist surgeons (excluding

Ophthalmologists) (Q50)
Specialist surgeons INCLUDE:

 All surgeons funded by the hospital or RHB
 All surgeons who are voluntary or funded by another source
 Surgical residents (R-II and above – general, OB/GY,
Orthopedic,etc)
 IESO
EXCLUDE:
 Ophthalmologists
Formula [Number of major surgeries (both elective & non-elective)
performed on public patients (Q48) + Number of major surgeries
(both elective & non-elective) performed on private wing patients
(Q49)] ÷ Average number of FTE specialist surgeons (excluding
Ophthalmologists) (Q50)
Data sources Surgical/operating room log book
Human resources/personnel database
reporting
Data entry Q48= Total number of major surgeries (both elective & non-
elective) performed on public patients = _________

Q49= Total number of major surgeries (both elective & non-
elective) performed on private wing patients = __________
Q50= Average number of FTE specialist surgeons (excluding
Ophthalmologists) = ___________
Calculated:
HUMAN RESOURCE
KPI 24: Staff satisfaction
Why is this Hospitals should strive to provide a good working environment for employees, with
important? opportunities for training and development and equitable remuneration.
Employees who are satisfied with their working environment are more productive
and provide higher quality care. In contrast when workers are dissatisfied in the
workplace their productivity tends to be low and the attrition rate is high.
The Satisfaction of Employees in Healthcare (SEHC) survey has been developed for
use in Ethiopian health facilities. The survey tool measures staff experience and
perceptions in relation to training and development opportunities, communication
and relationships between staff members, provision of adequate resources to
perform the job, and the overall rating of the hospital as a working environment.
By monitoring staff satisfaction, the hospital can identify areas for improvement
and take action to address problems identified.
Definition Proportion of “neutral and satisfied” staff responses among all staff surveyed in
the specified period.
Unit Percentage
Numerator Total number of “ Neutral” responses (Q51)+ Total number of “ satisfied”
responses (Q52)
Denominator total number of staff Satisfaction surveys completed( Q53) x total number of staff
satisfaction criteria’s evaluated (Q54)
Formula [[Total number of “Neutral” responses(Q51) + Total number of “satisfied”
responses(Q52)] / [total number of staff Satisfaction surveys completed(Q53) x
total number of staff satisfaction criteria’s evaluated (Q54)]] x 100%
The survey should also include interns, residents, other staffs seconded by other
Inclusion cri. organizations.
Exclusion cr. 6 months or less since a staff joined the hospital
Data sources Survey – For the survey tool and protocol – see Appendix 10
Frequency Biannually
Data entry Q51= Total number of “Neutral” responses = ________
Q52= Total number of “satisfied” responses = _________
Q53= Total number of staff Satisfaction surveys completed = _____
Q54= Total number of staff satisfaction criteria’s evaluated] = ______

HEALTH FINANCEING
KPI 25: Raised revenue as a proportion of total operating spending
Why is this Hospital income is generated from two sources: government
important? budget allocation (treasury) and raised revenue. Through
Healthcare Finance Reform (HCFR) hospitals now have the
autonomy to generate income from user fees, private wing and
other sources. This is known as raised revenue. Hospitals are
expected to generate income that should then be re-invested in the
hospital to improve the quality of services provided.
By monitoring the amount of raised revenue expenses and the ratio

between raised revenue spending and total operating expenditure
the hospital can assess the adequacy of HCF activities and plan
future service improvements.
Definition Raised revenue as a proportion of total operating expenditure (i.e.
raised revenue operating + Treasury operating) for the reporting
period
Unit of %
measurement
Numerator Operating retained revenue during reporting period (Q55)
Denominator Total operating expenditures for reporting period, i.e. operating

budget from treasury for reporting period (Q56) + Operating
retained revenue during reporting period (Q55)
*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.
Formula Operating retained revenue during reporting period (Q55) ÷ [Total

operating budget expenses for reporting period (Q56+Q55)] * 100
%
Data sources Hospital financial statement
reporting

CLINICAL GOVERNANCE
KPI 26: Patient satisfaction
Why is this
Patient satisfaction with the health care they receive at the hospital is a
important?
measure of 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.
Definition Proportion of “neutral and satisfied” client responses among all clients
surveyed in the specified period.
Unit of
measuremen Percentage
t
Numerator Total number of “ Neutral” responses (Q57) + Total number of “ satisfied”
responses (Q58)
Denominator total number of Patient Satisfaction surveys completed(Q59) x total number of

patient satisfaction criteria’s evaluated (Q60)
Formula [[Total number of “Neutral” responses (Q57) + Total number of “satisfied”

responses (Q58)] / [total number of Patient Satisfaction surveys completed
(Q59) x total number of patient satisfaction criteria’s evaluated (Q60)]] x
100%
Data sources Survey – protocol for the patient satisfaction survey is presented in Appendix
8.
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.

Frequency of
Quarterly
reporting
Data entry Q57= Total number of “Neutral” responses = ________
Q58= Total number of “satisfied” responses = _________
Q59= Total number of Patient Satisfaction surveys completed = _____
Q60= Total number of patient satisfaction criteria’s evaluated] = ______
Section 4: Hospital Supportive Supervision Site Visits
Supportive supervision is a process that promotes quality at all levels of the health system by
strengthening relationships within the system, focusing on the identification and resolution of
problems, optimizing the allocation of resources, promoting high standards, team work and better
two-way communication (MARQUEZ & KEAN, 2002). Supportive supervision involves
directing and supporting HSPs in order to enhance their skills, knowledge and abilities with the
goal of improving health outcomes for the patients they manage. It is an ongoing relationship
between HSPs and their supervisors.
4.1 Purpose of hospital supportive supervision site visits
The purpose of a hospital supportive supervision site visit is:
To provide guidance and technical assistance to improve hospital performance
To assure the RHB that KPI and any other performance data reported by the
hospital to the RHB is accurate
To identify, recognize and learn from good practice, which can then be shared with
other hospitals
To identify areas for improvement
To identify areas where additional support from the RHB or other partners is
required, and to plan with the hospital for the provision of that support
These are common to all site visits conducted by the RHB but there may be additional
reasons for site visits. The purpose of the site visit and specific areas of focus should
always be agreed by the site visit team and should be informed to the hospital in advance
of the visit taking place.
4.2 Overview of the supportive supervision site visit process

Step 1 Selection of the site visit team

Step 2 Pre-visit preparation
Step 3 the site visit
Step 4 Post-visit reports and follow up

Figure 1: Overview of the supportive supervision site visit process

4.3 Selection of the site visit team
The first step in the site visit process is to determine membership of the site visit
team.
The site visit should be led and coordinated by the RHB in collaboration with other
partners as relevant. Potential participants include FMOH staff, staff from other
hospitals (e.g. a respected hospital CEO), partners and others.
A minimum of three individuals should conduct the site visit. This will allow each
person to carry out specific functions during the site visit and minimize the time
required at the hospital.
A team leader should be assigned by the RHB to oversee the site visit process. The
roles of the team leader include:
To establish membership of the site visit team
To prepare the site visit briefing document
To co-ordinate the site visit process, following the steps outlined below
To ensure communication between site visit team members both before and
after the site visit is conducted
To communicate with the hospital CEO both before and after the site visit
To prepare the site visit report and distribute to relevant stakeholders (e.g.
RHB Head, Hospital CEO and GB Chair, site visit team members).
To ensure the hospital provides a written response to the site visit report. To
follow up on any action described in the site visit report or the hospital
response
To ensure the site visit report and the hospital response are maintained on file
by the RHB
To establish the date or timeline within which the next hospital site visit
should be conducted

4.4 Pre-visit preparation for a site visit
The success of a site visit is dependent on adequate planning and preparation by both
the site visit team and hospital management.
4.4.1 Preparation by the site visit team
Collate information
Firstly, the site visit team leader should collate all available evidence about the
performance of the hospital, in order to identify specific areas that should be
addressed during the site visit. Much of this evidence will already be on record with
the RHB. As a minimum, the following information should be reviewed:
The most recent site visit report and the hospital response & action plant
The most recent and previous hospital KPI reports
The most recent and previous hospital self-assessment reports on attainment of

EHSTG standards
The hospital KPIs and attainment of EHSTG standard reports should also be
compared with other hospitals in the region to assess how well the hospital is
performing in relation to others.
If any of the above information is not available in the RHB, the team leader should
contact the hospital CEO to request them to submit the missing information.
Prepare draft site visit briefing document

After gathering the above information, the site visit team leader should review all
evidence and based on this should prepare a site visit briefing document. This should
include:
Summary of hospital performance
Strengths/successes of the hospital
Areas of possible weakness
Evidence that requires validation (e.g. selected KPIs, selected chapters of EHSTG
self-assessments etc)
Priority areas for further investigation during the site visit
Service areas to be visited during site visit
Staff members to be interviewed during site visit

Additional information for the hospital to prepare for the site visit team. For example, if the
patient satisfaction rating score is low, the team leader may ask the hospital CEO to prepare
the full results of the patient survey for review at the site visit. If the physician attrition rate
is high the team leader may ask the CEO to provide a breakdown of the number and type of
physicians who have left during the reporting period.
Consultation and finalization of site visit briefing document
The team leader should send the draft site visit briefing document together with all the above
evidence (KPI reports, previous site visit report etc) to all site visit team members. Each team
member should review and give comments.
All team members should then meet in person, or communicate by telephone or
email, to agree the areas to be addressed during the site visit.
The team leader should then assign specific tasks and responsibilities to each team
member and should prepare a schedule for the site visit which describes in detail
the role of individual team members. A sample site visit schedule is presented in
Figure 11, below.
Table 3: Sample Site Visit Schedule
Site visit team Department &/or hospital staff

Time Activity
members involved involved
8.30am – CEO
Opening meeting All
9.30am Senior management team
Insert name of
departments/service areas to be
Insert name of first visited and staff members to be
team member interviewed (eg OPD Case Team
Leader) by first site visit team
member
Insert name of
Information
Gathering by Insert name of
9.30am – visited and staff members to be
visits to second team
3.00pm interviewed (eg OPD Case Team
departments and member
Leader) by second site visit team
service areas
member
Insert name of
Insert name of third visited and staff members to be
team member interviewed (eg OPD Case Team
Leader) by third site visit team
member
3.00pm – Collation of All n/a

information
4.00pm
gathered
4.00pm to CEO
Closing meeting All
5.00pm Senior management team
Inform hospital CEO of date and purpose of site visit

After finalization of the site visit briefing document and schedule the team leader
should contact the hospital CEO to confirm the dates of the site visit. The site visit
briefing document and schedule should be sent to the CEO so that he/she can
ensure that the required hospital staff are available on the days of the site visit, and
can prepare the additional evidence requested by the site visit team
4.4.2 Preparation by the Hospital

After receiving the site visit briefing document and schedule, the hospital CEO
should share these with the senior management team and should prepare any
supplementary evidence requested in the briefing document.
The CEO should inform all hospital staff that a site visit is being conducted; giving
a general overview of the purpose of the site visit and priority areas that the site
visit team will review. In particular, the CEO should ensure that the management
and staff of all service areas that will be visited during the site visit are available on
the days of the site visit.
4.5 Conducting the site visit

The site visit should last between one to two days, although may be lengthened if
necessary.
4.5.1 Opening meeting

On arrival at the hospital, the site visit team should first have an opening meeting
with the CEO and SMT to give an overview of the purpose of the site visit, to
confirm the schedule and to receive any additional information that had been
requested from the hospital. The SMT should also be given opportunity to
comment on the schedule and to add any areas that they think are missing and that
they would like the site visit team to review. The site visit team may also take this
opportunity to update the SMT on any relevant regional or national developments
that the hospital should be aware of.
4.5.2 Information gathering

The team should then split up, each team member visiting the departments and
services within the hospital as per the planned schedule.
Each team member should prepare detailed notes on their activities during the site
visit, ensuring that the specific questions raised in the site visit briefing document
are addressed.

4.5.3 Collation of evidence
After visiting the different service areas, the site visit team should meet together
and should report back to on their assigned tasks. Together, the team should agree
initial findings of the visit, including strengths and weaknesses of the hospital,
recommendations to the hospital and specific areas that the hospital should address.
The team should also identify areas where additional support from the RHB is
required and a provisional date/timeline for the next site visit.
4.5.4 Closing meeting

After the internal meeting among site visit team members alone, the team should
then invite the hospital CEO and SMT to join them for a closing meeting. The team
should present their overall findings as described above, and give opportunity to the
SMT to respond to these. These findings should be seen as provisional, with the
possibility of adding further areas or revising the focus after further reflection.
4.6 Post Visit Follow Up

Following the site visit, the team leader should prepare a detailed report that
describes how the visit was conducted and the main findings and recommendations
arising.
The report should be reviewed by all site visit team members. When reviewing the
draft report team members should consider:
Does the report present the impression of the hospital that you want it to
convey?
Does the report contain the key messages arising from the site visit?
Does the report describe any follow up action that is expected from the
hospital?
Are recommendations based on evidence gathered during the site visit?
Are all recommendations important? Are they feasible?
Does the report identify any follow up action or support that is required from
the RHB?
Will the report help to improve hospital services? If not, how can the report
be improved?

After finalizing the report by the site visit team, the report should be sent to the
hospital CEO who should review and prepare a hospital response & action plan that
describes specific actions that the hospital will take in the light of the report. When
reviewing the report the hospital CEO should consider:
Is the report factually accurate? If not, the CEO should include a correction of
any errors in their written response
What specific actions should the hospital take to address the recommendations
made in the report? In what time frame?
Does the report describe all areas of support that the hospital expects from the
RHB to assist the hospital to act on the recommendations?
Are there any additional comments that the CEO would like to raise with the
RHB about the site visit process itself? Anything that could be improved in the
process?
The CEO should send a copy of the hospital response and action plan to the site visit
team leader.
After finalizing the site visit report and the hospital response, copies of both should
be shared with the RHB Head and all relevant stakeholders. Copies should be kept
on file within the RHB and used as evidence when preparing subsequent site visits
and regional review meetings.

Section 5: Regional Review Meetings
5.1 Purpose
Regular meetings between the RHB and all hospitals in the region provide the
opportunity for communication and experience sharing between the RHB and
hospitals. Specifically review meetings can be used to:
Present and discuss hospital performance reports

Benchmark
Identify and reward good practice
Share successes and challenges discuss
other relevant topics
5.2 Frequency of meetings

Review meetings should be held as a minimum every six months.
5.3 Length of meeting

In general the meeting should last for two days, but may be longer if the need arises.
5.4 Participants
a) RHB staff
The meeting should be attended by RHB curative and rehabilitative

core process team members. The RHB Head and deputies should
also attend whenever possible. Additional RHB staff members
should be invited if the agenda includes topics that are of relevance
to them.
b) Hospital staff
As a minimum the hospital CEO and Medical Director should attend

the meeting. Additional participants could include other members of
the hospital senior management team and/or the Governing Board
Chair.
c) Health Services Quality Directorate
The FMOH regional focal persons for the region should be invited to
attend since this will maintain strong communication between
FMOH, the RHB and hospitals and will build capacity in FMOH to
support the RHB and hospitals when required.
d) Other
Additional partners could be invited to attend according to their area

of expertise and relevance for the agenda.

5.5 Pre -Meeting Preparation
Before each meeting the RHB should determine the venue, set the meeting agenda,
identify participants and send an invitation letter plus agenda to all hospitals,
describing which participants should attend to represent the hospital. Additional
partners such as FMOH staff or NGO partners should be invited as relevant. The
invitation letter and agenda should be sent at least 3 weeks in advance of the
meeting, with a follow up email or phone call to confirm attendance approximately
one week in advance of the meeting.
To prepare for each meeting, the RHB should review all hospital KPI reports and
the most recent site visit report and hospital response and action plan. Using these
reports the RHB should identify successes and challenges within individual
hospitals or across the region as a whole.
Based on the findings, the RHB should identify specific hospitals to give
presentations or share experience at the meeting and should inform these hospitals
in advance so that the hospitals can prepare all necessary information.
5.6 Conducting the meeting

The meeting should be chaired by the RHB, with additional facilitators for each
session or topic according to need.
Specific individuals from within the RHB, FMOH or partners should be assigned to
take minutes of the meeting.
At each meeting the RHB should give a presentation on the KPI and EHSTG
standards assessment reports from each hospital, including regional averages and
recommendations from the RHB in response to the findings. Other agenda items
will vary from meeting to meeting according to need.
5.7 Post meeting follow up

The RHB should prepare minutes and circulate these to all participants within a
maximum of two weeks following the meeting. The minutes may also be sent to
others as relevant (for example the RHB Head and FMOH/HSQD).

Section 6: FMOH and RHB Meetings
6.1 Purpose
Regular meetings between FMOH and all RHBs provide the opportunity for
communication and experience sharing between regions. Specifically FMOH/RHB
meetings can be used to:
Present and discuss regional performance reports

Benchmark
Identify and reward good practice
Share successes and challenges
Share recent research reports related to hospital
Performance discuss other relevant topics
6.2 Frequency of meetings

FMOH/RHB meetings should be held biannually.
6.3 Length of meeting

In general the meeting will last for three days, but may be longer if the need arises.
6.4 Participants
a) FMOH Staff
All members of the FMOH should attend the meeting. Additional

FMOH staff should be invited if the agenda includes topics that are of
relevance to them.
b) RHB Staff
Ideally, all members of each CRCPT of all RHBs should attend

every meeting, but as a minimum the RHB core process owner and
hospital lead should be in attendance.
c) Hospital staff
A selected number of hospital CEOs, governing board chairs and/or

other senior managers should be invited to attend meetings
depending on the agenda items.
d) Other
Additional partners could be invited to attend according to their area

of expertise and relevance for the agenda.

6.5 Pre- Meeting Preparation
Before each meeting FMOH should determine the venue, set the meeting agenda,
identify participants and send an invitation letter plus agenda to all RHBs +/-
specific hospitals +/- other partners as relevant. The invitation letter and agenda
should be sent at least 2 weeks in advance of the meeting, with a follow up email or
phone call to confirm attendance approximately one week in advance of the
meeting.
To prepare for each meeting, FMOH should review all regional KPI reports to
identify successes and challenges within individual regions or across the country as
a whole.
Based on the findings, FMOH should identify specific RHBs to give presentations
or share experience at the meeting and should inform these RHBs in advance so
that the RHB can prepare all necessary information.
6.6 Conducting the meeting

The meeting should be chaired by FMOH, with additional facilitators for each
session or topic according to need.
Specific individuals from within FMOH or partners should be assigned to take

minutes of the meeting.
At each meeting FMOH should give a presentation on the KPI and EHSTG
standards assessment reports from each region, and recommendations from FMOH
in response to the findings. Other agenda items will vary from meeting to meeting.
6.7 Post meeting activities

FMOH should prepare minutes and circulate these to all participants within a
maximum of two weeks following the meeting. The minutes may also be sent to
others as relevant (for example all RHB heads, and other FMOH directors or
Ministers).
7. Glossary
Abdominal route Through a surgical incision in the belly

Abdominal surgical delivery Removal of the fetus, placenta etc. through a surgical
incision in the belly
Admission Going into hospital
Anesthesia Method of putting patient to sleep or stopping feeling in a

part of the body for surgery
Ante partum Pregnancy before delivery of a baby
Assisted delivery Birth of a baby in which the midwife or surgeon manipulates

the baby as it moves through the birth canal
Caesarian section Operation to deliver a baby through an incision in the uterus
Cartilage Tissue between bones
Case team A team within the hospital i.e. for in patients
Craniotomy Procedure to remove part of skull
Day surgery unit Department in the hospital where patients are operated on
then go home the same day
Delivering mother Woman in the process of delivering a baby
Dental Concerning teeth
Discharge Leaving hospital
Eclampsia Seizures/fitting - potentially fatal disorder of pregnancy
Elective Planned ahead, not emergency
Emergency attendance Occasion when a patient goes to the emergency room for
treatment
Emergency room Department in the hospital where emergency patients are

treated
Family planning Service to advise on controlling fertility so pregnancy is

planned
Fetus Baby in the uterus

Forceps delivery Delivery of a baby using forceps to pull the baby out
Gestational age Age of the baby in the womb during pregnancy, i.e. how far
on in pregnancy
Gynecology Medical specialty concerned with areas of women's health

such as fertility, pregnancy, continence
Hemorrhage Bleeding
Hospital performance Ethiopian system for monitoring the performance of health

monitoring framework facilities
In patient Patient staying in the hospital
Incision Cut in the skin by a surgeon
Infection prevention Procedures like regular hand washing and sterilization of

processes instruments which stop the spread of infections
Instrumental delivery See assisted delivery
Intensive care unit Department in the hospital for acutely ill patients with higher
levels of medical and nursing care
Intra partum During delivery of a baby
Key performance indicator An agreed measure that all facilities collect in the same way
Laboring mother Woman in labor
Live birth Baby who is born alive
Maternity Concerning pregnancy and childbirth
Medical record Papers that document the care and treatment a patient
received
Morbidity Illness or disability
Mortality Death
Neonatal Concerning newborn babies
Ophthalmology Medical specialty for eye diseases

Out patient Patient visiting the hospital for treatment
Performance improvement Process to improve the organization’s performance
Postpartum A description of the mother after delivery of a baby
Pressure ulcer Skin breakdown because of continued pressure
Private wing Part of the hospital where patients pay for all services they
receive
Psychiatry Medical specialty for mental health
Purulent With pus, infected
Referral Recommendation that a patient attend another hospital or

clinic
Sacrum Bottom of the back above the buttocks
Stillbirth Baby who is born dead
Subcutaneous tissue Tissue under the skin
Supportive supervision site A visit by the RHB and partners to the hospital to review
visit performance
Surgical delivery Baby delivered by an operation
Surgical site infection Infection at the place on the body where a surgical incision
was made
Triage A process of sorting patients into priority groups for

treatment according to need
Uterus Womb
Vacuum delivery Delivery of a baby using a suction instrument to pull the

baby out
Vaginal delivery Baby delivered normally
Well baby clinic Clinic to checks on babies' development
Wound Area of damaged skin for example from an injury or surgery
Wound dehiscence An area of a wound which is not healing and has come apart

or broken down
8. Appendices
Appendix1: HOSPITAL CASH AUDIT TOOL
Clean and safe health care facility(CASH) Audit Tool

Hospital General Information
Date of Assessment
Hospital Name
Region, Zone/Sub city, District/ woreda
CEO Name
phone no
Email
CASH focal person Name
phone no
Email
Number of Staff(Total )
Number of
Environmental health
officers
Number of Staff(Cleaners
)
Number of Staff(Laundry
staffs )
Name of Assessors

1. CASH Structure and management
N Standard Verification Criteria Score Remark
o
* ** *
*
*
1 Managem  Governing board support
ent, & monitor CASH/IPPS
commitme activities
nt, support  SMT establish a system to
and support and monitor
coordinati CASH/IPPS activities
on  SMT ensure adequate
resource allocation
(human & budget for
material & supplies)
 Department performance
assessment and
mechanism of recognition
in place
2 Functional  Updated TOR for the

/Active committee
CASH/IP  Availability of annual
PS CASH specific
coordinati operational plan at focal
ng point, committee and
committee SMT
 Conduct regular meeting
at least quarterly and
minutes should be
documented
 Conduct progressive
assessment quarterly
&report should be sent to
SMT
 All hospital health
professionals, laundry
staffs, kitchen staffs and
housekeeping staffs
should be trained on
CASH/IPPS
 Conduct Hospital wide
Campion at least quarterly
with focusing changing
the attitude of people
3 The  Involvement of all
hospital departments/units
has a  Involvement of patients
strategy to  Involvement of
improve communities
the  Involvement of senior
implement physicians
ation of
CASH.
2. Facility Management
No Standard Verification Score R
criteria e
* ** *
m
*
a
*
r
k
4 Protective  Fence which surrounds all
Surrounding the hospital ground which
fence will not allow the entrance
of pets and other animals
with a functional gate
 Safe especially for
psychiatric and pediatric
patients
 At least with two gates that
could aid in case of
emergencies.
5 External ground  Hospital external ground

appearance and (at least 5m-20m from the
tidiness fence) is free from any
hospital & community
generated waste

6 The hospital  Tidy and well maintained
should have internal ground
good Internal  Free abandoned medical
compound equipment/ old cars, etc
appearance and  Designated social green
tidiness areas/parks with seating

facilities
 Clinical and General waste
containers placed only in
recommended places
 Clearly marked, well lit,
and safe walk ways
including from parking
area
 Electrical wires are secured
and safely fixed within the
compound
7 The hospital  Easily visible Hospital sign
has an directing people from
appropriate around (approximately 3- 5
Signage so as to meters from floor level,
make accessible framed, legible text and
for visible at day and night)
clients/patients  Clear signage in the
hospital showing the name
of the hospital wards,
departments, clinics,
hazards, etc
 Signs on doors, toilets, etc
described/written either in
pictures, words or both and
consistent in appearance
 Signs for toilets are visible
from all patient areas
8 The hospital  Clean, tidy, and free from
has a Clean and cracks Hospital buildings
tidy Hospital  Drainage system within
buildings& and around hospital
immediate building(s) e.g. gutters,
surrounding pipes, etc, should be free
from any obstructions, e.g.
vegetation
 Doors, windows, and
window frames are clean,
not damaged, properly
fixed, and painted
9 The hospital  Visibly clean, free from
should have any obstacles, well lit and
clean and safe suitable for any whether
Hospital condition
building  Stairs, steps and lifts,
corridors and internal and external,
waiting area including all component
parts, are visibly clean and
well-maintained
 Waiting area with adequate

space, clean & not
damaged chairs, and health
education program
10 The hospital  Defined and posted time
ensures good (schedule) for visitors
Traffic flow  Restrict only authorized
management persons at those high risk
areas
11 The hospital  Continuous electricity
has a regular availability (24/7) in the
supply safe hospital with backup
Electric supply source
 All electric lines, switches,
sockets, and ventilation
grills are properly,
insulated, and safe
12 The hospital  The Hospital has Fire
has a Fire safety plan
safety plan  Fire Emergency drill
conducted at least annually
 Contact address in case of
fire emergency posted on
working areas
 Staff trained on fire safety
 Functional fire
extinguishers (expire date
is up to date) placed at
easily recognizable place.
 Functional & annually
inspected water hose
13 The hospital  There are adequate
practices number of cleaners per
Housekeeping the standard
works  There is adequate
cleaning supplies
 Cleaning work plan
developed and
implemented
 Established system for
monitoring cleaning
activity
14 The hospital  Established
has Pest & system/mechanism for pest
rodent control and rodent control
system (outsourced or trained and
assigned personnel)
 Regular pest & rodent
control/inspection every 3
month

15 The hospital  Free from internal sound
has Noise disturbance (e.g. sounds
pollution from generator,
control system constructions, workshop,
etc)
 No noise pollution sign
should be posted inside the
compound
16 The hospital  All rooms/service areas
has adequate have adequate natural or
Ventilation and artificial light access
Illumination  All service areas/rooms are
well ventilated with natural
or artificial system
Water, Sanitation, and Hygiene
No Standard Verification criteria Score Re
ma
* ** * rk
*
*
17 The  Improved water supply
hospital piped into the facility or in
ensures premises
availability  Water available at all times
of adequate (24 hrs/day7 days a week)
water and of sufficient quantity
supply for all service areas.
 A reliable drinking water
station is present and
accessible for staffs,
patients and care givers at
all times and all
locations/wards.
18 The  Water storage is sufficient
hospital has to meet the needs of the
appropriate facility for 2 days
Storage/Re  Drinking water is safely
servoir to stored in a clean bucket/
ensure tank with cover and tap
continuous  Reservoirs are made from
water rust resistant material
supply  Cleaning of Reservoirs
conducted on regular base
twice a year (at least every
six month)
 Reservoirs placed at least
50 cm above the ground
and are protected with
surrounding fence.

19 The  Hospital have a water safety
hospital plan
should  All water pipelines are
have Water installed underground and
safety plan free from leakage
 Water is tested regularly
four times a year through
collecting a representative
sample
 Drinking water has
appropriate chlorine residual
(0.2mg/l or 0.5mg/l in
emergencies)
20 The  A separate male and female

hospital based shower for in-patient
should wards (one shower per 40
have patient)with continuous
adequate water availability and light
Showers  A separate male and female
staff shower
 Free from any solid and
liquid waste
 Visibly clean wall-attached
shower chairs (free from
blood and body substances,
scum, dust, lime scale,
stains, deposit or smears.)
 Showers have a door with
lock. If there is no door,
privacy curtains should be
installed
Sanitation and Waste Management

No Element Standard Score Remark
** * *
* *
21 The hospital  Availability of
should have proportional toilet to
adequate patient ratio (one
rest room toilet to 20-24
patients)
 Separated for male
and female
patients/clients
 Separated for patient
and staff
 Visibly clean from
any solid and liquid
waste
 Free form bad odor
 Ensure privacy with
functional door and
lock.
 Adequate functional
artificial light for
the night time.
 At least one toilet
meets for menstrual
hygiene
management (tap
water inside the
room etc)
 Toilets at maternal
waiting
area/maternity ward
are suitable for
pregnant mothers
 At least one toilet
meets the needs of
people with reduced
mobility.
 Functional hand
hygiene stations
(running tap water,
soap, dust bin, etc)
within 3 m from
latrines.
 Functional waste bin
22 The hospital  Health care waste
should management
practices manual/SOP
Proper available in clinical
solid Waste areas
managemen  Functional waste
t system collection containers
for 1) non -
infectious (general)
waste, 2) infectious
waste and 3) sharps
waste in close
proximity at
necessary service
point.
 Waste correctly
segregated at all
waste generation
points.

 Separate functional
waste transport
equipment for
clinical, domestic
and in the case of
Mercury & other
toxic materials
 Domestic waste
pit(for burning of
non-infectious
waste) and burial
pit(for the burial of
non-combustive
waste) free from
odor/offensive smell
 Dedicated ash pits
available for
disposal of
incineration ash
 Fenced and
protected waste
storage and disposal
site (burial pit,
incinerator,
placental pit, etc)
 Separated storage
area for Hazardous
and non-hazardous
waste before
treatment/disposal
of or moved off site.
 Appropriate
personal protective
equipment for all
staff in charge of
waste transportation,
treatment and
disposal.
.
23 The hospital  Functional and well-

should have designed incinerator
an (type)
appropriate  A trained person is
and responsible
functional operating
Incinerator incinerators
 Sufficient
energy/temperature
supply for

incinerator for
complete
combustion
24 The hospital  Clean and functional
should have placental pit without
an unpleasant or
appropriate distasteful odor
and  Anatomical-
functional pathological waste is
placental pit put in a dedicated
(Where pathological
applicable) waste/placenta pit,
burnt in a crematory
or buried in a
cemetery
The hospital  Proper liquid waste

25 should management system
practices with sewerage line
Proper connected to a
Waste municipal or own
managemen septic tank.
t system  Functional liquid
waste treatment
system before
discharging from the
facility
 Sewerage lines
connected from
liquid waste
generation points
source are free from
any leakage
 Separate sewerage
line & septic tank
for
pathogenic/chemical
waste and
general/non
infectious connected
Hygiene
N Element Standard Score Remar
o ** * * k
* *
26 The hospital  Functioning

has Proper hand hygiene
hand hygiene stations (running
stations tap water, soap,
alcohol hand rub,
etc) are available
at all points of
care/service area
and waste
disposal site
 Visibly clean
sink and wall-
attached
dispensers/soaps
 Hand hygiene
promotion
materials clearly
visible and
understandable
at key places.
 Hand hygiene
compliance
activities are
undertaken
regularly.
27 The hospital  Visibly clean,

ensures shine, washable
hygiene and & uniform
cleanliness physical
of all rooms appearance floor
with no cracks
and holes
 Visibly clean &
washable wall
surface and
ceiling including
skirting with no
cracks and holes
 All furniture’s
(chairs, tables,
commodes/locke
rs,
curtains/screens,
mirrors, and
notice board) are
visibly clean and
not damaged
 All parts of the
bed (including
mattress,

bedsheets/linen,
bed frame,
wheels, castors,
patient pajamas,
and bed nets) are
visibly clean and
not damaged
 All medical
equipments
(weighing scales,
drip stand,
oxygen cylinder,
autoclaves, baby
incubator, etc)
are visibly clean
and non
functional stored
away from the
room
 The waste
receptacle are
visibly clean and
covered
 Beds for patients
separated by a
distance of 1
meter from each
other edge.
28 The hospital  Developed,
should posted and
ensure Food practiced SOP at
hygiene least for Dish
practices washing & Food
Safety
 Separate kitchen
room and store
are
 Kitchen room&
store visibly
clean, well
ventilated, odor
free, well lit and
free from rodents
 Food preparation
& serving
equipments are
visibly clean, not
damaged, not
stained, and free
from rust

 Food
transportation
carts are made
from aluminum
with functional
door
 Dishwashers are
three
compartment
with detergent,
and running hot
and cold water
 Cutting boards
are made from
plastic
(propylene
plastic)
 All food
handlers have
regular medical
checkup every
three month
 The Hospital
provides food
hygiene training
twice a year for
all food handlers
 All food
handlers wear
the
recommended
PPE while on job
and apply
personal hygiene
practice
 Fridges and
freezers are
available
separated with
food type
 All fridges and
freezers are
visibly clean,
temperature
monitored, and
with functional
gage
 The Hospital
establish
functional food

safety
monitoring team
29 The hospital  Staff dresses

should clean uniforms
ensure with name and
personal job title
hygiene and identification
appearances  All staff wears
of staff proper PPE on
task specified
 Staff uniforms
are not allowed
in staff
canteens/restaura
nt
30 The hospital  Prepared, posted,
ensures the and applied
availability SOPs for linen
of processing.
Laundry/Lin  Designated area
en for sorting soiled
processing/ and non soiled
service linen
 At least two
separately
designated sink
system for
soaking soiled
linen
 Adequate
laundry
machines for
washing,
twisting, drying,
and ironing.
 Sufficient and
separate trolleys
for transporting
clean/washed,
soiled, and non-
soiled linens.
 Two separate
door system for
receiving soiled
and exit of
cleaned linen
 Separated room
for cleaned linen
with clean and

not damaged
shelves
 Designated,
adequate, clean,
and protected
place for natural
air drying that
can serve in any
weather
condition
31 Instrument  Prepared and
processing posted SOPs and
job aids for
instrument
processing.
 Staffs properly
follow the
recommended
steps of
instrument
processing soon
after the
procedure (i.e.
decontamination,
cleaning,
sterilization and
storage).
 Adequate and
functional
instrument
processing
machines are
provided
 Clean and
protected shelves
for
processed/steriliz
ed instruments
 Instrument
processing
machines are
calibrated
(preventive
maintenance)
annually
 Instrument
processing
equipments
(buckets, tooth
brush, etc) are

clean and not
damaged
Appendix 2: 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:
a) Assign surveyors to the areas where patients arrive at the outpatient

department as follows:
If outpatients undergo registration before triage  assign surveyors to

patient registration area
If outpatients undergo triage before registration  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) 
assign surveyors to OPD waiting areas
b) 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.
d) 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.

e) 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.
f)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.
g) 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.
h) 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.

Appendix 3: 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.
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.
a) 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.
b) 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 (Q9) ÷ Number of patients included in emergency room triage time
survey (Q10) 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.

Appendix 4: 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.
a) 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
For each of the selected Medical Records complete the following 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. Progress note- documented at least once a day
throughout the hospital stay?
3. Order sheet:
- Is this present and revised daily?
4. Nursing Care Plan:
- Is this present?
- Revised daily, V/S taken at least QID for all
admitted patient?
5. Medication Administration Record -
Is this present?
6. Discharge summary
- Is this present?
7. 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: _____________________________

9 Pressure Ulcer Report Form
Appendix 5: 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 6: 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 (የተወሰዯውእርምጃ):
Reported by :
Name :_____________________________ Position : ____________________________

Outcome (to be completed at time of discharge) :

Signed : _____________________________ Position:_________________________
Appendix 7: WHO Safe surgical check list

Appendix 8: Patient Satisfaction
Survey Protocol: Patient Satisfaction
Purpose of Survey:
To provide a standardized survey for outpatients‟ and inpatients‟ experiences which hospitals can
use to monitor patient satisfaction with services, and changes in satisfaction over time.
The Key Performance Indicator “Patient Satisfaction” will be calculated using the proportion of
neutral and satisfied client responses among all clients surveyed in the specified period.
Period of Survey:
Hospitals should perform a total of 120 surveys each quarter (30 from each of the OPD, IPD,
maternity and Emergency departments). The surveys should be collected over a time period of
two weeks. No more than 3 surveys should be collected in a day and surveys should be collected
on different days and different times of day (morning and afternoon; weekends, holidays and
night duty shifts for OPD, IPD, maternity surveys).
All surveys should be administered at the time of discharge (if admitted) or at the end of the
visit/stay right before the patient leaves the service area.
Role of KPI owner:
The hospital should assign an „owner‟ for the KPI „Patient Satisfaction‟. He/she is responsible to
oversee the survey, to select and train surveyors, to issue surveys to each surveyor, to receive
completed surveys from centralized collection area, calculate patient satisfaction (KPI 26) and
response rate, and give all completed surveys to a data entry person who will enter them into the
Access Database.
Each health facility should assign one or more individuals to administer the surveys to patients.
The individual conducting the survey (also referred to as “surveyor”) should understand the
survey well, including all survey questions and answer choices. To minimize bias the surveyor
should not be involved in direct patient care. A surveyor must have good interpersonal skills to
interact sensitively with patients and must not lead the patients to particular responses but should
administer the survey objectively. Each surveyor must be trained to ensure he/she understands the
purpose and process of the surveys. Surveyors are responsible for collecting all completed
surveys and returning them to a centralized collection area determined by the health facility.
Surveys can be completed by the patient themselves (written) or the surveyor may read each
survey question to the patient and transcribe the patient response (oral). When orally
administering the survey, the surveyor should read the question exactly as written on the survey
tool. If the patient has a query about certain questions on the survey, surveyors should not provide
responses or more detail about what the question might be. This will introduce the surveyor’s
interpretation into the question, which is a form of bias. When encountering such a challenge, the
best approach is for the surveyor to remind the respondent that there is no right or wrong response
and that the interpretation of the patient is the best possible one. Then, the surveyor should re-
read the question for the patient.
Patient recruitment:

Participation is voluntary and patient anonymity must be maintained. No identifying information
(such as patient’s name) should be collected. All patients must be 18 years old or older. In
addition, for admitted clients, participants must have a hospital stay of 2 days or more.
Participants should be excluded from both surveys if cognitively impaired and unable to
understand the survey questions. For the outpatient survey, patients should be selected to reflect a
diversity of outpatient areas. Emergency room services may also be assessed using the outpatient
survey. For the inpatient survey patients should be selected from a range of different wards to
reflect the diversity of services.
The surveyor should not select patients based on his/her presumptions about whether the patient
appears pleased or not pleased with services rendered.
a) Assign and train surveyors
Selection and training of surveyors should be in accordance with above stated protocol and
should be done well in advance of survey period.
b) Select patients for survey
Surveyors should be provided with a logbook to record the number of patients asked to participate
in survey, number of surveys actually completed by patients and what type of survey was
administered (written or oral). This is to measure the survey response rate as well as track
surveys.
Patient recruitment should be in accordance with above stated protocol. Surveyor should then
approach the patient to inquire if he/she is interested in completing a patient survey. The surveyor
should explain the purpose of the survey and assure the patient of his or her anonymity. If the
patient does want to participate they must then give their consent verbally before the survey can
be administered.
c) Oral or written completion of survey
The survey may be completed by the patient themselves (written) or administered by the surveyor
who will transcribe the patient’s answers (orally). An ID number should be assigned to each
survey sequentially as it is conducted. The ID should be entered on the survey form and in a
logbook.
Written Survey:
Surveyors will provide a blank patient survey to the patient to be completed by him/her. Patient
should complete the survey at the time it is distributed and be notified of a centralized collection
area where they can return their completed survey.
The surveyor should record the Survey No. in logbook and identify it as a “written survey”.
Oral Survey:
If the patient requests that the survey be conducted orally surveyors will read each question on the
survey to the patient, transcribing the responses of the patient on to the survey form (tally their
rating as per the service area). The surveyor should record the Survey No. in a logbook and
identify it is as “oral survey”. Once the survey is completed the surveyor should deliver it to a
centralized collection area for the KPI data owner to collect.
d) KPI owner calculates Patient Satisfaction Indicator and response rate

At the end of the survey period the KPI owner should collect all completed surveys from the
centralized collection area. The KPI owner should calculate Patient Satisfaction score by
calculating the proportion of a clients responded by giving a neutral or satisfied score from the
total number of clients participated in the survey.
The formula for the indicator is as follows:
[[Total number of “Neutral” responses + Total number of “satisfied” responses] / [total number
of Patient Satisfaction surveys completed x total number of patient satisfaction criteria’s
evaluated]] x 100%
e) KPI Owner reports to KPI focal person and Data Entry Person
After calculating Patient Satisfaction the KPI owner should report all data elements and indicator
to the KPI focal person. The KPI focal person will then check the calculations and enter them into
the KPI report form.
Additionally, all surveys should be given to the appropriate data entry person to enter into the
Access Database. See Appendix 8 for guidance.

THANK YOU FOR YOUR COOPERATION!
Date in Ethiopian calendar: date…………………..…month……………..…

year………………………………
Service area …………………………………………………….
Characteristics Outpatient Emergency Inpatient Maternity

department department department department
D N A D N A D N A D N A
D = Disagree N = Neutral A = 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
st
OPD/1 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
counseling 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
counseling 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 Gr
an
d
tot
al
N.B: Black shaded – not applicable to the departments at all times

Appendix 9: Essential lab tests availability
ሠንጠረዥ-9-በሆስፒታልእናበሪጅናልላቦራቶሪደረጃየላብራቶሪየምርመራዝርዝርእስታንዳርድ
ቀድሞየነበረእስታንዳ በዚህጥናትበማሻሻያነትየቀረበ አስታ
ዲፓርትመ ርድ የት
ንት በጀነራልሆስፒታልላብ
በሆስፒታልላብራ በሪጅናል
ራቶሪደረጃ
ቶሪደረጃ ላብራቶሪደ
ረጃ
Clinical Blood glucose Blood glucose Blood
glucose
chemistry
Alkaline phosphatase Alkaline Alkaline
phosphatase phosphata
se
ALT ALT ALT
SGPT SGPT SGPT
SGOT SGOT SGOT
Total bilirubine Total bilirubine Total
bilirubine
Direct bilirubine Direct bilirubine Direct
bilirubine
Total protein Total protein Total protein
Albumin Albumin Albumin
Urea Urea Urea

Creatinin Creatinin Creatinin
Uric acid Uric acid Uric acid
GGT GGT
Cholestrol Cholestrol
Triglyceride Triglycerid
e
LDL-Cholestrol LDL-
Cholestrol
HDL-Cholestrol HDL-
Cholestrol
Lipase
Parasitol Stool microscopy Stool microscopy

ogy Blood film for Blood film for
malaria and other malaria and
hemoparasite / other
Malaria Rapid Test hemoparasite
Occult blood
Urine Urinalysis Urinalysis
and CSF analysis CSF analysis
body
fluid
analysis:
Ascitic fluid Ascitic fluid
Pleural fluid Pleural fluid
Mycolog KOH test KOH test

y
Hematol Hemoglobin Hemoglobin CBC+Diff
ogy (All CBC
Pofile)
Total WBC count Total WBC
count
Differential white Differential
cell count white cell
count
ESR ESR
Hematocrit Hematocrit
Platelet count
CBC+Diff
(All CBC
Pofile)
Serology ASO ASO HIV-test
:

RF RF
RPR RPR
HIV-test HIV-test
H.Pylori (Ag/Ab) H.Pylori
(Ag/Ab)
HBs Ag HBs Ag
HCV HCV
Salmonella Typhi- Salmonella
O Typhi-O
Salmonella Typhi- Salmonella
H Typhi-H
Proteus-OX19 Proteus-OX19
HCG HCG
Blood Anti-A፣Anti-B፣ Anti-A፣Anti-
Group & Anti- D B፣ Anti- D
Compati Cross match Cross match
bility
testing
Indirect
coomb's test
Bacteriol Gram stain Gram stain Gram
ogy stain
ZiehlNeelson stain ZiehlNeelson ZiehlNee
stain lson
stain
Indian ink Indian ink
wet smear
Culture and Culture
Drug and
sensitivity test Drug
sensativi
te test

Immuno CD4 count CD4 count CD4
hematol (CD Pannel count
ogy (CD4, CD8, (CD
CD3, ratio...) Pannel
(CD4,
CD8,
CD3,
ratio...)
ferritin Ferritin
folate III folate III
Anemia Iron Iron
panal RBC FOLATE RBC
FOLATE
Vitamin B12 Vitamin
B12
Transferrin Transferrin
UIBC UIBC
PT PT PT
Bleeding time PTT PT
Coagulla T
tion test INR INR
Fibrinogen Fibrinoge
n
Bleeding time
Electroly Na Na Na+
te Serum
K K K+
Serum
Cl Cl Cl-
Serum
Mg
PO4 Phospate

Serum
Ca Calcium
seru
Fertility Spermatozoa
Pap Smear
Tumer CA-125 CA-15-3
markers CA-15-3 CA 19-9
CA-19-9 CA-19-9
CEA
Molecula Viral
r tests load
EID
(Early
infant
diagnosi
s)
Hormon T3 T3 (FT3) T3 (FT3)
analysis T4 T4 (FT4) T4 (FT4)
TSH TSH TSH
FSH FSH FSH
LH LH LH
Testesteron Testeste
ron
Prolactine Prolactin
e
Cardiac LDH LDH
marker CK-MB CK-MB
Troponine Troponine
CPK CPK
Blood Co2
gas PH
analysis Po2

Visit Briefing Document
Appendix 10: STAFF SATISFACTION SURVEY TOOL

Survey Protocol: staff Satisfaction
Purpose of Survey:
To provide a standardized survey tool for hospitals, they can use it to monitor staff satisfaction
in their workplace, and changes in satisfaction over time.
The Key Performance Indicator “staff Satisfaction” will be calculated using the average responses
to questions in the staff satisfaction survey tool.
Period of Survey:
Hospitals should perform satisfaction of at least 50% of their staffs biannually. The surveys
should be done in the first week of the last months of the first and the second half of the budget
year (i.e. first weeks of December and June). As indicated in the survey tool, different categories
of health care providers (physicians, nurses, midwives, laboratory/pharmacy/imaging workers)
and supporting staffs has to be included in the survey.
Role of KPI owner:
The hospital should assign an owner‟ for the KPI staff Satisfaction (HR or Quality unit staff).
He/she is responsible to oversee the survey, to select and train surveyors, to issue surveys to each
surveyor, to receive completed surveys from centralized collection area, calculate staff
satisfaction (KPI …) and response rate, and give all completed surveys to a data entry person who
will enter them into the Access Database.
Each health facility should assign one or more individuals to administer the surveys to staffs. The
individual conducting the survey (also referred to as “surveyor”) should understand the survey
well, including all survey questions and answer choice. A surveyor must have good interpersonal
skills to interact sensitively with staffs and must not lead the staffs to particular responses but
should administer the survey objectively. Each surveyor must be trained to ensure he/she
understands the purpose and process of the surveys. Surveyors are responsible for collecting all
completed surveys and returning them to a centralized collection area determined by the health
facility. Surveys can be completed by the staff themselves (written).

Staff recruitment:
Participation is voluntary and staff anonymity must be maintained. No identifying information
(such as staff’s name) should be collected. Staffs should be selected to reflect a diversity of staffs,
including physicians, nurses, midwives, laboratory/pharmacy/imaging workers and supporting
staffs. The surveyor should not select staffs based on his/her presumptions about whether the
staff appears pleased or not pleased with the working environment.
a) Assign and train surveyors
Selection and training of surveyors should be in accordance with above stated protocol and
should be done well in advance of survey period.
b) Select staffs for survey
Surveyors should be provided with a logbook to record the number of staffs asked to participate
in survey and the number of surveys actually completed by staffs. This is to measure the survey
response rate as well as track surveys.
Staff recruitment should be in accordance with above stated protocol. Surveyor should then
approach the staff to inquires if he/she is interested in completing a staff survey. The surveyor
should explain the purpose of the survey and assure the staff of his or her anonymity. If the staff
does want to participate they must then give their consent verbally before the survey can be
administered.
c) Written completion of survey
The survey should be completed by the staff themselves (written). An ID number should be
assigned to each survey sequentially as it is conducted. The ID should be entered on the survey
form and in a logbook. Surveyors will provide a blank staff satisfaction survey tool to the staff to
be completed by him/her. Staff should complete the survey at the time it is distributed and be
notified of a centralized collection area where they can return their completed survey.
Accordingly, they fill their rating in the satisfaction tool as per the category of their profession.
d) KPI owner calculates Staff Satisfaction rate
At the end of the survey period the KPI owner should collect all completed surveys from the
centralized collection area. The KPI owner should calculate Staff Satisfaction using staff answers
to question on the survey tool. The formula for the indicator is as follows:
[[Total number of “Neutral” responses + Total number of “satisfied” responses] / [total number
of Staff Satisfaction surveys completed x total number of staff satisfaction criteria’s evaluated]] x
100%.
e) KPI Owner reports to KPI focal person and Data Entry Person

After calculating Staff Satisfaction the KPI owner should report all data elements and indicator to
the KPI focal person. The KPI focal person will then check the calculations and enter them into
the KPI report form.
Additionally, all surveys should be given to the appropriate data entry person to enter into the
Access Database. See Appendix 10 for guidance.
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, midwiv pharmacy/ g staffs
specialist es radiology
s) workers
D N A D N A D N A D N A
D = Disagree N = Neutral A = Agree
The hospital clearly
conveys its mission to its
employees.
I agree with The hospital’s
overall mission.
I understand how my job
aligns with the hospital
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
14 Template for Site Visit Brief Document
This template should be used in the preparation phase of the supportive site visit process to provide all team
members with information about the hospital. The site visit leader should complete prepare the document and
distribute it to team members prior to the site visit.
Site visit briefing document:
Hospital Name: Region: Type of Hospital:
Document prepared by: Date of completion:
Section 1: Review of hospital data, reports and information

What data, reports and information have been reviewed? (Tick all that apply)
Hospital response/action plan to most recent site visit
Most recent site visit report
report
Hospital annual report Hospital KPI reports
Hospital Self-Assessment reports on attainment of
Partner reports on hospital
EHSTG standards
Other (please describe)

Section 2: Site visit briefing notes
Summary of action agreed following previous site visit
Enter here a summary of the action that the hospital was expected to take following the previous site visit
(based on the most recent hospital response and action plan)
Describe (if known) whether the hospital has undertaken this action and any issues that remain.
Summary of hospital performance
Enter here a summary of information gathered from the most recent KPI report and EHSTG report
Strengths or successes of hospital
Enter here areas of performance that appear strong based on KPI/EHSTG reports or information gathered
from other sources
Areas of possible weakness
Enter here areas of performance that appear weak based on KPI/EHSTG reports or information gathered from
other sources
Evidence that requires validation
Enter here any data that should be checked/validated during the site visit. For example selected KPI data or
selected EHSTG standards
Areas for investigation
Enter here areas of the hospital that should be investigated during the site visit (based on the information
entered above). This could include follow up on actions that should have been completed following the
previous site visit, or performance issues that have been identified through the KPI or EHSTG reports.
Be sure to include areas that are possible strengths of the hospital so that best practice can also be identified.
Service areas to be visited
Enter here the specific service areas of the hospital that should be visited by members of the site visit team.
This will be based on the information entered above. For example, MR Department, Billing Offices/Finance
Dept, ER Department, Inpatient Wards etc.

Staff members to be interviewed
Enter here the staff members who should be available for interview during the site visit. This should be based
on the information entered above. For example, CEO, SMT, Head of MR, Finance Head, ER Case Team Leader,
IP Case Team Leader etc
Additional information for the hospital to prepare
Enter here any addition information that the CEO should prepare for your visit. If feasible this information
should be sent to the site visit team before the site visit. However if this is not possible then the information
may be presented at the opening meeting of the site visit. For example; patient or staff survey results etc
Enter here any unresolved action from the previous site visit. Include a description of progress made by the
hospital or RHB (if relevant) to resolve the issue.
Section 3: Scheduling
Date of proposed site visit:
Date hospital CEO informed of site visit:
15 Template for Site Visit Report
The following is a template with guidance for preparing a supportive supervision site visit report. It
should be used after conducting a hospital site visit and reviewed by all team members. Once agreed
the report should be sent to the hospital CEO for comments. Once finalized the report should be
distributed to the RHB and all relevant stakeholders.
Cover Page
Should include region, name of hospital, names of site visit team members, date of site visit and date
of report completion
Table of Contents Introduction
This section should include background information about the site supervision process, general
hospital information (hospital level, services offered, catchment population, etc.)
Main Findings
This section should provide a summary of the findings of the site supervision team. It informs readers
of:
- Key findings from the site visit
- Strengths and improvements made
- Areas for improvement
- Overall progress in implementing hospital reforms (EHSTG, BPR, BSC, etc.)
Recommendations
This section should describe any follow up actions the hospital should take based on the findings of
the site supervision team.

16 Conclusion Template for Hospital Response to Site Visit Report
Hospital Name: Region: Date of Site Visit:
Site visit team members:
Hospital response:
Enter here any specific comment you have on the Site Visit Report. State if you accept the findings and
recommendations of the site visit report.
If there are any observations or comments made in the site visit report that you think are inaccurate describe
those here.
Action plan:
Include an action plan that describes:
- The specific action that the hospital will take to address the recommendations made
in the site visit report
- The responsible person for each action
- The timeline to complete each action
Support expected from RHB or other partners
Enter here any support or action that you expect the RHB or other partners to take to assist the hospital to
fulfill its action plan or to respond to recommendations made by the site visit team.
Suggested areas for review during next site visit
Enter here any suggestions you would like to make to the site visit team for their next visit to the hospital.
This could be areas of the hospital that were not reviewed during the current site visit where you would like
to demonstrate good practice, or areas where you would like the site visit team to have better understanding
of the challenges you face.
Any other comments
Enter here any other comments you have. For example, suggestions on how the site visit process could be
improved.

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Federal Ministry of Health

Health Services Quality Directorate

Hospital Performance Monitoring and

Hospital Performance Monitoring and Improvement Manual – October, 2017 1

Hospital Performance Monitoring and Improvement Manual – October, 2017 2

Director, Health Service Quality Directorate

Federal Democratic Republic of Ethiopia Ministry of Health

Hospital Performance Monitoring and Improvement Manual – October, 2017 3

FMOH Led Core Team

Hospital Performance Monitoring and Improvement Manual – October, 2017 4

Hospital Performance Monitoring and Improvement Manual – October, 2017 5

Hospital Performance Monitoring and Improvement Manual – October, 2017 6

Table 1: KPIs reporting hierarchy of public health facilities, 2017.........................................16

Hospital Performance Monitoring and Improvement Manual – October, 2017 8

ANC Antenatal Care

ALOS Average Length of Stay

BOR Bed Occupancy Rate

BPR Business Process Reengineering

CEO Chief Executive Officer

CHAI Clinton Health Access Initiative

CRCPTs Curative and Rehabilitative Core Process Teams

DOTS Directly Observed Therapy (Short Course)

EHSTG Ethiopian Hospital Services Transformation Guidelines

EHMI Ethiopian Hospital Management Initiative

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

HSQD Health service Quality Directorate

HSTQ Health sector transformation in Quality

I-PAHC Inpatient Assessment of Health Care

KPI Key Performance Indicator

Hospital Performance Monitoring and Improvement Manual – October, 2017 9

MCH Maternal and Child Health

NHS National Health Service (UK)

NGO Non-Governmental Organization

OPD Outpatient Department

O-PAHC Outpatient Assessment of Health Care

PNC Post Natal Care

RHB Regional Health Bureau

SMT Senior Management Team (Hospitals)

SEHC Satisfaction of Employees in Health Care

Hospital Performance Monitoring and Improvement Manual – October, 2017 10

Measurement is central to the concept of quality improvement; it provides a means to define

Hospital Performance Monitoring and Improvement Manual – October, 2017 11

1.2 Rational for Revision of the HPMI Manual

Hospital performance monitoring and improvement can be defined as a process by which

Hospital Performance Monitoring and Improvement Manual – October, 2017 12

1.3 Purpose of the Manual

1.4 Target Audience for the Manual

Hospital Performance Monitoring and Improvement Manual – October, 2017 13

1. The establishment, reporting and review of a core set of hospital KPIs;

 Identify relevant  Collection, aggregation  Regular KPI reporting

Continuous Quality improvement process

Public health stakeholders

Hospital Performance Monitoring and Improvement Manual – October, 2017 14

3.1 What are Key Performance Indicators?

3.2 KPIs for Ethiopian hospitals