Ethiopian Hospital Alliance for Quality 4TH

Cycle Audit Tool

Clinical Service Directorate

February 2022
ACKNOWLEDGMENT
Ministry of Health Clinical Service Directorate would like to express its gratitude to all
institutions and individuals involved in the preparation of EHAQ 4th cycle Audit Tool. MOH
appreciates the contribution of EHAQ core team which was instrumental in drafting and
finalizing the entire document. The MOH would like to acknowledge the critical
contribution of each of the individuals annexed.

LIST OF NATIONAL EHAQ Audit tool preparation team

Dr. Hillina Tadesse Biruk Kefelegn

Dr. Abas Hasen Sem Daniel

Biniyam Kemal Desalegn Bayisa

Gezashegn Denekew Esayas Melese

Kasu Tola Dr. Naomi Assegid

Dr. Fekadu Assefa Alemayehu Berhanu

Dr. Ashenafi Beza Ermias Mulatu

Dr. Dawit Yifru Kirubel Eshetu

Deneke Ayele

Hailegabriel Abomsa

ii
INTRODUCTION
Hospitals have always played an indispensable role in the prevention, diagnosis, treatment,
and management of diseases in a given community. Despite the different efforts made, in
Ethiopia, the growing needs of hospital customers added to the disease dynamism requires
renewed commitment and continuous improvement to be properly addressed. Presently,
the hospitals infrastructure and quality service for all service types remain in nascent stages
in most of the regions of the country. In order to meet or exceed customers’ needs, Hospitals
are expected to systematically audit their status and improve their limitations through
consistent quality management system implementation.

Healthcare audit is used to be practiced globally as well as in our country using various
approaches for several years and it is an essential tool for Continuous Quality Improvement
(CQI) and monitoring of evidence-based practice. It is a process used by health care
professionals to assess, evaluate, and improve patient care in a systematic way. The audit
measures current system and practice against a desired standard which aims to ensure a
high quality of care for patients. Quality improvement activity is becoming a day to day
practice by various healthcare workers in different Hospitals.

The purposes of EHAQ audit is to monitor hospitals’ compliance to evidence based care
standards, assess to what degree the standards are met, identify reasons why they are not
met, and develop and implement feasible changes to meet the standards .

Hospitals participating in the EHAQ program are expected to be evaluated against the
requirements set accordingly. This audit will be carried out first by the Hospitals internally
as self-assessment, and once they implement those requirements, they will be audited
externally by trained assessors authorized by the ministry/RHB. The audit checklist is
designed to address the following components of Evidence based practices and section on
Cluster Activity (EHAQ Networking and engagement)

1. Mechanism to avail high quality evidences (Change Concepts 1 &2)

2. Evidence Generation and Utilization (Change Concepts 5, 7,& 8)
3. Focus Service Areas (Change Concepts 4, 6, 9 &10)

3
 4. Patient Preferences and Value (Change Concept 3)
5. Cluster Activity (EHAQ Networking and engagement)

The key customers/stake holders for this initiative are Patients, Hospital leadership, Quality
Management team, Infection Prevention team, staff, and visitors, FMOH, RHB, and
Development Partners. The EHAQ audit tool can be used by all those stakeholders for training,
mentoring, supportive supervision purposes and the national EHAQ audit team uses to
support Hospitals and eventually used to auditing and recognition purpose.

Hence, the EHAQ further provides a learning opportunity for continuous quality improvement
of health care service and helps as an ideal mechanism for identifying and managing
resources effectively and efficiently.

EHAQ AUDIT TOOL OBJECTIVES

The key objectives of the audit tool are:

• To be used as a self-assessment tool by the 4th cycle EHAQ enrolled facilities for gap
identification and improvement planning.
• To be used by by RHBs & MOH as monitoring and mentoring tool during supportive
suepervision and mentroring sessions.
• To contribute to the continuous/progressive Performance monitoring for selecting
regionally and nationally best performing health facilities
• To serve as main reference for Final validation tool.

EHAQ AUDIT TOOL SCOPE

This Audit Tool is designed to be used by the hospitals enrolled to the 4th cycle EHAQ
platform for self-assessment and to address system, practice, and performance towards
quality focusing on evidence based care that included Scope based practice, Standard based
clinical services, Person-centered care, Quality nursing care, Evidence generation and
utilization, Surgical service efficiency and safety, System redesign and EHSTG Boosters,
Efficient use of healthcare resources, Improve neonatal intensive care and Improve

4
Emergency, trauma and critical care. This tool is subject to change based on emerging issues
arising from change of priorities at MOH due to commencement of new initaiations/projects
at hospital level.

This audit tool assesses the 10 Change Packages and Cluster acctivites classified into five
major Components with a number of standards and verification criteria.

S.No Focus area initiative Score 100% (Percentage)

1. Mechanism to Avail High Quality Evidence 60 20.00
2. Evidence Generation and Utilization 84 28.00
3. Focus Service Areas 102 34.00
4. Patient Preferences and Value(Person-centered Care 30 10.00
5. Cluster Activity (EHAQ Networking and engagement) 24 8.00
Total Score 300 100%

AUDIT SCORING
To reach a rating, assesses each requirement and take account of objective evidence. For
each requirement, please circle or make a tick mark as relevant Yes (Y), or No (N) or Not
Applicable (NA), all verification criteria of the item must be satisfactorily present to indicate
“Yes”. Provide explanation or further comments for each “No” or “NA” response. For each
standard, use the verification criteria listed to assess the presence or absence of evidence.
For further information, follow “Auditor’s Quick Guide”. The total audit score will be
calculated as follows:

Total score X 100

Total Audit Score Percentage =
300

5
AUDIT SECTIONS

This audit tool has Seven different sections as described below:

SECTION I: Hospital Information
SECTION II: Mechanisms to Avail High Quality Evidence
SECTION III: Evidence Generation and Utilization
SECTION IV: Focus Service Areas
SECTION V: Patient preferences and Values
SECTION VI: Cluster Activity (EHAQ Networking and engagement)
SECTION VII: Audit Summary
SECTION VIII: Auditors’ Quick Guide

6
SECTION I: Hospital Information
Hospital Information
Date of Audit
Hospital’s name
Hospital Address (Region, Zone/Sub city,
District/Woreda)
Hospital CEO/CED: ____________________
Hospital Medical Director/CCD: ____________________
Contact Information
Hospital Quality Unit Head: _______________________
Tel No. Fax: Email:
Level of the hospital Tertiary General Primary
Staff Profile Number
Specialist
General Practitioner
Nurse
Health Officer

Medical Laboratory Technologist/Technician

X-ray technician
Pharmacy
HIT
Midwives
Others
Name of Auditors Signature
1

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

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

Standard(S) and Criteria(C)

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

C1. The Hospital Has protocol defining facility level/specific • Chech for the availability of the
scope of practice. 2
protocol/ guideline
C2. Scope of practice defined for Different levels of • Check the personnel files of each • Intern and
physicians - 4 levels of care (Intern, GP and Junior residents, category of physician working at the Resindent-not
Senior residents, Consultants) 2 four focus areas (8-10 files) applicable for
• Interview at least 2 staff from each Primary
from each focus area hospital
C3. Scope of practice is defined for Specialists and sub- • Check the personnel files of at least 2
specialists in order to prevent fragmentation of care. 2 Specialists and Sub-Specialists
working at the four focus areas.
C4. Scope of practice is defined for Different level of nurses, • Check the personnel files of at least
midwives and anesthetists based on specialty and years of two professionals from each category
experience. of health professionals working at the
3
four focus areas
• Interview at least 2 staff from each
each focus area
C5. Interdepartmental Consultations are requested by at • Check for availability of
least Senior residents/GP and above. If the required provider Interdepartmental Consultation
level is not available, the client should be seen by the highest Protocol
3
available scope and referred if required. • Randomly check 5 consultations
conducted for each focus area during
the last one year.

8
 • Verify availability of monitroring
system for the implementation of
scope based practice.
S 1.2 Dispose patients to the appropriate scope level by
arranging an emergency and non-emergency triage system 4
based on the EHSTG Standards.
C1. Triage has to be done by at least GPs and above • Check for availability of triage
Protocol
4
• Check letter of assignment for the GP
• Observation of Triage services
S1.3 Client evaluation at the initial point of contact should
8
be by physicians with the appropriate level of scope
C1. Patients referred from other facilities should be seen by • Check this in the scope of practice
protocol
at least 1 step higher professional from referring clinician
• Review charts of 10 randomly
4
selected clients accepted by referral
and verify their were seen by higher
professional
C2. Referral clinics should be covered by the responsible • Observe the schedule of referral
Clinic
specialist or subspecialist 4
• Review Charts of 10 randomly
selected clients seen at referral Clinics
S 1.4 All consultations are carried out by senior residents
9
and above
C1. Based on the hospital tier level all consultation responses • Verify that the interdepartmental
Consultation Protocol includes this.
should be made by senior residents if not available, by
• Review charts of 5 clients for whom
consultants . In a setup where the above aren’t available, the 3 Consultation responses were received
most senior clinician for the setup should respond to the
consultation
C3. Consultation requests, request time, responses & • Verify that the interdepartmental
3 Consultation Protocol includes this.
response time should be recorded appropriately

9
 • Review charts of 5 clients for whom
Consultation responses were received
and verify the times were recorded.
• Check for availability Monitoring
system for adherence to consultation
protocol
C3. All elective surgeries should be done in the presence of • Check for availability of surgical
services protocol and verify that this
the senior physician
is included.
3
• Review randomly selected charts of
10 clients for who elective surgery
was performed.
Sub-total score for Scope based clinical practice /33

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

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

Standard and criteria

Yes/No/NA Score Means of verification Remark
2. Standard Based Clinical Service
S2.1 Prepare adapt or adopt guideline or protocol based on
hospital morbidity and mortality burden of priority focus 10
area
C1. Evidence based Clinical Practice Protocols are prepared • Verify the availability of protocols at
for at least surgical Services, OPD Clinics, Emergency services delivery points of the focus
Services, and Neonatal ICU. areas.
3 • Observe the utilization of the protocols
at each services delivery units of the
focus areas.
• Conduct random Chart review
C2. Protocols/policy/procedures are developed for Rounds, • Check for availability of
Selected nursing procedures, Patient transportation, Bad protocols/policy/procedures for:
news breaking, Surgical scheduling, Standard treatment 1. Patients rounds including bedside
guideline teachings
3 2. Nursing Procedures
3. Patient Transportation
4. Bad news breaking
5. Surgical Scheduling
6. STG
C3. Staff were trained on the protocols and their utilization • Check minute for staff training on the
monitored protocols
• Review Regular clinical audit conducted
on selected diseases condition and
4 apporpiated action plan or
improvement plan was designed

11
S2.2 Avail the established Protocol / STG to Clinical Staff 7
C1. Ensure orientation training is provided to the staff, • Check minute for staff training on the
protocols
• Randomly interview staff working at
4
focus area services
• Observe for the availability of the
protocols at services delivery units.
C2. Protocol is printed and given in booklet form to clinical • Clinician Interview
3
staff • Observation of the booklets availability
S2.3.Monitor the consistent utilization of the clinical
10
protocols
C1. The facility should conduct regular clinical audit to • Selected staff interview
ensure the implementation of STG and Clinical protocols • Check for protocols utilization
at least in the aforementioned focus areas 4 monitoring mechanism
• Verify for findings of utilization
monitoring findigs.
C2. The facility designed Improvement plans based on the • Check the improvement plan
protocol utilization monitoring findings. 6 • Check the for the implementation of the
improvement plan
Sub-total score for Standard Based Clinical Service /27

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

Standard and criteria

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

13
C3. There is timely and complete report of data to • Verify hospital specific report
appropriate body 1 completeness and timeliness in
DHIS2
C4. The PMT Conducts analysis and discussion on data • Review for PMT Minutes and check its
2
prior to reporting regularity
S3.4. There is a regular mechanism to ensure quality of
5
data
C1. Regular LQAS/DQA conducted by the HMIS Team • Review for LQAS/DQA
documentation and check for its
3
regularity
C2. Verified by PMT • Review for PMT Minutes and check its
2
regularity
S3.5 Regular data driven decision making is practiced
6
(2 point)
C1. There is facility specific data analysis. • Check for availability regular trend
1 analysis at each focus area
C2. Facility-based data utilization and institutional QI • Review for available or implemented
project devised based on data findings QI Project
1
• Verify that the QI Projects are linked
to analysis facility-specific data
C3. Data quality triangulation between units • Availability of protocol for
triangulation of selected data
1
• Review for reports on data
triangulation reports
C4. Facility plan is based on in house generated data • Check for annual plan linkage to
facility specific historical
0.5 performance data
• Facility has active strategic plan that
addressed its past performances
C5. The hospital has the mechanism to encourage • Review document for budget
eveidence generation (Gap oriented research) 2.5 allocation.
• Check research report
Sub-total score for Evidence Generation and Utilization 28

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

Standard and criteria Yes/No/ Means of

Score Remark
4. System Redesign and EHSTG Boosters NA verification
S4.1 Establish a triage system which is well equipped • Observation • Check the traiage area with all the
and facilitate one stop triage, registration and cashier • Document review available equipment & supplies
service and accommodate for the needs of highly • Check for the ETAT protocol availability
2
infectious cases and implementation
• Observe for screening and Source
Control
C1. Pre-triage set up screen for highly infectious cases • Observation • Check for availability of pre-triage
and isolate them • Document review screening protocol
0.5
• Observe for pre-triage screening and
isolation services
C2. Diagnostic triage tool kit - BP apparatus, • Observation • Observe the availability those kits at
stethoscope, pulse oximeter, glucometer, weighing 0.5 • Document review triage area
scale • Staff interview for its interruption
C3. Cough corner and cough clinic • Observation • Check for availability protocol for patient
0.5 • Document review channeling to the cough clinic
• Observe the clinic
C4. Adhere to EHSTG guideline recommendation • Observation • There is a central triage.
• Document review • There are personnel trained in triage
processes working in both the central
0.5
triage
• Central triage is equipped with necessary
supplies and equipment.
S4.2 - OPD clinics meets all the minimum standards
2
required for an examination room
C1. Well designed with good lighting • Observation • Observe the OPDs with good premisis &
0.25
lighting

15
C2. Well ventilated and ensures privacy • Observation • Observe the OPDs premisis for having
• Document review adquate windows and doors to be
0.25 opened
• Review the airborn and droplet
precaution protocols
C3. - Well furnished - a table with at least two chairs • Observation • Observe the OPDs with needy furniture
0.25
having atleast one table and two chairs
C4. Well equipped - at least BP apparatus, stethoscope, • Observation • Observe for availability of those
reflex hammer (weighing scare and glucometer at least • Observe equipment
0.25
for department pools) • Document review • Review list of the medical equipments
available at the OPDs level
C5. Hand washing/hygiene facility • Observation • Observe for functionality of hand
• Document review washing basins with water & soap
• Observe the availability of 70% of ABHR
0.25
solution at each of the OPDs
• Review the CASH audit reports on hand
hygine section
C6. Adhere to EHSTG guideline recommendation • Observation • Outpatient department is managed by at
• Document review least a GP and specialty clinics by a
service specific specialist/ sub- specialty
clinic by sub specialist as per hospital tier
0.5
level of care.
• Review for the Human resourse
assignment list & the BPR staffing
standard is met
C7. Adequate OPD waiting area for patients , • Observation • Observe the OPD Waiting Areas
proporational to the number of OPDs and number of 0.25
patients seen per day
S4.3. Early Initiation of Outpatient Clinics and block-
based Appointment System 3
C1. Protocolize - start time, service and academic • Observation • Check for availability of OPD Services
activities to be conducted in parallel, lunch time • Document review Protocol
0.5
service • Patient interview • Observe for services initiation time
• Conduct client interview
C2. Block based appointment system is in place • Observation • Check for appointment schedule
0.5 • Patient interview • Conduct client interview
• Document review • Review for the appointment register

16
C3. Make Clinics functional during lunch/break hour • Observation • Observe for continuity of services at
• Patient interview lunch time
1
• Document review • Conduct client interview
• Review for staff assignment schedule
C4. Divide Clinic work hours based, For specialty • Observation • Observe clinic services
Service to morning and afternoon hours (for general & • Document review • Review Clinic service hours arrangement
0.5
specialized Hospitals) • Patient interview schedule
• Conduct Client indepth interview
C5. Regularly assess patients not seen on same day • Document review • Check for availability of assessment
• Patient interview mechanism (checklist) (refer to the
0.5 appointment register)
• Interview clients not seen on the same
day
S4.4. Hospital has separate Pediatric Wards
composed of separate critical, general, SAM, isolation 2
and procedure rooms.
C1. Established pediatric ward with at least • Observation • Check that the pediatric ward is
Therapeutic feeding room for children with • Document review composed of the following rooms:
complicated SAM, Pediatric ICU or at least HDU for - Therapeutic feeding room for children
critically ill children next to the nursing station, with complicated SAM
Isolation room , procedure room • Pediatric ICU or at least HDU for critically
ill children next to the nursing station
• Isolation room for children with
communicable diseases (in primary
hospitals, this may be shared with
0.25 procedure room for adults)
• Clean, ventilated procedure room with
good light source (in primary hospitals,
this may be shared with procedure room
for adults)

17
C2. All ward room paintings are child friendly • Observation
• Check that the hospital has pediatric
• Document review ward separate from adult ward and
painted in child friendly manner
0.25 Therapeutic feeding room for children
with complicated SIsolation room for
children with communicable diseases
(in primary hospitals, this may be
shared with procedure room for adult
C3. National guidelines and job aids should be readily • Observation • Observe for availability of guidelines and
available 0.25 • Staff interview job aids
• Conduct staff interview
C4. Protocol for rounds and clinical care • Observation • Check for the availability of the protocol
• Document review • Observe that rounds are conducted
0.25
• Staff interview based on the protocol
• Conduct staff interview
C5. Vital signs are measured with stated protocol • Observation • Check for vital sign protocol
0.25 • Document review • Observe its measured as per the protocol
• Staff interview • Conduct staff interview
C6. Growth monitoring is performed for all U5 children • Observation • Review 5 Charts of admitted Patients
admitted to the ward 0.25 • Document review • Observe growth monitoring performed
for at admission
C7. Pain management accordingly practiced • Chart review • Pain management at least for those with
0.25
• Client interview burn, surgery, cancer
C8. Adhere to EHSTG guideline recommendation • Observation • Children admitted to the wards should be
• Document review evaluated by physicians (preferably
pediatricians) on daily basis ( twice per
0.25 day for critical children)
• Critically sick children should be
evaluated by registered clinical nurses
every 4 hours
S4.5 The hospital has a rehabilitation and palliative
1
care service with necessary equipment (2 point)
C1. Integrated or separate rehabilitation and palliative • Observation • Observe for Palliative and rehabilitative
service • Document review clinic
0.5
• Check for Rehabilitative and palliative
care protocol
C2. Established physiotherapy service • Observation • Observe for Physiotherapy services
0.5
• Document review unit/clinic

18
 • Check Protocol above
S4.6 The hospital has a general maintenance center
2
with adequate resources.
C1. Technical personnel, sufficient space and • Observation • Observe the biomedical equipment
adequate ventilation to conduct maintenance and • Document review workshop
repair (e.g., electrical, water, sanitation, sewerage and • Check for availability of Biomedical
0.25
ventilation) and equipment. equipment maintenance protocol
• Adequacy of HR as per the standard
• Staff Interview
C2. Appropriate tools and testing equipment to • Observation • Staff Interview
perform repairs, as well as procedures to ensure the • Document review • Observe for the availability of the tools
0.25
routine calibration of the testing equipment is • Review for the calibration procedure
performed as required
C3. Conducts regular preventive maintenance for all • Observation • Observe the preventative maintenance
facilities and operating systems (e.g., electrical, water, • Document review schedule for major equipments
1
sanitation, sewerage and ventilation) to ensure patient • Check for availability of Preventive
and staff safety and comfort. maintenance protocol
C4. There is a notification and work order system for • Observation • Check for the availability notification
facility and operating system (e.g., electrical, water, • Document review protocol
0.5
sanitation, sewerage and ventilation) repairs. • Observe the requested services
• Conduct user interview
S4.7 The hospital establishes and institutionalizes
Human Resources Information Management Systems 1
(HRIS) that enhance the HR management functions.
C1. The hospital HRIS in place Document review • Check for availability and functionality of
HRIS
1
• Review the randomly selected personnel
file
S5.8 The hospital has a human resource development Document review • Check for the HRIS at the human resource
plan that addresses staff numbers, skill mix and staff 2 department and refer to the BPR staffing
training and development. crirtera
C1. Check Plan address skill mix for short term trainings Document review • Review the HRDP and check for those
(offsite and onsite), long term trainings contents
0.25

C2. Ensure that the plan by HR department addresses Document review • Check for availability of need assessment
staff numbers, necessary budget and training schedule 1 • Verify that the need assessment findings
on the basis of need assessment with departments were used for the HRDP

19
C3. Check the plan approved by GB and SMT Document review • Review the plan and verify that it was
0.25
approved by both GB & SMT
C4 Check whether the plan implemented was Document review • Review the performance review
evaluated or not decrement/report
0.25
• Check for the availability of performance
review plan/schedule
C5. HR Management Manual Document review • Verify that the hospital has HR Manual
0.25
• Check that the following are included??
S4.9 Standardize food and beverage service 2
C1. Establish facility specific menu • Observation • Review the facility specific menu
0.25 • Document review • Observe at one meal is served as per the
menu
C2. Monitoring mechanism is established for assuring • Observation • Observe for the cleanliness of the kitchen
the quality of catering services • Document review • Review the Quality monitoring
0.5 protocol/checklist
• Observe the quality monitoring schedule
• Review quality monitoring report
C3. Establish patient feedback and monitoring • Observation • Review the patient feedback monitoring
mechanism • Document review mechanism/tool
1
• Observe the findings of patient
feedbacks analyzed
C4. Hospital has food and beverage service manual • Observation • Review the Manual
• Document review • Observe that the services delivered as per
0.25
the manual.
• Conduct staff interview
S4.10 Standardize duty room service provision 2
C1. Duty rooms should be gender based not profession • Observation • Observe the duty rooms for both genders
based • Staff Interview • Conduct staff interview
0.5 • Check the duty rooms are near to the
stated service units.

C2. Duty bed should be available to half duty team • Observation • Observe for number of beds and
• Staff Interview compare with number of person on duty
0.5
on average
• Conduct staff Interview
C3. There should be at least desktop computer with • Observation • Observe the availability of Computer with
connection to internet or reference books loaded on 0.5 • Staff Interview connectivity
computer and TV. • Observe for availability of functional TV

20
 • Staff Interview

C4. There should be a water boiler • Observation • Observe that there water boiler
0.5 • Staff Interview (Functionality of Boilers)
• Conduct staff interview
S4.11 Improve functionality of medical
equipment’s by establishing Medical Equipment
3
amintenace center and Implementation of Medical
equipment Management information system.
C1. Protocol - Prioritized medical equipment list with • Document review • Check for the availability of MEMIS
an inspection and preventive maintenance plan • Staff interview • Review for availability of prioritized
0.5
equipment list
• Conduct staff interview
C2. There is a notification and work order system for • Document review • Review the format
0.5
medical equipment mmaintenance request. • Staff interview • Observe for documented formats
C3. Regular calibration and quality assurance programs • Document review • Refer above
for prioritized medical equipment 1 • Staff interview • Interview the MEM personel for having a
history file for MEM
C4. Regular inventory is conducted for medical • Document review • Review inventory report
equipment and history file for each medical equipment 0.5 • Staff interview • Conduct staff interview

C5. Technical personnel, sufficient space and adequate • Observation • Observe the maintenance workshop
ventilation to conduct maintenance and repair of • Document review • Review personnel for technical staff
0.5
Medical equipment(e.g., electrical, water, sanitation, availability
sewerage and ventilation) • Conduct Biomedical staff interview
S4.12 Develop a mechanism/system which
encourages the rational use of medications and
2
stipulates mitigation strategy for irrational use of
medications.
C1. The strategy addresses prioritized drug lists for • Document review • Review the strategy for rational use of
monitoring, problem identification and the need for • Staff interview drugs and review its content
action, identification of underlying causes and 0.25 • Conduct staff interview
motivating factors, list out and implement possible
interventions
C2. Adapt/adopt recommended management guides • Document review • Check the availability of management
with a focus on the selected prioritized health 0.25 • Staff interview guideline
conditions and prioritized drug lists • Conduct staff interview

21
C3. Prioritized drug list should include 2nd/ 3rd line • Document review • Review the prioritized drug list for its
antibiotics, narcotic drugs, other expensive drugs 0.25 • Staff interview content
• Conduct staff interview
C4. Problem-based training on pharmacotherapy is • Document review • Review training documents
0.25
undertaken when indicated/needed • Staff interview • Conduct staff interview
C5. A system to prescribe, dispense and monitor • Document review • Check for the availability of Protocol
appropriate and rational use of the selected and 0.5 • Staff interview • Conduct staff interview
prioritized drugs is established
C6. Adhere to Rational use of Antibiotics and • Document review • Random review of prescription paper
Antibiotics Stewardship Principles 0.5 • Staff interview • Staff interview for awareness on rational
use & AMR principles
S4.13 The hospital Conducts regular clinical
audits and links improvement opportunities to CQI. 3

C1. The Hospitals has clinical audit team. • Document review • Review the TOR of clinical Audit team &
• Staff Interview availability of quality projects on the
• Chart review audit topics
• Established department based audit
0.5 team for general and above , hospital
based audit team for primary hospitals
• Conduct staff interview
• Observe patient charts discussed for
clinical audit
C2. Regular clinical audit is conducted and finding was • Document review • Review the findings of Clinical audit and
presented. • Staff Interview check for regularity as per the TOR
1.5 • Chart review • Conduct staff interview
• Review all charts presented for clinical
audit for the past 3 months
C3. Improvement opportunities identified by audits are • Document review • Check for improvement plans, QI projects
linked with CQI. 1 • Staff Interview linked to clinical audit findings
• Chart review
S4.14 Senior physicians are consistently engaged
in all clinical care activities and decisions which 3
necessitate their involvement.
C1. Daily senior led multidisciplinary round that • Document review • Check for availability multidisciplinary
addresses nursing care, IPC, client education, clinical • Staff Interview round (Grand round) protocol
pharmacy and client satisfaction is made possible 0.5 • Observe at least one multidisciplinary
round

22
 • Conduct staff interview on the conucted
major rounds and grand rounds

C2. Senior physicians are assigned on duty including • Document review • Observe duty schedule for weekends and
weekends and holidays. • Staff Interview holydays
0.25 • Chart review • Conduct staff interview
• Review patient charts seen by senior
physians on weekends and holidays
C3. All new admissions are audited and co-signed by • Document review • Check for availability of such protocol
day time and duty time assigned senior physicians 0.5 • Staff Interview • Conduct chart review
• Chart review • Conduct staff interview
C4. Duty senior physician should make handover from • Document review • Check for the availability of handover
day time senior physician • Staff Interview protocol
0.25
• Chart review • Conduct chart review
• Conduct staff interview
C5. Weekly senior chart round practice is implemented • Document review • Review weekly chart review schedule
and identified gaps are linked with CQI. • Staff Interview • Check for the status of QI linked to Chart
0.5
• Chart review review finding
• Conduct staff interview
C6. Chart round should address clinical evaluation and • Document review • Review for the availability chart round
decision process, use of an appropriate and justified • Staff Interview checklist and verify that it includes those
work up, rational use of drugs, nursing care • Chart review contents
0.25 • Conduct staff interview
• Review for the clinical pharmacy
medication care plan with in the patient
chart
C7. Quality improvement projects led by senior • Document review • Review QI Project documents and
physicians are undertaken • Staff Interview identify role of senior physicians
0.5 • Chart review • Check for those patient charts suggested
for QI project reviewd with senior
physians
C8. Engagement of senior phusians in clinical audit • Document review • Review documents for clinical audit
• Staff Interview training report
0.25 • Conduct staff interview assigned focal on
the clinical audit

23
Sub-total score for System redesign and EHSTG Boosters 30

24
 Section III (c). Efficient use of healthcare resources Audit tool
Description: Efficiency is one of the healthcare quality dimensions, related to avoiding waste including waste of equipment,
supplies, ideas, and energy. The Health Sector Transformation Plan has prioritized three main causes of inefficiencies:
procurement; supply chain management; and, health human resource.

Standard and criteria Yes/No Means of Remark

Score
5. Efficient utilization of healthcare resources verification
S5.1 Explore options to strengthen and outsource clinical and
5
non-clinical services (including the supply chain management)
C1. Outsourced Non-clinical Services • Document review • Review outsourcing documents
• Staff interview and visit the unit
2.5 • Interview at least 1 staff from
each focus area and atleast two
Senior management members
C2. Explore options for outsourcing clinical service( Eye care, ENT, • Document review • Review documents/Minute for
Pathology, Radiology, dialysis etc) based on needs • Staff interview outsourcing clinical
services/efforts
2.5
Interview at least 1 staff from
each focus area and atleast two
Senior management members
S5.2 - Implement different staff incentive and recognition
10
mechanism for enhancing efficiency and effectiveness
C1. Transparent staff incentive and recognition system is in place • Document review • Review the staff incentive and
• Staff interview recognition procedure/guide
6
• Interview at least 1 staff from
each focus area
C2. Benchmarking of staff incentive mechanisms are undertaken • Document review • Review the source documents for
• Staff interview staff incentive guide
• Review implementing guide,
minute
• Interview Interview at least 1 staff
4
from each focus area and all
Senior management members

25
S5.3. Assess sources of inefficiency in procurement, human
6
resource for health and supply chain.
C1. Prioritized mitigation measures are developed and the • Document review • Review the document of
progress is continuously monitored. • Staff interview efficiency assessment
• Review efficiency monitoring
2
system
Interview atleast 1 staff from each
focus area
C2. Identified gaps are linked to CQI. • Document review • Check the status of QI Project
4
linked to improving efficiency
S5.4. Enhance transparent, accountable and sound resource
5
utilization and financial tracking management system
C1. Harmonization of planning, budgeting and budget • Document review • Review the plan document for
execution processes, including producing and disseminating the • Staff interview harmonization
required financial and audit reports 5 • Review response actions on
financial audits
• Interview atleast 1 staff from each
focus area
Sub-total score for Efficient use of healthcare resources 26

26
Section IV Focus Service Areas (34%)

Section IV (a). Quality Nursing Care Audit tool

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

Standard and criteria

6. Improved Quality of Nursing Care Yes/No Score Means of verification Remark
S6.1 Nursing care protocol and procedure prepared for prioritized
3
health conditions
C1. Have a nursing care protocol known and adhered by the • Check for availability of nursing care
nursing staff protocol
1 • Selected staff interview
• Check for Availability of adherence
monitoring mechanism and its findings
C2. Key Nursing Procedures ( IV line securing, NG-Tube insertion • See protocol above
, Catheterization etc.) and do regular KAP assessment 2 • Review for KAP assessments conducted
and actions taken.
S62 Regular nursing care audit and identified gaps linked with
QI project 5

C1. Establish nursing care round and audit team with TOR • Check for availability of nursing round
0.5 protocol
• Check for the nursing audit team TOR
C2. Audit should address the implementation and quality of • Verify that the Nursing Audit Protocol
nursing process, patient monitoring, pain management, addresses these topics
medication administration and client education (Audit against the 0.5 • Review the findings of nursing audit for
standards set under S3.1) these contents
C3. Regular performance report review (Every month) involving • Check for monthly performance report
key stakeholders 2 • Check for monthly performance review
minutes
C4. Data driven QI projects conducted based on identified gaps • Check for QI Projects linked to gaps
2 identified during Performance reviews
• Verify the status of the QI Projects

27
S6.3. Conduct daily nursing round (prepare round packages -
Emergency preparedness, shift handover, attendance, dressing 5
code adherence, cleanliness etc.)
C1. Daily nursing round is conducted (1 hour vs 3 hrs. nursing • Inclusion of these in nursing round • Docume
round for 4P‟s,) protocol nt
• Conduct chart audit on randomly Review
1.5 selected clients at IPD, Emergency • Observa
tion
• Chart
review
C2. Shift handover is properly executed and documented to • Check for availability of shift handover • Docume
assure continuum of care protocol nt
1.5 • Verify handover docuementation at the Review
four focus areas. • Observa
tion
C3. The nursing staff adhere to the code of conduct including • Chech for the availability of nursing code • Docume
dress code, cleanness and IPC practices. of conduct nt Revie
1 • Observation for cleanliness • Observa
• Staff interview tion
• Client interview
C4. Nusrse prepared daily round package and emergency tables • Observe for daily round package and • Observa
emergency tables tion
1 • Check for availability round package and • Docume
emergency table preparedness protocol. nt
review
S6.4. Implement ICU nursing care packages as per the standard 3
C1. Protocolize - ICU nursing care package with their indications • Check for availability of ICU nursing care
and implementation requirements 0.5 package/protocol
• Conduct Client Chart audit
C2. The package should at least address V/S and fluid balance 0.5 • Review the package/protocol for these
monitoring requirements, enteral nutrition, GI prophylaxis, DVT contents.
prophylaxis and medication administration • Conduct client Chart audit
C3. ICU nursing care packages Implementation evidences - client • Review Clients’ charts for inclusion of the
chart formats should be adopted/adapted for documenting all charts as per the package
nursing care services provided to the client 2 • Conduct selected staff interview for their
awareness of the formats
S6.5 Established a skill Lab and regular need based capacity
5
building for nursing staff

28
C1. Established a skill Lab • Observe for availability of clinical skill lab
• Check for the schedule for the utilization
2 of the skill lab.
• Review the skill lab register

C2. Conducted Regular capacity building based on identified gaps • Check for availability of skill gap
assessment
2 • Need based capacity building plan
• Documentation of capacity building
Performance
C3. Participating in MDT meeting, round, audit, and research • Capacity building protocol/ guide
(protocol and document) 1 • Attendance verification mechanism
• Review Meeting minutes
S6.6 Standardizing nursing stations 3
C1. Availability of Nursing station 0.5 Observation
C2. Location of the nursing station easily accessible for patients 1 Observation
C3. There should be a reception service available at nursing Observation
0.5
station
C4. There should at least be 1 desktop available at nursing • Observe for the functionality of the
station with important information on patient admission and 0.5 desktop computer
status in the wards
C5. There should be a TV , health education material and • Observe for functionality of the TV.
different protocols available at the nursing station • Observe for availability of the
0.5
aforementioned protocols
• Conduct staff interview
S6.7 Patient preference included in decision making 3
C1. Patient clearly understand the diseases process • Check for the availability of patient
orientation protocol
• Review clients’ chart for Documentation
1
of patient orientation in their chart
review
• Conduct Patient interviews
C2. Involvement in care plan, intervention, expected discharge • Verify that these are included in the
planning, estimated cost, and expected outcome 2 patient orientation protocol
• Conduct Patient interviews
Sub-total score for Cleanliness of ca Quality Nursing Care 26

29
Section IV (b). Surgical service efficiency and safety Audit tool
Description: Access to Emergency and essential surgical care (EESC) is one of the prioritized global initiatives with the aim
of improving access to safe, affordable and timely care for the population.

Standard and criteria

Yes/No Score Means of verification Remark
7. Surgical service efficiency and safety
S7.1 Standardize OR efficiency and the minimum
6
productivity per table
C1. The hospital has the minimum number of table • Observation
is as per the requirement of hospital tier level • 1 for primary hospital
0.5
• 4 for general hospital
• 7 for specialized hospital
C2. The hospital conducts a Minimum of 3 cases per 1 • Document review OR
table per day register review
1 • Triangulate the table
output with hospital
backlog
C3. The hospital starts first case incision before 8:00 Document review OR register OR schedule
am for elective surgeries. review Observe the time of surgery
1 initiation for elective cases
from patient chart/ anesthesia
sheet.
C4. The hospital Turn around time b/n cases 20 Document review OR register Review Elective surgery
minutes and has a mechanism to monitor adherence review Protocol
to the time Chart audit Randomly select two
0.5 consectative elective surgery
sechdules ; check the first case
end time and second case start
time from the patien charts.
C5. 2-3 shift implementation - Morning, afternoon Document review OR register Observe OR Schedule
0.5
and private wing review
C6. The hsospital has a customized Format and Document review OR register Schedule communication
schedule notification system for head nurse and review formats
1
scrub nurses (prior preparedness for adequate drape
and required instruments and suturing materials)

30
C7. Regular monitoring mechanism linked with • Check the status of QI
quality improvement project Project on improving OR
efficiency
1
• Verify that the QI Projects
are derived from regular
performance Monitoring
C8. Elective surgical service productivity - >90% of • Compare plan versus
the initial performance plan 0.5 performance for the last
two years
S7.2 - Establish OR patient preparation unit 1
C1. Established OR patient preparation room Observation Observe floors ,walls and over
all physical structure of the
1
OR patient preparation room
for cleanliness
S7..3. Implement measures to reduce cancellation 4
C1. Establish multi-disciplinary preadmission • Observation • Check for availability of
evaluation clinic ( including anesthetic evaluation ) • Document review Pre-admission evaluation
• Patient interview protocol
• Check pre-operative
format is attached and
recorded before
admission (5patients
• Check all investigations
are done at list a day
before elective surgery
1
admission
• Check consent-form is
signed before surgery day
• Check all pre-operative
preparation is done
(Abdominal preparation,
Prophylactic drugs and
counseling) before surgery
done
• Interview 5 patients
C2. The hospital has Standardize preoperative • Observation • Check for availability of
evaluations and work-ups 0.5 • Document review pre-operative workup
• Patient interview protocol

31
 • Randomly check for 10
patient charts
• Chech for availability and
utilization of peri-
operative checklist for
nurses
• Interview 5 Patients
C3. Regular monitoring mechanism linked with • Observation • Check the status of QI
quality improvement project • Document review Project on reducing
• Patient interview cancellation
1.5
• Verify that the QI Projects
are derived from regular
performance monitoring
C4. Tthe hospital conducts a multidciplinary per- • Document Review • Verify the schedule for
operative conference a day before surgery to • Staff Interview Peri-operative Conference
1
finilize patient preparartion plan before scheduling • Conduct surgical staff
inteview
S7..4. Standardize and monitor pre-elective and
1
postoperative hospital stay
C1. Protocolize - Preoperative and postoperative Document review • Check for availability of
hospital stay Protocol on Pre- and Post-
0.5
operative hospital stay

C2. Regular monitoring mechanism linked with Document review • Review for hospital stay
improvement and/or accountability mechanisms monitoring mechanism
0.5
for the identified gaps. • Check for actions linked to
monitoring findings
S7..5 Establish surgical governance and
3
management structure that ensures team functions (2 point)
C1. OR led by OR director • Document review • Observe for letter of
0.5
• Staff Interview assignment
C2. Department specific teams - for multi-specialty • Document review • Check for department
hospitals 0.5 • Staff Interview specific team
• Conduct staff interview
C3. The hospital has a daily team briefing and • Document review • See briefing and
debriefing at the bigning and end of the OR day. • Staff Interview debriefing protocol
1 • See documetentions of
feedbacks and action
plans

32
C4. Daily OR director and coordinators monitoring • Document review • Check for trend analysis
mechanism linked with quality improvement project • Staff Interview linked to improvement
1
and/or accountability mechanisms for the identified actions
gaps • Conduct staff interview
S7..6 Establish Day care surgery unit and ensure its
2
active functioning
C1. Protocolize - define day care surgery clinical • Observation • Check for availability of
conditions for each department and ensure • Document review day care surgery protocol
necessary infrastructure • Staff interview • Observe infrastructure for
day care surgery (define)
2 • Conduct staff interview
• Register review for
number of patients who
get access to day care
surgery
S7..7 Regular performance audit and identified
gaps linked with QI and/or accountability 4
mechanisms
C1. Regular performance report review (at least • Document review • Check for performance
every two weeks) involving key stakeholders • Minutes review minutes and its
• Action plan regularity(SaLTS
• Implementation reports, committee )
2 • Project documents • Review bi-weekly
performance report
document
• Improvement Plan liked to
performance review
C2. Data driven QI projects conducted based on • Document review • Status of QI Projects
identified gap • Minutes • Minutes on QI Project
2 • Action plan decision
• Implementation reports, • Review QI Project
• Project documents document
S7..8 The hospital Regularly follows adherence
to WHO SSC and identified gaps linked with QI 2
and/or accountability mechanisms

C1. Regular audit conducted for the completeness Chart review • Check for SSC Audit
1
of SSC protocol

33
 • Check for availability of
SSC audit report and its
regularity
C2. Regular mechanism of implementing a direct Chart review • Randomly review 10 Client
observation in the Operating theater for adherence 1 charts for completeness of
to the SSC SSC
S7..9 Established system of SSI tracking and
3
intervention to reduce SSI
C1. Institution integrated the SSI registers in service • Document Review • Check for availability of SSI
areas and monitor utilization • Staff Interview Register at major OR and
• Chart Review C/S room
0.5 • Randomly review client
charts and triangulate with
registers
• Conduct staff interview
C2. Establish a system of close follow-up for sign • Document Review • Check for availability of SSI
and symptoms of SSI for each patient ( WHO SSI • Staff Interview Protocol
checklist, wound assessment and documentation on • Chart Review • Conduct staff interview
charts for every patient) • Chart review( utilization of
1 WHO SSI surveliance tool
in the charts , check
documentation of surgical
wound condition in eacha
chart
C3. Mechanism established for SSI tracking After • Document Review • Verify that these are
discharge • Staff Interview included in the SSI
• Chart Review protocol
1.5 • Check documentation for
outpatient follow-up for
SSI
• Conduct for staff interview
Sub-total score for Surgical service efficiency and safety 26

34
Section IV (C). Improve neonatal intensive care Audit tool
Description: Improving the Neonatal ICU service is one of the critical areas that will reduce morbidity and mortality of
neonates in a hospital setting and beyond. Additionally, NICU care for a hospital setting shows the quality of care and it is
by far the known litmus of better organizational function.

Standard and criteria

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

35
C3 - Regular monitoring of services provided on 2 • Check minutes for Regular performance
protocols adherence review meetings (3 months)
• Staff Interview for the presence of regular
meeting
S8.3. Perform continuous clinical audits for NICU care 7
services and link with QI for the findings
C1. Perform clinical audits on NICU services 3 • Check Documents for performed clinical Expected at
audits in NICU in the last 6 months least 2 audits
C2. Perform Quality improvement projects for NICU care 2 • Check approved QI in NICU service Expected at
services improvements in the last 6 months least 1 QI
C3. Documented or Published QI in NICU service 2 • Check for availability of documented or
published QI in NICU services
S8.4. Implement Neonate and Family centered care 4
C1. Establish a family counseling corner 1.5 • Observe if the facility assigned a corner or
room for neonatal family counseling
• Neonates parent Interview for practice of
counseling
C2. Monitor family participation in decisions making 2.5 • Check 5 random charts for presence of
starting from evaluation to discharge process parent engagement in the decision making
• Parent interview
• Staff Interview on their practice of
engaging parents

Sub-total score for Improved neonatal intensive care 26

Section IV (d). Improve Emergency, trauma and critical care Audit tool

36
Description: Emergency, injury and critical care system is a spectrum of activities including prehospital care and
transportation; initial evaluation, diagnosis and resuscitation; in hospital care (emergency units and Intensive care units
(ICU)) as well as referral system to deliver time sensitive health care services for acute illness and injury across the life course.

Standard and criteria

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

37
C2. Upgrade facilities to meet ICU standards • Check for plans of upgrading ICUs to meet
national standards
• Check equipment availability and
2
functionality in ICUs.
• Staff Interview on capacity building
conducted
C3 Ensure adherence of ICU admission, treatment and discharge • Observation: Check for availability of ICU
protocols protocols
• Check clinical rounds adhere to the protocol
3
• Document review: review charts to check
adherence.
• Staff interview
S9.3. Avail protocols and guidelines for Evidence based
emergency, injury and critical care and adhere to protocols of 4
services
C1. Ensure availability of standard Protocols and guidelines for • Documents Review: Check for the availability
referral, triage, burn, poisoning, trauma ED ICU services 1 of protocols and guidelines.
• Staff Interview
C2. Ensure adherence to guidelines and protocols • Check charts to Verify the use of guidelines
and protocols in Clinical practice at services
3 delivery points
• Observe the utilization of the protocols in
EDs and ICUs.
S9.4. Use of standardized registries to capture a reliable data for
4
evidence-based decisions
C1. Implementation of the WHO trauma registry • Documents Review: Check for availability of
trauma registry
• Chart review: Review charts of randomly
2 selected patients to verify the trauma registry
is filled
• Staff Interview
C2. Availability of the revised ICU, Emergency, Liaison referral • Documents Review : Check for availability of
and ambulance service registers. registries
2 • Staff Interview
• Chart review: Review charts of randomly
selected patients to verify that the registries
were filled properly
S9.5 Perform clinical audit for selected conditions, used to inform
5
QI projects

38
C1. Continuous quality improvement for EICC services • Staff interview: Check if clinical audits are
conducted
• Documents: Check the clinical audit findings
5
• Documents: Check if a QI project on EICC has
been designed, Review QI project plan
• Observation: Check status of QI project
Sub-total score for Improved Emergency, trauma and critical care 24

39
Section V. Patient Preferences and Value Audit tool
Description: Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring
for persons of all age groups. Person-centered care is an approach to meet these aims in such a way that assures the privacy
of individuals’ health and life goals in their care planning and in their actual care.

Standard and criteria

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

40
C2. Local language use is advised • Observation • Observe and check the presence of
1 active mini media for health
education.
C3. Audio visual Health education material is • Observation • Randomly select contact number of
recommended 2 clients/patients from the register
2 of the four focus areas, and then call
and ask if they received all the
necessary information
S10.3. Comprehensive Information provision is
4
delivered entirely and consistently
C1. Information provision should address clinical • Client interview • Conduct client interview
diagnosis, treatment options and plan, subsequent • Phone call interview
1
follow up scheme and parameters, expected life style
modifications
C2. Patient preference was heard in treatment options • Client interview • Randomly select contact number of
• Phone call interview 2 clients/patients from the register
1 of the four focus areas, and then call
and ask if their preferences were
heard during their care
C3. Mechanism established to address patient and • Client interview • Randomly select contact number of
family concern • Phone call interview 2 clients/patients from the register
of the four focus areas, and then call
2 and ask if all their and their concerns
were addressed.

S10.4. Practice patient discharge planning 4

C1. Hospital established a protocol for discharge • Observation • Check the presence of a protocol
planning • Document review detailing the discharge planning.
• Client interview • Randomly ask 2 ward nurses from
0.5 • the four focus areas and ask them
about the discharge planning
protocol.

C2. Create and standardize discharge plan format for • Observation • Observe the discharge planning
selected diseases based on hospital morbidity and • Document review format.
0.5
mortality • Client interview • Check the presence of the format at
least in the wards of the four focus
areas.

41
 • • Randomly select 2 (from each of the
C3. Attach discharge plan on every patients admitted • Observation focus areas) medical record numbers
• Document review of patients that have already been
1
• Client interview discharged from the admission and
discharge register and check the
presence of the copy of discharge
plan.
C4. Regular monitoring mechanism in place to assess • Observation • Interview head nurses in the four
the practice • Document review focus areas and how they monitor
• Client interview the implementation of discharge
2
planning.
• Review self-assessment
documents/reports
S10.5 Regular Client awareness and knowledge audit
5
and identified gaps linked with QI projects (2 point)
C1. Design mechanism to assess the awareness and • Document review • Check for availability of
knowledge audit. • Client interview mechanism to assess awareness and
knowledge of the client on their
1.5
specific case
• Conduct random Client interview in
the four focus areas
C2. Regular performance report review (at least every • Document review • Review bi-weekly performance
two weeks) involving key stakeholders report document
• Improvement Plan liked to
1.5
performance review
• Check for two weeks performance
review minutes
C3. Data driven QI projects conducted based on • Document review • Check for QI Projects linked to gaps
identified gaps identified during Performance
2
reviews
• Verify the status of the QI Projects
S10.6 Control pain for all emergency, outpatient and
3
admitted patients
C1. Establish pain clinic or integrate to the existing • Document review • Verify the availability of pain
all the service delivery points • Client interview Clinic/Practice at all services delivery
0.25 • Observation points of the focus areas.
• Observe the pain clinic
• Client interview

42
C2. Prepare/adapt pain management protocol • Document review • Check for the availability of pain
• Client interview management protocol
0.25
• Observation • Conduct staff interview on the
utilization of the pain protocol
C3. Pain assessed in a regularly as 5th V/S, Integrate • Document review • Observe for availability of pain
documentation with the existing V/S sheet • Client interview assessment regularity, Tally sheets
• Observation and reporting formats
0.5
• Review Clients’ charts for inclusion of
the charts as per the package
• Conduct random Client interview
C4. Pain managed accordingly (According to • Document review • Conduct Chart review and verify the
prepared protocol) • Client interview management was as per the
1
• Observation protocol
• Conduct Staff interview
C5. Advocate pain management through use of • Document review • Check the availability of pain
different methods -“Zero tolerance for pain” posters in • Client interview management posters at wards and
all wards and rooms, 0.25 • Observation rooms
• Client interview.
• Conduct Staff Interview
C6. Address clients with chronic pain and those • Document review • Observe for chronic pain and
requiring palliative care • Client interview Palliative care clinic
0.5
• Observation • Check for chronic pain and Palliative
care clinic guideline/protocol
C7. Assign focal person for pain management • Document review • Check letter of assignment for the
• Client interview pain management focal person
0.25
• Observation • Review the Job description of the
focal person
S10.7 Regular audit for adequacy of pain control and
2
identified gaps linked with QI projects
C1. Regular performance report review (at least every • Document review • Review bi-weekly performance
two weeks) involving key stakeholders report document
• Improvement Plan linked to
1
performance review
• Check for two weeks performance
review minutes
C2. Data driven QI projects conducted based on • Document review • Check the status of QI Project linked
1
identified gaps to improving efficiency

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S10.8 The hospital has established hospital based
social service which addresses the psycho-social care 4
needs of clients
C1. Establish or strengthen a social service unit • Document review • Check for the availability of social
1
service unit
C2. Has a guideline/ protocol for the functions • Document review • Check for the availability and
1 utilization of social service
protocol
C3. Regular audit conducted and improvements made • Document review • Review for the social services audit
reports and its recommendations
2
• Review the actions taken based on
the Audit findings
Sub-total score for Person- centered care 30

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

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

CLUSTER ACTIVITY (8%)

Note: all standards will apply for all hospitals except standard 1& 2 which will be used only for Coordinator
hospitals Audit.
11. AUDIT TOOL FOR CLUSTER ACTIVITY AND COMMUNITY ENGAGEMENT- Total score -8.60%
Yes /No Score Data Source Remark
S11.1. Clusters have regular meeting 8
C1. There is approved TOR and shared with all members of the Check approved TOR document
1
cluster
C2. There is agreed activity plan and performance report for Check approved plan activity
1
cluster. Performance report
C3. Cluster regular meeting is conducted, recorded and Check the meeting minute at least three every
follow-up action plan is developed 3 three months
Interview technical expert
C4. Best practices are documented and shared among Check availability of documented best
member hospitals 3 practices
Interview member hospitals
S11.2. Cluster conducts regular mentorship and
supportive supervision 8

C1. Lead hospital conducted regular mentorship or supervision Document review

3
to member hospitals. Interview member hospital
C2. Regular feedback is given to member hospitals Check availability of written received feedback
2
Interview member hospital
C3. Lead hospital regularly monitored member hospitals Check performance report
2
cluster performance Interview member hospital
S11.3. Community discussion panel 5

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C1. Quarterly community forum is conducted Check the minutes
2
Interview community representative
C2. Community forum action plan developed, communicated Check the action plan and performance report
3
and implemented Interview community representative
S11.4. Hospital to health centers support 5
C1. Hospital conducted regular mentorship or supervision to Check performance report
1
catchment Lead health centers. Interview Lead health centers
C2. Hospital regularly monitored performances of Lead Check performance report
1
health centers Interview Lead health centers
C3. Hospital regularly supported Lead health centers with Any evidence of support (e.g Letter, model
human resource, medical equipment and supply 2 invoice)
Interview Lead health centers
Total score for cluster activity 24

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SECTION VII: AUDIT SUMMARY
Noted Challenges

Noted Recommendations

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Section VIII: Ethiopian Hospital Alliance for Quality (EHAQ) 4th Cycle
Audit
Auditors Quick Guide
1. Pre-Audit
a. Site specific audit plan prepared
b. Establish central coordinating team
c. Form audit team at national level
d. Logistics preparation and communication
e. Training on audit process and tool for the selected audit team
f. Pre-opening Meeting- Audit team leader ensure that EHAQ audit team has
site-level verification checklist/audit tool and supplementary materials (In
the form of Hard copy and Soft copy).
g. Opening meeting-detail brief on the overall audit process with the
Management team
2. During Audit
a. Apply Audit techniques as follows: Auditors complete this audit using the
following methods to evaluate the verification criteria under each standards:
i. Interview: interview health care professionals, administrative staff and clients
when applicable
Note: Ask open ended questions to clarify documentation seen and
observation made by asking questions like “show me how...” or “tell
us about….”
ii. Document review: review the necessary/applicable documents to verify that
Guidelines, Manuals, SOPs are complete, current, accurate, and periodically
reviewed.
iii. Record review: review implementation evidences such as patient
card/charts, Protocols, guidelines, maintenance record, reports, improvement
records, registers/logs, and survey and inspection records retrospectively with
the defined time frame. Write deficiencies and non-conformities identifies are

48
 adequately reviewed, investigated and resolved/corrective action taken
within established time frame.
iv. Visual observation: observe the hospital operation process to ensure that it
follows written guidelines, policies, procedures. Write deficiencies and non-
conformities identified are adequately investigated and resolved within
established time frame.
b. Consider the following definition of terms during the audit
i. Adequately: satisfactory or acceptable in quality or quantity against a
reference measurement
ii. Regularly: with a constant or definite pattern or a uniform interval of time
iii. Properly: correctly or satisfactorily or exactly against a reference
measurement/standards.
iv. Random: selected without method or conscious decision
v. Observe: active acquisition of information from a primary source or it
involves the perception and recording of data using data sources/indicators.
vi. Interview: meeting/asking individuals/team face to face
vii. Verify: make sure or demonstrate that the evidence is true, accurate, or
justified
viii. Effective communication: when the information communicated between
hospitals accurately transferred, received and interpreted.
ix. Monitoring system: a system used to monitor activities and performances
routinely
x. Preventive Maintenance: a type of maintenance performed in a scheduled
manner regularly before any failure happened
xi. Corrective/curative Maintenance: a type of maintenance performed by
service engineers or trained personnel after failure is noted and reported
xii. Functional and Consistent Operation: is an indicator for a system,
instrument, software, or utility working as intended to be without interruption
or failure

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 xiii. Availability: the required item is being able to be used or obtained or
accessed
c. Scoring
i. EHAQ Checklist contains main sections, standards and verification criteria.
Each item has been awarded specific point value based upon relative
importance and/or complexity.
ii. To give score, assess each requirement and take account of objective
evidence. Please circle or make a tick mark as relevant Yes (Y), or No (N) or
Not Applicable (NA)
iii. Items marked “Yes” receive the corresponding point value. All elements of a
question/verification criterion must be satisfactorily present in order to
indicate “yes” for a given item and thus award the corresponding points.
iv. Items marked “No” receive 0 point.
Note: When marking “No”, notes or explanation should be written in
the “Remark” field to explain why the hospital did not fulfill this
requirement to improve the hospital by addressing these areas of
identified need following the audit.
v. The total audit score will be calculated as follows:
Total score X 100
Total Audit Score Percentage =
300
vi. Where the checklist question does not apply, indicate as “NA”. Subtract the
sum of the scores of all questions marked “NA” from the total of 1000. Since
denominator has changed, the overall score is then determined using %
score.
3. Post-Audit
a. Pre-closing Meeting: Audit team gathers and evaluate the process and
ensure the Audit is completed (verify the completeness of audit checklist,
analyze and reach to conclusion) as per the plan through the audit team
leader chairmanship.

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 b. Closing Meeting: Conduct closing meeting with the Management. The
main purpose of the meeting is to acknowledge the cooperation and
participation of the Hospital throughout the audit process. Note that in this
meeting there must be finding disclosure.
c. Compile, sign, pack, and submit the report to the central team.
4. Guiding Principles
a. Confidentiality
b. Emotional intelligence
c. Clear and precise communication
d. Respecting auditee
e. Professional judgment
f. Integrity
g. Objectivity
h. Punctuality
i. Denying any gift

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