1. Yale School Ethiopian Federal Ministry William J. Clinton
of Public Health of Health foundation
Ethiopia
Hospital
Management
Initiative
Blueprint
Standards
for
Hospital
Management
in
Ethiopia
CLINTON
FOUNDATION

2. 1
Ethiopia
Hospital
Management
Initiative
Blueprint
Standards
for
Hospital
Management
in
Ethiopia
Ethiopia Federal Ministry of Health
Yale School of Public Health
William J. Clinton Foundation

3. 2
Published by
Yale Reprographic and Image Services
155 Whitney Avenue
New Haven CT 06511
USA
Blueprint for Hospital Management in Ethiopia and the accompanying Standards for Hospital
Management are subject to copyright © by Yale University and William J. Clinton Foundation.
This document has been developed for use by
the Ethiopia Hospital Management Initiative (EHMI).
Printed in New Haven, CT, United States of America, 2007
Editors
Josh Pashman, Erika Linnander and Martha Dale
Correspondence
Elizabeth H. Bradley, PhD
Professor, Department of Public Health
Yale School of Medicine
60 College Street
New Haven CT 06520-8034
USA
Tel. 203.785.2937
Fax. 203.785.6287
Email: Elizabeth.Bradley@yale.edu
Yale School of Public Health William J. Clinton Foundation
Yale University 55 West 125th
Street
60 College Street New York, NY 10027
P.O. Box 208043 USA
New Haven, Connecticut 06520-8034
USA
publichealth.yale.edu www.clintonfoundation.org
Federal Ministry of Health
Federal Democratic Republic of Ethiopia
Lideta Subcity, Sudan Street
P.O. Box 1234
www.moh.gov.et

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Standards for Improved Hospital Management
Human Resource Management 4
Governing Boards 5
Patient Flow 5
Medical Records Management 6
Nursing Standards and Practice 6
Infection Prevention Policies 7
Pharmacy Inventory and Warehouse Management 8
Global Budgeting and Financial Management 8
Equipment Management 9
Facilities Management and Safety 9
Laboratories 10
Referrals between Facilities 11
Other Service Unit Standards 12

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EHMI Blueprint Standards for Hospital Management
June 28, 2007
These Standards are consistent with the Blueprint Document for Hospital Management
in Ethiopia, which provides greater detail on guidelines and approaches to meeting
these Standards. In addition, several categories (equipment management, facility
management and safety, laboratories, and referrals between facilities) have been added
in order to provide a more comprehensive set of hospital operating Standards.
Human Resource Management
1.1. The Hospital has a Human Resources Department that maintains a personnel file
for each hospital employee.
1.2. Human Resources Department provides services to employees to ensure
satisfactory productivity, motivation, and morale as evidenced by effective
policies and procedures for personnel recruitment, retention, compensation,
training, and employee relations.
1.3. A representative of the Hospital’s Human Resources Department is on the
Hospital’s senior management team/committee.
1.4. The Human Resources Department has an operations manual that includes all
personnel policies, including policies for work schedules, hiring procedures, new
employee orientation, compensation, benefits and payroll information, workplace
injuries, and performance review, evaluation, and management.
1.5. Based on the Human Resources operations manual, Hospital Management has
responsibility for recruiting, hiring and retaining staff, utilizing performance
management to reinforce high performance or improve substandard
performance. Corrective action and performance rewards will be undertaken
using the performance review process, as specified in Human Resources
operations manual.
1.6. Job descriptions are developed collaboratively with the Human Resources
Department and Hospital department directors for all positions.
1.7. The Hospital has a performance management process for its personnel in which
all employees are formally evaluated at least annually and action plans for
improved performance are documented.
1.8. The Hospital has a new-hire orientation program and on-going training and
development programs for employees.

6. 5
Governing Boards
2.1. The Hospital Governing Board is developed using clear and transparent policies
and includes a representative sample of community members.
2.2. There is a qualified Board Chairperson that leads and manages the Board.
2.3. The Board has open communication via effective and regular meetings and
written minutes of meetings, which are reviewed and approved by vote of the
Board members.
2.4. The Board selects the Chief Executive Officer (CEO), who leads all Hospital
operations and functions. All Hospital staff ultimately report to the CEO, who
reports to the Board. Physician staff report to the Medical Director, or Chief
Medical Officer, who reports to the CEO.
2.5. The Board approves an annual strategic plan for the Hospital to achieve its goal
of improving its community’s health and welfare.
2.6. In collaboration with the CEO, the Board has established performance indicators
for the Hospital, and the CEO and Board regularly monitor Hospital performance.
2.7. The Board evaluates the CEO annually to ensure he/she is meeting operational
and strategic plans as established by the Board and the CEO collectively.
Patient Flow
3.1. Procedures are established to ensure efficient patient flow; such procedures are
specific to emergency, outpatient, and inpatient settings and seek to reduce
patient crowding.
3.2. The Hospital has a centralized triage location in order to avoid patient crowding.
3.3. A clinical staff member is stationed in the triaging area near the emergency room
to readily determine patients’ clinical status.
3.4. Patient appointment systems are in place wherever possible.
3.5. The Hospital has criteria for surgical admissions, criteria for admission referral,
and criteria for discharge.

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Medical Records Management
4.1. The Hospital utilizes a single, unified registration system for all patients, including
both in-patients and out-patients.
4.2. The Hospital utilizes a Master Patient Index with a single, unique Medical Record
Number for each patient.
4.3. The Hospital utilizes a paper-based or computer-based medical record tracking
system, or both, to facilitate the generation, completion, and filing of medical
records. This system is the central tool for the patient registration process.
4.4. The Hospital utilizes a uniform set of forms that comprise a complete medical
record for the duration of a patient’s care. The documents include at least the
following: front sheet, observation sheets (vital signs record), physicians’ orders,
medication administration record, inpatient admission form, progress notes with
lab results and daily progress of care, and discharge summary.
4.5. The proper handling and confidentiality of medical records is ensured.
Nursing Standards and Practice
5.1. The Hospital has established management structures and job descriptions that
detail the roles and responsibilities of each nursing staff member.
5.2. Nurses complete a nursing admission assessment for each new inpatient.
5.3. The Hospital has established guidelines for verbal and written communication
about patient care that involves nurses. Written communication includes the use
of clinical forms, nursing Kardex, progress notes, and/or nursing care plan for
each patient and discharge instructions. Verbal communication includes reporting
to physicians, nurse-to-nurse reporting, communication with other clinical staff,
and patient and family education.
5.4. The Hospital has streamlined procedures for standardized, safe, and proper
administration of medications by nurses or designated clinical staff, including
regular checks of patients’ medications and proper documentation of
administered medications.
5.5. There is a clear organizational structure for all staff in the nursing department;
delineating that health assistants report to staff nurses or a nurse manager, staff
nurses report to a nurse manager, and nurse managers report to the nursing
director (also called Matron or Chief Nursing Officer), who in turn reports to the
CEO.

8. 7
Infection Prevention
6.1. The Hospital develops clearly defined policies, procedures, and financial
mechanisms to ensure supply of all necessary materials for proper infection
prevention including all personal protective equipment, waste management and
cleaning supplies.
6.2. Senior Hospital Management supports improvement efforts in infection
prevention (IP) and ensures that operational and technical capacity required to
adhere to IP guidelines is available.
6.3. Capital investment is made to ensure that sinks and running water are available
at all times in all patient care areas, that washers and dryers are in working order
100% of the time, towels and linens are regularly laundered and essential
supplies such as gloves, disinfectant and soap are available in all patient care
areas.
6.4. The Hospital has access necessary to an incinerator that is in working order.
6.5. The Hospital has an Infection Prevention Committee charged with annual review
of operating standards for IP.
6.6. The Hospital has established a Hospital Acquired Infection (HAI) Committee and
HAI surveillance system.
6.7. Hospital staff members are trained in and adhere to IP and HAI guidelines,
including proper hand hygiene, environmental cleanliness, and waste
management.
6.8. There are clearly defined policies and procedures as well as surveillance of staff
adherence to policies and procedures to ensure patient and visitor crowd control.
6.9. The Hospital implements universal precautions and conducts surveillance to
assess adherence to policies and procedures for implementing universal
precautions.
6.10. The Hospital is working towards developing and implementing adequate
transmission-based precautions for patients with specific diseases.
6.11. There are clearly defined policies and procedures as well as surveillance of staff
adherence to policies and procedures to ensure that there is adequate use of
post-exposure prophylaxis, which is consistent with the documented Hospital
policy on post-exposure prophylaxis.

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6.12. There are clearly defined policies and procedures as well as surveillance of staff
adherence to policies and procedures to ensure adequate environmental
infection prevention is in place.
6.13. There are clearly defined policies and procedures as well as surveillance of staff
adherence to policies and procedures to ensure proper waste management.
6.14. The Hospital has necessary personal protective equipment and infection
prevention materials to implement existing IP policies and procedures.
Pharmacy Inventory and Warehouse Management
7.1. The Hospital has a Drugs and Therapeutics Committee that includes
representation from physicians, nurses, management, and pharmacists. This
Drug and Therapeutics Committee works in an open and transparent manner to
establish and implement clear guidelines for cost effective and clinically effective
medication evaluation, selection, quantification and procurement.
7.2. The Hospital has a formulary that details the medications that a physician can
prescribe and that are routinely stocked by the hospital pharmacy.
7.3. The Hospital has and implements a plan for training pharmacy staff on
appropriate pharmacy management techniques including ordering, storing,
dosing, and distributing drugs as well as inventory management skills.
7.4. The Hospital has a paper-based or computer-based inventory management
system to reduce the frequency of stock-outs, oversupply, and drug expiry.
7.5. There is proper and safe disposal of all expired drugs.
Global Budgeting and Financial Management
8.1. The Hospital collaborates with Regional or City Health Bureaus to implement
performance-based global budgeting, with agreed upon indicators for
performance.
8.2. The Hospital tracks patient volume (in-patient and out-patient) as well as
expense and revenue budget variances on a monthly basis. Hospital senior
management presents these reports to the Governing Board at least quarterly.
These reports are provided to the relevant Health Bureau at least twice per year.
8.3. The Hospital reviews operating cash flow regularly to ensure financial liquidity.

10. 9
8.4. The Hospital reports operating costs per quarter to the relevant Health Bureau so
that Health Bureaus can ensure sufficient budget is allocated for Hospital
sustainability.
Equipment Management
9.1. The Hospital maintains an inventory of existing equipment. The Hospital has a
plan for equipment maintenance, to include replacements, upgrades, and new
equipment.
9.2. The Hospital has a Biomedical Technology Department that manages medical
equipment at the Hospital. The Biomedical Technology Department, as directed
by Hospital senior management, procures equipment, performs equipment
inventory management functions, evaluates and coordinates equipment
donations to the Hospital, and manages equipment maintenance and disposal.
9.3. The Hospital Biomedical Technology Department staff are trained by a
biomedical technician training program and supported by the Equipment
Maintenance Center in the country.
9.4. There are Hospital policies (which are consistent with existing government
policies) that direct staff on discarding equipment that cannot be repaired. Safe
disposal procedures are in place so that the disposal of items does not create a
hazard or unsafe environment.
9.5. An effective tracking system is used to monitor equipment maintenance activity.
9.6. The Hospital has a monitoring method that ensures laboratory equipment
operates with predicted specificity and sensitivity.
Facility Management and Safety
10.1. There is a monitoring and improvement plan for important systems in the
following areas: safety (fire safety and the safety of staff, patients and visitors),
security, control and disposal of hazardous materials, medical equipment,
facilities and physical plant management.
10.2. The Hospital regularly inspects its facilities and physical plant and has a plan to
reduce risks and to provide a safe physical environment for patients, families,
staff and visitors.
10.3. Potable water and electrical services are available 24 hours a day, seven days a
week through regular or alternate sources to meet essential patient care.

11. 10
10.4. The Hospital has a disaster plan for responding to likely community or Hospital
emergencies, epidemics and natural or other disasters. The Hospital conducts
staff trainings in each department at least annually on this plan.
10.5. The Hospital conducts regular preventative maintenance for all facilities and
operating systems (e.g., electrical, water, ventilation) to ensure patient and staff
safety and comfort.
10.6. There is a notification and work order system for facility and operating system
repairs.
10.7. There is a planning and budgeting system for facility refurbishments and
upgrades that is incorporated into the overall Hospital budget and strategic plan.
10.8. Dedicated Hospital staff members are assigned to all facility maintenance and
safety functions.
Laboratories
11.1. Hospital management ensures that the Hospital laboratory has the necessary
space, working environment, reagents, consumables, analyzers and associated
equipment needed to conduct the required repertoire of tests.
11.2. The Hospital has available and follows standard operating procedures and
conducts routine quality assessments to ensure reliable patient specimens.
11.3. The laboratory provides and adheres to defined turn-around times for each
laboratory test.
11.4. Laboratory staff members are trained in all required procedures and are
assessed periodically to review current competence in laboratory procedures.
11.5 . The laboratory work environment is organized and clean, with safety procedures
for handling of specimens and waste material to ensure patient and staff
protection from unnecessary risks at all times.
11.6 . Laboratory equipment is calibrated regularly and routine preventive maintenance
is performed by Hospital staff to prevent errors and breakdowns.
11.7 . Laboratory staff members monitor stocks of testing reagents and other
consumables so that supplies are ordered early and in sufficient quantity to
prevent stock-outs or oversupply.

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11.8 . Patient samples are stored only as long as necessary to conduct the designated
tests (or other permitted procedure) according to fixed storage times, and are
destroyed safely and confidentially immediately after storage.
11.9. Patient information and laboratory data are handled according to defined
procedures and archived securely for fixed periods of time to ensure minimal
errors or loss of patient test results.
11.10. There are laboratory ordering and reporting systems that ensures accurate and
timely processing of patient laboratory tests and timely reporting of results as
needed for patient care.
11.11. The Hospital has policies and procedures in place for sample collection and
transport.
Referrals Among Facilities
12.1. Standards and criteria for the referral of patients from the Hospital to other health
facilities are established, including standardized referral forms and necessary
clinical documents to accompany referred patients.
12.2 Hospital staff members are familiar with the referral systems including relevant
standards, criteria, and forms.
12.3. There is a designated referral person(s) at the Hospital in order to monitor and
manage the referral systems. This person(s) will work with staff to create and
maintain effective linkages between the Hospital and other health facilities.
12.4. The Hospital has a listing of facilities to which the Hospital may refer patients,
categorized by the type of clinical services they provide.
12.5. The Hospital conducts periodic meetings with health facilities used as referral
centers and facilities from which the Hospital receives referrals in order to
effectively manage and trouble-shoot gaps that may exist in the referral systems.
12.6. There is a standardized method for tracking and monitoring referrals.
12.7. A two-way referral system is established that allows the Hospital to both refer
and receive patients from other facilities as appropriate.
12.8. The Hospital promotes and publicizes the referral system throughout the
community in order to ensure all constituents are aware of the applicable service
pathway.

13. 12
Other Service Unit Standards
13.1 Treatment Guidelines for service area (e.g., pediatrics, medical, maternal,
surgical, emergency services) will be established and implemented as
established by the Hospital to ensure the best patient care possible.

14. Yale School of Public Health
Yale University
60 College Street
P.O. Box 208034
New Haven, Connecticut 06520-8034
USA
publichealth.yale.edu
William J. Clinton Foundation
55 West 125th Street
New York, NY 10027
USA
www.clintonfoundation.org