Somali Regional Health

Bureau
Warder General Hospital

WARDER GENERAL HOSPITAL

SCOPE OF PRACTICE

March 2024

Warder, Somali Ethiopia

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FOREWORD
Ethiopian Standards Agency (ESA) published standard (requirements) for every level of health
care.

ESA recommended General Hospitals shall provide services in accordance with the standard and
shall comply with all the requirements.

The intention of the standard is to ensure the quality and public safety of health services through
standardized licensure, inspection procedures & through scope based practice, to promote access
to quality health services and encourage health investment.

In our case, here we have clearly stated the scope of practice our hospital considering that it is
upgraded to General Hospital level a month ago.

The standard explains the scope of the hospital with respect to practices, premises, professionals
and products or materials as of today.

Dr Ahmed Dek

CEO, Warder General Hospital

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ACKNOWLEDGEMENT
I would like to extend my special thanks to members of the technical working group organized
by CG & QIU preparing the real time scope of practice of our General Hospital.

In addition, I would also thank all the participants from the clinical staff, for their commitment to
enrich the draft document.

Dr Ahmed Dek

CEO

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Table of contents

FOREWORD..................................................................................................................................................................................... 2
ACKNOWLEDGEMENT................................................................................................................................................................3
Table of contents................................................................................................................................................................................ 4
Introduction........................................................................................................................................................................................ 5
Scope of Practice of Warder General Hospital...............................................................................................................................6
1. Licensure.............................................................................................................................................................................. 6
2. Governance.......................................................................................................................................................................... 6
3. Patient Rights and Responsibilities...................................................................................................................................6
4. Human Resource Management.........................................................................................................................................6
5. Service Standards................................................................................................................................................................8
A. General Nursing Services..............................................................................................................................................8
B. Outpatient Services......................................................................................................................................................10
C. Inpatient Services.........................................................................................................................................................12
D. Emergency Services.....................................................................................................................................................14
E. Internal Medicine Services..........................................................................................................................................17
F. Pediatric Services.........................................................................................................................................................20
G. Surgical and Orthopedic Care Services................................................................................................................25
H. Gynecology and Obstetrics Care Services............................................................................................................27
I. Anesthesia Services......................................................................................................................................................29
J. Intensive Care unit (ICU) Services.............................................................................................................................31
K. Mental Healthcare Services....................................................................................................................................34
L. Dentistry Services.........................................................................................................................................................36
M. Ophthalmology Services.........................................................................................................................................39
N. Otorhinolaryngology (ORL), Dermatology, Oncology, Rehabilitation and Pathology Services..........................40
O. Radiology Services...................................................................................................................................................41
P. Medical Laboratory Services......................................................................................................................................42
Q. Pharmaceutical Services.........................................................................................................................................45
R. Blood Transfusion Services.........................................................................................................................................51
S. Ambulance Services.....................................................................................................................................................52
6. Other Hospital Services....................................................................................................................................................53
I. Infection Prevention.....................................................................................................................................................53
II. Medical Recording..................................................................................................................................................54
III. Food and Dietary Services......................................................................................................................................55
IV. Sanitation and Waste Management.......................................................................................................................57
V. Housekeeping, Laundry and Maintenance Services.................................................................................................57
VI. Social Work Services...............................................................................................................................................57
VII. Morgue Services......................................................................................................................................................57

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Introduction
General Hospital shall mean a health facility at secondary level of healthcare which provides
promotive, preventive, curative and rehabilitative service that requires diagnostic facilities and
therapeutic interventions with a minimum capacity of 50 beds and at least shall provide
gynecology and obstetrics, pediatrics, internal medicine, surgery, psychiatry and emergency
services.

In addition, it shall provide laboratory, imaging and pharmacy services and other related services
stated under the standard.

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 Scope of Practice of Warder General Hospital
1. Licensure
Warder Hospital is licensed with transformation to General level since a month back after
fulfilling the requirements.

2. Governance
Warder General Hospital have Governing Board, Chief Executive Officer (CEO), Chief Clinical Officer
(CCO)/Medical director and necessary staffs indicated in this standard with clear role and responsibility.

3. Patient Rights and Responsibilities

Our hospital as clear policy and monitoring & evaluation mechanism of towards the patients’
rights and responsibilities, regarding:

 Informed Consent
 Patient Rights and
 Patient Responsibilities

4. Human Resource Management

The Hospital has functional Human Resource Department which deals with every Human
Resource Management activities according to the rule and regulation. The department has its own
policies and procedures for assuring adequate staffing at all times.

Here is the list of category of staffs we have as of today

S.No Category of Staff Available Remark

Number
1 CEO 1
2 Medical director 1
3 HRM 1
4 Finance & Logistics 6
5 Cashiers 9
6 Internist 1
7 Pediatrician 1
8 Gynecologist and Obstetrician 1

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9 General Surgeon 1
10 Orthopedician 1
11 Radiologist 1
12 Anesthesiologist -
13 Psychiatrist -
14 Emergency specialist -
15 Pathologist - Planned to
have, but these
16 Dermatologist -
are optional
17 ENT specialist -
18 Ophthalmologist -
19 Oncologist -
20 Dentist 1
21 General Practitioners 16
22 Radiographer (MRT) 1
23 HO 9
24 Optometric nurse 1
25 Psychiatric nurse 1
26 BSc Anesthetist 4
27 BSc Nurse 50
28 Diploma Nurse 63
29 Midwifery 24
30 Medical Laboratory 14
Technologist/Technician
31 Pharmacist 11
32 Biomedical Engineer 1
33 Environmental Health 1

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 34 Health information 1
35 Archive 3
36 Social worker 1
37 Physiotherapist -
38 Complaint Handler 1
39 Liaison officer 3
40 Supportive staff 147
Total 377

The hospital provides staff education through continuous capacity building trainings.

And also has policy and procedure through which it care & promote the employee’s health
through vaccination and prevention methods.

The Hospital has Dress Code and Employee Identification in line with the ministry.

5. Service Standards
A. General Nursing Services
 All nurses of different service point, execute their role according to their scope mentioned in their
job description.
 The nursing care plan shall be initiated upon admission of the patient and as a part of the long –
term goal and shall include discharge plans.
 All nurses are expected to:
o Have nursing evaluation, care plan, V/S taking & drug administration, progress
evaluation and close communication with other staff, especially with the physician.
 Nurses shall work with others discipline staff to protect and promote the health and wellbeing of
patients under their care.
 Nurses shall be open and honest, act with integrity and uphold the reputation of their profession.
 All nursing staff shall wear easily readable name tags that include their name and status,
 Nurses providing care and service at specific units like OR, ICU, Recovery, cardiac unit, etc.,
shall have proper orientation and minimum basic trainings on related nursing activities in each
unit.

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 Provide patient specific nursing care to each patient which is consistent with medical care
planning.
 Restrict number of visitors and/ or care takers based on the condition of the patient.
 Document and complete all patient’s files
 Not to disclose confidential information relating to their patients.
 To explain and seek informed consent from their patients or their relatives/next of kin (for
incompetent patients) before carrying out any procedure.
 Find solutions to conflicts caused by deep moral, ethical and other beliefs arising from a request
for nursing service through dialogue with patients.
 Document patient discharge instructions in the patient's medical record at the time of discharge.
 List Allergies on the front cover of the patient's chart and/or, in a computerized system,
highlighted on the screen and this shall be posted in patient’s bed.
 Take and document the necessary vital signs as ordered and communicate to treating /attending
physician immediately if abnormal findings observed, for admitted patients.
 Identify & label Patients who required/prescribed to have special diet/care
 Adhere to the policies on:
o General and oral hygiene of patients
o Procedures for communicating with laboratory, laundry and food service.
o That state reporting of any signs suggestive of child abuse, substance abuse and /or
abnormal psychiatric manifestations by the nursing staff.
o That assigns nurses to different specific disciplines such as ENT, OR, ophthalmic clinic
and others.
o Reporting and documenting medication errors, product quality defect and adverse drug
reaction immediately to the prescriber and ADE focal person.
o Maintaining medicines, needles and syringes in patient care areas under proper conditions
as per the pharmaceutical service standards
 Identify each patient prior to medicines administration.
 Observe administration of prescribed oral medications.
 Return unfit-for-use medicines to the central medical store of the hospital for disposal.
 Store and use needles, syringes and other medical wastes in accordance with the infection
prevention standards of the Hospital.
 Evaluate and ensure appropriate monitoring & documentation of the effects of all psychotropic
medications
 For dead body care which at least contain:

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 o Confirmation of death by at least attending physician or any independent practitioner and
the nurse giving care (at least 2 medical personnel)
o Care for the body shall be carried out according to the religion and culture of the patient
as per the hospital protocol.
o If there is need of pathologic examination the request shall be sent to morgue.
o If there is document of consent for organ donation (i.e. cornea), the consent shall be sent
to morgue
o The body shall be taken to morgue immediately.
o The time of death shall be documented on the patients chart.
 Premises
o Our hospital have the followings premises for nursing services:
(a) Room /space for isolation or special care, with toilet room and shower
(b) Hand washing basin and toilet room at nurse station
(c) Procedure room for nursing procedures
(d) Nurse changing room with cabinet, chairs, cupboard
(e) Nurse’s station located in the middle of the wards with free access to all rooms.

B. Outpatient Services
 The scope of our hospitals’ outpatient services comply with the standards.
 The hospital OPD service have a triage system and corners
 Our OPD service is available in working days for at least eight hours a day
 The hospital ha follow up clinic services, which is led by a specialists for eight on all working
days in each department.
 The hospital has organized system to make follow up of patients easy to access
 The hospital has organized comprehensive liaison service for OPD cases with:
o Pre referral communication
o Referral forms
o Referral tracing mechanism (linkage)
o Feedback providing mechanism
o Documentation of referred clients
o Consultation forms
 All OPD service provision is according to the national and international protocol with
competent, motivated and compassionate workers.

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  The OPD clinics are having clinical protocols for management of at least common disease
entities and locally significant diseases in line with the national and international guidelines.
 There is a policy and procedure through which range of relevant treatment options and the
clinical impression shall be fully described to client and/or their families and documented
accordingly
 Premises
 Our hospital’s outpatient layout include the following:
a) Dedicated entrances
b) Waiting area, sink bathes and gender specific toilets
c) Dedicated patient consultation and examination rooms
d) Room for minor procedures
e) Room for providing injections
f) Storage place for supplies
g) Staff room
h) Janitors closet
i) All rooms have adequate light, water and ventilation
j) The room arrangements of outpatient services is in consideration with proximity between
related services
k) Our OPD has its own dedicated pharmacy, laboratory services.
l) The OPD is marked and easily accessible for all kind of patients
 Professionals
 At least one GP per discipline (Internal Medicine, Pediatrics, Surgery, Gynecology and
Obstetrics) for OPD is assigned and one more on IM and Pediatrics in most of the cases.
 At least one specialist per discipline (specialty) to run the respective specialized OPD service
is assigned.
 The actual number of personnel shall be determined by workload analysis using recognizable
methods
 The staff shall have regular supportive supervision by senior staff or peer review or case
conferences every three months and it shall be documented
 Products
 Necessary Products are fulfilled in every specific discipline:
a) Weighing Scale
b) Vital Sign and Diagnostic Set

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 o Thermometer
o Stethoscope
o Sphygmomanometer
o Fundoscope
o Otoscope
o Pulseoxymeter
c) Reflex hammer
d) Snellen’s chart
e) Dressing Set
f) Minor Set
g) Examination Coach
h) Catheterization set
i) Trolley
j) Folding Screen
k) X – Ray Film viewer

C. Inpatient Services
 Practices
 The Hospital’s inpatient service delivery scope comply with the standard
 The inpatient service is available 24 hrs of a day and 365 days a year.
 The inpatient service have consultation and functional intra and inter facility referral system
 Our inpatient service provide the following services for admitted patients:
o Taking comprehensive medical and social history, comprehensive physical
examination and performing important laboratory & other medical workups upon
admission and when indicated.
o Nursing care service over the 24 hrs of each day of admission until discharge
o Organized MDT and business rounds according to the schedules
o Have clinical protocols for management of at least common causes of admission in
the hospital
o Has organized appointment and follow up system
o The right of the patient to know the whole courses and options of management is
respected
o Quality of the service is monitored and audited by QIU
o Provide dietary service for patients who are admitted

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 o Provide a clean gown to admitted patients
o Secure the properties of admitted patients in a cabinet or room with shelves
o Has a dedicated & easily accessible lab and pharmacy service
o The respect of the privacy, dignity and right of admitted patients is one of our core
value.
o Arrange the appropriate post discharge and follow up instructions per protocol
o Provide a post mortem care and morgue service to deceased
o Has excellent coordination with different stake holders from outside too, when
indicated.
 Premise
 Inpatient service has the following rooms
a) Wards separate for male and female
b) Nursing Station per ward
c) Doctors office (consultation room)
d) Bathroom for patients per ward
e) Staff bathroom
f) Duty room
g) Clean utility room
h) Soiled utility room
i) Store
 Each room, beds, and other utilities are made, arranged and utilized per protocol
 Professionals
 Specialists or sub-specialists of the related discipline with a minimum of one is physically
available during working hours in respective wards.
 At least one general medical practitioner per discipline is physically available in all the shifts
in respective wards.
 One nurse for a maximum of six (6) patients is available to provide nursing care services
 All groups of support staffs are available for 24 hrs a day
 Biomedical Engineers and general facility maintenance are available at any time they are
needed.
 Products
 The following products are available in our inpatient services.

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 o Beds with wheels
o Bed side cabinet
o Urinal or plastics
o Bed pans
o IV Stand
o Stretcher
o Wheel chair
o Safety Box
o Suction machine
o Resuscitation set
o Thermometer
o Stethoscope
o Sphygmomanometer
o Fundoscope
o Otoscope
o Reflex hammer
o ECG machine
o Refrigerators
o Minor operation set
o Dressing Set
o Enema Set
o Lumbar puncture(LP) set
o Catheterization set
o Folding screens
o Oxygen cylinders and concentrators

D. Emergency Services
 Practices
 Our hospital has emergency service of all departments available 24hrs a day and 365 days a
year.
 Have an emergency triage system.
 Infection prevention standards are being implemented in the emergency room as per the IP
standards

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  Every emergency patient get the service without any prerequisite and discrimination.
 We provide a complete emergency service at least to the level of our specialization (scope) .
 Have functional intra and inter facility referral system with working guideline.
 Have ambulance service and accompanying professionals to transfer the patient.
 Every procedure, medication and clinical condition is done as protocol and with
communication to the patient or family member.
 There is policy and procedure to handle complaints and grievances
 For labor and delivery emergencies, the hospital have direct access with the delivery facility.
 Our emergency services and the provision of this service is usually done in accordance with
the clinical protocols of the service
 The emergency service have clinical protocols for the initial management of at common
emergency cases
 Premises
 The emergency room is in easily recognizable location to the public and labeled in bold.
 It is low traffic area and there is reserve parking place for ambulances.
 Has stretcher friendly and spacious enough corridor.
 The emergency area has adequate area for:
(a) Triaging.
(b) Accepting and providing immediate care including emergency procedures.
(c) Admitting for a maximum of 24 hrs to provide emergency care with enough beds.
(d) Emergency pharmacy
(e) Staff/duty room
(f) Toilet facilities separate for patients and staff
(g) Functions and able the users to exercise their rights
(h) The emergency rooms have the following facilities:
 Adequate water, light and ventilation.
 Fire extinguishers placed in visible area
 Telephone
 Hand washing basin in each room
 Waiting area for attendants and caregivers
 Professionals

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  The emergency service is directed by emergency trained physician.
 The team of emergency is changed every eight hours.
 The emergency service is open for 24hrs a day and 365 days a year.
 Run by an emergency team:
o Emergency trained physician or emergency medicine specialist
o Nurses
o Cleaners
o Runner
o One specialist for each major discipline is available
 All health professionals working in the emergency are expected to have adequate skill.
 Rotation of staff is dealt cautiously.
 The staff have regular supportive supervision by senior staff.
 Products
 Our emergency service have readily arranged emergency medicines and
supplies
 The following are some of the products:
o Emergency Bed with wheel
o Stretcher with wheel
o Wheelchair
o IV Stand
o EKG
o Suction machine
o Defibrillator
o Tracheotomy set
o NG tube
o Minor surgical set
o Different types of splints
o Mobile examination light
o Hot air oven
o Oxygen supply: oxygen, cylinder with flow meter, trolley and nasal prongs

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 o Examination Lamp
o Resuscitation set on trolley
o Intubation set
o Ambu bags
o Examination coach

E. Internal Medicine Services

 Practice
 We have written protocols and procedures on the management of the medical conditions,
consultation and transfer of patients admitted to this unit or other units
 For non – emergency medical service is available during the regular working hours
 For admitted patients the service available for 24hr
 The service has written policies and procedures that include:
o Admission and discharge criteria specific to the service.
o Visitors policy
o Infection prevention & control
o Transfer and referral of patients
o Monitoring and follow-up of patients
o Well-kept documentation
o Follow-up service for patients with chronic ailments.
o Avail updated reference materials, treatment guidelines and manuals.
o Involvement of the caretakers and/or patients in the development of the nursing
patient care plan.
 Premises
 The rooms are designed fulfilling the standard set by ESA
 Have adequate isolation rooms
 In addition to the ward rooms, our internal medicine service have the following rooms and
facilities:
o Examination & counseling rooms
o Physicians’ office
o Duty room

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 o Meeting room
o Nurse station
o Utility rooms
o Procedure room
o Follow-up clinics
o Care after death room;
o Soiled utility room
o Store
o Staff Toilets, showers and changing room
o Patient Toilet and shower at least one per each room.
 Professionals
 The services is directed by a licensed internist
 There are also licensed medical (GP) and nursing personnel available at all times
 There are also number of adequate different technical staff.
 An internist or general practitioner is responsible for the follow – up clinics.
 Have adequate support staffs available as per the service need.
 Products
 Medical OPD have the following supplies and functional equipment in addition to office
furniture’s:
o Torch, Otoscope, ophthalmoscope
o Weighing scales for adults
o Measuring board for length and height
o Tape meter, thermometer
o Stethoscopes
o Sphygmomanometer
o Examination couch
o Lumbar puncture, bone marrow aspiration set, pleural (peritoneal) biopsy set, cut
down set, Pericadiocentesis set, wide bore needles for thoracentesis
o Hand washing basin
o Spatula, K-Y jelly, surgical and disposable gloves, antiseptics, cotton, gauze

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 The inpatient service have the following supplies and functional equipment
o Torch, Otoscope, funduscope
o Weighing scales
o Tape meter, thermometer, patella hammer
o Stethoscopes and Sphygmomanometer
o Examination couch, medicine trolley, Cup board
o Lumbar puncture, Bone marrow aspiration set, pleural biopsy set, tracheotomy set,
chest tube
o EKG machine
o Suction machine
o Drip counters/Infusion pump, Tourniquets and IV stands
o Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
o Self-inflating bags for respiratory support, Masks, endotracheal tubes,
o Laryngoscope
o Cannulas, Nasogastric tube
o Beds
o Hand washing basin
o Nebulizers
o Equipment for skin scrapings and biopsy of dermatological lesions, bone marrow
trephine needles and slides and others
o Glucometer and glucostick
o Pulseoximeter
o Wheelchair
o Over bed table( for feeding)
o Bed side cabinet and bed curtain fixed with the roof and the ground
o Waste paper basket
 The general follow-up clinic have the following supplies and functional equipment:
o Torch, Otoscope, funduscope, Snellen’s chart
o Weighing scales
o Tape meter, thermometer, patella hammer

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 o Stethoscopes and Sphygmomanometer
o X-ray viewer
o Examination couch
o Medicines and supplies

F. Pediatric Services
 Practices
 We have 24 hours a day and 365 days a year Pediatric service in pediatrics emergency, ward
and NICU/ICU
 All pediatric services have their own policy and procedure on how to proceed with their
deeds.
 Pediatric OPD service is available during regular working hours
 There is a policy for pediatric wards on:
o The age below which to admitted to a pediatric service
o Admission and discharge criteria specific to the service
o A visitors policy
o Infection prevention & control as per the standard
o Transfer and referral of patients
o Safety measures for preventing electrical and bodily injury to pediatric patients.
o Monitoring and follow-up of pediatric patients
 Child development based nursing assessment and care
 Involving the parents or guardians of pediatric patients in the development of the nursing plan
 Immunization services is available and all children have their immunization status checked
before discharge
 There are updated reference materials, treatment guidelines and manuals avail
 Complete, sufficient information and records are kept – well.
 The Growth monitoring and malnutrition management
 Have a follow-up service for patients with chronic ailments.
 There is means (channel) for communication of incidents or outbreaks between stake holders
 Premises
 All rooms in all pediatric service areas are in accordance with the standard set by ESA.
 Each room have a hand washing sink, toilet and bath room
 The pediatric OPD have a functional resuscitation corner

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 Have adequate isolation rooms
 The pediatric OPD have the following rooms:
o Waiting area with safe playground
o Examination room(s)
o Procedure room
o Room(s) for follow-up cases
o Nurse station
o Store
o Separate toilets for patients and staff
o Patient waiting area.
 The pediatric emergency have the following rooms:
o Space for patient triaging/ reception
o Examination room
o Resuscitation room
 The pediatric inpatient has the following rooms:
o Inpatient care room
o Procedure room
o SAM ward
o Nutritional supplement preparation roo
o Nurses station
o Isolation room
o Staff toilet and bath
o Toilet and bath for patients and care takers
o Store room
o Office for physicians
 Neonatal unit has the following rooms
o Room for care of critical newborns
o Isolation room for septic cases
o Procedure room
o Nurses station
o Room for mothers
o Milk preparation room

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 o Kangaroo mother care room
o Toilet and bath for Staff
o Toilet and bath for others
o Store room
o Office for physicians

 Professionals
 Our pediatric service is directed by a licensed pediatrician.
 There are also adequate, qualified medical (GP) and nursing staff available at all times in
all pediatric service points.
 The neonatal unit have trained professionals of all groups:
 Has nurse head
 There are adequate support staff available all the time
 Products
 The pediatric emergency unit has the following equipment and supplies:
o Resuscitation stretcher, examination couches, beds for emergency services.
o Sphygmomanometer (pediatric and adult sizes), stethoscope, thermometer.
weight scale, tape meter, Torch, Otoscope, ophthalmoscope, patella hammer.
o Oxygen cylinder with flow meter.
o Nasal prongs catheters.
o Self – Inflating bags for respiratory support.
o Masks (infant size, child size, adult size).
o Endotracheal tubes (pediatric and adult sizes).
o Laryngoscope
o Glucometer with glucostick.
o Pulse oximetery
o EKG machine
o Lumbar puncture set
o Minor set
o Chest tube set
o Tracheostomy set
o Suction machine
o Medicine trolley, Cup board

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 o Hand washing basin
o Nebulizers (electricity driven, or oxygen driven or manual)
o Spacers with masks for sprays
o Butterflies and/or cannulas of pediatric size
o NG – tubes and urinary catheters (pediatric size)
o Gloves (surgical and disposable)
o Antiseptics (alcohol, savlon, iodine), cotton, gauze, K-Y jelly
o Spatula
o Emergency medicines
 The pediatric OPD has the following functional equipment and supplies:
o Diagnostic equipment: Torch, Otoscope, ophthalmoscope, reflex hammer.
o Weighing scales for children and infants
o Measuring board for measuring length and height
o Measuring tape
o Thermometer, Stethoscopes, Sphygmomanometer (pediatric and adult sizes)
o Examination couch
o Lumbar puncture, Bone marrow aspiration set, pleural biopsy set,
o Hand washing basin
o Spatula, KY Jelly, Surgical and disposable gloves, antiseptics, cotton, gauze
 The pediatric inpatient have the following functional equipment and supplies:
o Diagnostic equipment: Torch, Otoscope, ophthalmoscope, reflex hammer,
o Weighing scales for children and infants
o Measuring board for measuring length and height
o Measuring tape, thermometer
o Stethoscopes and Sphygmomanometer (pediatric and adult sizes)
o Examination couch, medicine trolley, Cupboard
o Lumbar puncture, Bone marrow aspiration set, pleural biopsy set
o EKG machine
o Suction machine
o Drip counters
o Infusion pump
o Tourniquets

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 o IV stands
o Radiant or Heat source
o Beds for patients, mothers and croup tents
o Oxygen cylinder, Flow-meters for oxygen
o Nasal prongs catheters
o Self-inflating bags for respiratory support,
o Masks (infant size, child size, adult size)
o Endotracheal tubes (pediatric and adult sizes), laryngoscope
o Equipment for intra-osseous fluid administration
o Nebulizers for administration of salbutamol
o Spacers with masks for administration of metered doses of salbutamol
o Spatula, K-Y jelly, Surgical and disposable gloves, Butterflies and/or cannulas of
pediatric size, NG-tubes-pediatric size, antiseptics, cotton, gauze,
o Emergency medicines
 The NICU has the following equipment:
o Neonatal bed/ cradle
o Incubator
o Oxygen source
o Baby weighing scale
o Cardiorespiratory monitor
o Pulse oximeter
o Glucometer
o Infusion pump
o Phototherapy light with bed
o X-ray viewer
o Diagnostics: Torch, Otoscope, ophthalmoscope, Stethoscopes, thermometer
o Measuring board for measuring length, Measuring tape
o Examination couch
o Medicine trolley
o Medicine Cup board
o Lumbar puncture
o Suction machine

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 o Tourniquets
o IV stands
o Exchange transfusion sets
o Radiant warmers
o Oxygen cylinder with flow meters
o Nasal prong catheters
o Self-inflating bags for respiratory support
o Masks (infant size)
o Endotracheal tubes (new born sizes)
o Laryngoscope (new born size)
o Refrigerator
o Butterflies and/or cannulas of paediatric size,
o NG – tubes-paediatric size
o Umbilical catheters
o Beds for mothers

G. Surgical and Orthopedic Care Services

 Practices
 Comprehensive emergency surgical service & surgical admission care are available 24
hours a day, 365 days a year
 Surgical OPD & SRC is available on working days
 There are written protocols and procedures for:
o Admissions and discharges with follow up.
o The management of the surgical conditions in the unit.
o Consultation and transfer of patients
o Handling emergency surgical conditions.
 Admission of emergency and elective surgical patients is decided by surgeon.
 There is mechanism of interdepartmental consultations
 All surgical procedures (except in life-threatening emergencies) are performed only after
appropriate history, physical examination, and indicated diagnostic tests are completed
and documented in the patient’s medical record.
 The preoperative diagnosis is recorded in the medical record for all patients prior to
surgery by the surgeon.

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  The surgeon always explain the disease condition, possible surgical intervention and
outcome possibilities in clear, simple and understandable terms to the patient and/or
family.
 The surgeon usually obtain an informed written consent and documented in the patient’s
medical record.
 The nursing care of patients undergoing surgery is planned and
documented in the medical record, directed by a trained nurse, and includes:
o Pre-operative care
o Location of post-operative care
o Type of post-operative care and monitoring needed
o Pain management
o Discharge instructions.
 Complete Operative reports is always written in the patient’s record and in the OR
registration book immediately after surgery with proper registration paper
 There is a policy, procedure and guideline that allows everyone to perform every
intervention and care according to the protocol with medical ethics uphold.
 When indicated, pathologic samples are taken and sent to pathology department with
proper form.
 There is a policy and procedure for every other activities, like:
o Preparing and availing appropriate and properly functioning supplies, equipment,
and instruments
o Proper Patient transfer from operation theatre to recovery room and from the
recovery to wards.
o Surgical activities to be done at outpatients level, surgical referral clinics, follow
up clinics, minor operations and orthopedic procedures.
o Always availability of the surgeon.
 Post- operative patient in the wards get proper & complete post-operative care per
protocol
 There is a mechanism for the patients to easily access nursing care
 Premises
 Surgical Unit:
o Our hospital has adequate OT table per our patient load
o OT is accessible to the surgical wards.

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 o The surgical unit is composed of:
 Operation room, recovery room, the surgical wards, toilet rooms,
showers and changing rooms with lockers, offices, store rooms, clean
and dirty utility rooms, duty rooms and cleaner’s room and central
sterilization room.
o All rooms and utilities are designed, made, organized and practiced in as per the
standard set by ESA.
 Professionals
 The surgical services is directed by a licensed experienced surgeon.
 We have adequate number of staff for each service within surgery
 The nursing services in the OR is coordinated by a licensed nurse experienced in surgical
nursing
 Orientation and continuous training is provided for cleaners for proper handling and
disposal of sharp materials and surgical wastes by OR nurse coordinator or via IP
committee.
 Products
 All surgical service points are equipped with all necessary minor & major, surgical,
orthopedic, anesthetics, nursing, IPC and medical instruments, sets, clothing,
medications, etc as per the standard set for general hospitals by the ESA.

H. Gynecology and Obstetrics Care Services

 Practice
 Our OBGYN service has written protocols and procedures including:
o Antenatal care
o Follow up of delivery
o New born care
o Postnatal care
o Immunization
o Pre and post-operative care
o Administration of antibiotics, uterotonics and anticonvulsants
o Assisted delivery
o Manual removal of placenta

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 o Infertility
o Admission and discharge
o Transfer and referral
o Infection prevention
 Normal delivery, comprehensive emergency obstetric care, essential new born care,
emergency gynecologic care is available 24 hours a day, 365 days a year.
 Routine examination for detection of congenital hip dysplasia and other congenital
anomalies is done.
 Management of minor and major gynecological conditions is available
 Non-emergency maternal health services are available during regular working
hours.
 Full range of gynecologic and obstetric OPD cares are available with necessary supplies
 There is a mechanism of interdepartmental consultations
 Gynecology and obstetrics records are kept for each patient.
 All gynecologic and obstetrics surgical procedures are performed only after appropriate
history, physical examination, and indicated diagnostic tests are completed and
documented in the patient’s medical record (unless there is a reason not to do so).
 The preoperative diagnosis are recorded in the medical record for all patients prior to
surgery.
 The gynecologist/obstetrician is expected to explain the disease condition, possible
surgical intervention and outcome possibilities in clear, simple and understandable terms
to the patient and/or family.
 The complete protocoled nursing care of patients undergoing gynecologic/obstetrics
surgery is planned and documented in the medical record, directed by a trained nurse, the
same way as in surgery
 The gynecological and obstetrics services strictly follow the infection prevention &
control principles
 Premises
 The Maternity Unit is comprised of:
o The maternity ward, delivery suite and nursery and operating theatre, neonatal
resuscitation corner.
 All components of the maternity unit are designed, built, furnished, equipped, practiced
in in accordance to the standard set by ESA.

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  All service areas are necessary supplies, medications, follow up sheets, staffs as per the
standard
 Professionals
 The gynecology and obstetrics services is directed by a licensed obstetrician
and gynecologist
 There are adequate qualified medical and midwife nursing professionals in the
gynecology and obstetrics unit available at all times
 Always the adequacy every staff number is maintained based on the work load.
 Products
 All service areas within OBGYN, are equipped with necessary type, number & size of
materials, instruments, drugs, both diagnostic, evaluation, OR, delivery, neonatal care
and IPC utensils, are available.
 And also necessary space with equipment for every service is designed and allocated.

I. Anesthesia Services
 Practices
 We have a written policy on:
o Administration of regional and general anesthesia
o Monitoring minor regional blocks
o Anesthesia services administration
o Planning and documenting anesthesia care, which includes moderate and deep
sedation, is in the patient’s record.
o A pre-anesthesia/sedation assessment is done by anesthetist or anesthesiologist
prior to the induction of anesthesia.
o The patient is reassessed immediately prior to induction of anesthesia by
an anesthesiologist or anesthetist.
o Prior to administration of any pre-anesthesia medication, a written informed
consent for the use of anesthesia is obtained and documented in the medical
record.
o Each patient’s complete physiologic status is continuously monitored during
anesthesia or sedation administration and the results of the monitoring are
documented in the patient’s medical record on proper an anesthesia form.

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 o The patient shall be monitored during the post-anesthesia/surgery recovery
period and the results of monitoring shall be documented in the patient’s
medical record.
o There is standard protocol on anesthesia care
o Unless immediately transferred to ICU, all post – op patients stay at recovery
(PACU) until fully recover from the anesthesia effect.
o Every follow up results are documented by the responsible anesthetist on
Medical Record.
o All necessary equipment, materials, and rooms for anesthesia service are
available, functional, designed per protocol.
 There is adequate number anesthetists or anesthesiologist available for full time coverage
of the service.
 Premises
 The general anesthesia service is provided in the Operation theatre (OR), together with
the surgical services.
 There is well equipped Operation theatre and Anesthesia store.
 Staff office with chairs, table, cabinet and other necessary premises per the standard.
 There is recovery Room with necessary tools and designed per protocol.
 Professionals
 Anesthesia service is directed by licensed BSc in anesthesiology or anesthetist with
experience.
 We have experienced anesthetists that can perform whole range of care including ACLS
with basic anesthesia cares.
 Product
 We have all anesthesia supplies, equipment and safety systems that are operated per the
standard.
 We have anesthesia supplies, equipment and patient monitoring which include:
o A respirometer (volumeter) measuring exhaled tidal volume
o A complete “difficult airway container or trolley” is available for handling
emergencies.
o A precordial stethoscope
o Supplemental oxygen and a delivery system is available for patient transport
o Recording and reporting forms

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 Equipment:
o Anesthesia machine with ventilator, vaporizers, and gas cylinders
o Adult and pediatric anesthesia circuits with filters
o Mechanical ventilators
o Oxygen cylinders, oxygen trolley and oxygen regulator
o Worktable with laminated top
o Resuscitation equipment; Ambu bags (adult/ pediatric/ neonates), with inflatable
bag
o Refrigerator
o Time clock
o Stools
o Clips
o Weight scale; adult & pediatric
o Resuscitation trolley
o Syringe pump
o Defibrillator
o Blood gas analyzer (optional)
o Dust bin
o Blankets
o IV stands
o Operation table
o Patient transferring Stretchers
o Suction machines
o Patient monitor
o ECG monitor
o Pulse oximeter
o Temperature monitor
o Nerve stimulator
o Dual head stethoscope
o BP apparatus with different size cuffs
o Complete Intubation gadgets
o All medicines and supplies are available as per the national medicines list

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J. Intensive Care unit (ICU) Services
 Practices
 Our ICU service is available for 24 hours a day, 7 days a week and 365 days
a year with Advanced Life Support (ALS) service.
 The ICU have written policies and procedures that are reviewed every time necessary and
implemented which include:
o Criteria for admission to ICU
o Criteria for discharge and transfer
o A list of procedures that physicians may or may not perform
o For transfer and transport of patients within the hospital or from the hospital to
another facility.
o Infection control procedures
o A visitors policy
o On the removal of a patient's life support system
o Defining the physician, specialist and consulting physician to be called for
patient emergencies.
o Standing orders for patient emergencies.
o Ensure that priority laboratory services will be available to critical care patients
at all times if medically indicated.
o Roles and responsibilities of specialists in management of ICU patients
 Nursing care is the responsibility of a licensed nurse.
 Complete medical records are kept for each patient
 There is adequate nursing staff per the work load
 Promoting harmony between critical care providers and families.
 There is portable life-support equipment for use in patient transport
 There is a system for immediate repair of the equipment up on malfunctions.
 There is a program of continuous quality improvement for the ICU service
that is integrated into the hospital continuous quality improvement program
 Premises
 The ICU is located in access restricted area of the hospital and well identified.
 ICU room:
o Is being modified to align with the standard
o The beds are spaced and arranged per the protocol.

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 o There is a nurse station within the ICU having necessary supplies and equipment.
o Have easily accessible hand wash basin
o In addition the unit have the following spaces (rooms):
 Toilets, nurse room, utility room, store, duty room, cleaner’s room, staff
tea room, and spacious corridor for stretchers and wheelchairs.
 Professionals
 The hospital ICU is directed by a ICU trained nurse with respective specialist.
 Trained nursing staff
 All practicing nurses in the ICU are trained and certified in basic cardiac life support.
 Nursing staff in ICU is for 24 with shifts
 The following professionals are available:
o Anesthesiologist or BSc in anesthesiology
o Nurse anesthetist
o ICU trained GP
o Nurses
o Cleaners
o Porters
o General technician

 Products
 Medicines selected for ICU services by the hospital are available at all times
 The hospital ICU have the following equipment, instruments and system:
o ICU beds with side protections
o Mechanical ventilator
o Different size endotracheal tubes and tracheotomy sets
o Monitoring equipment
 Standard 12 lead EKG machine
 Defibrillator
 Oxygen cylinder and oxygen concentrator
 Oxygen regulator
 Pulse oximeter
 End – tidal carbon dioxide monitoring
 Infusion pumps
 Suction pumps

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  Infusion pump
 Laryngoscopes with different size blades
 Ophthalmoscope
 Mouth gags, different size
 Air ways, different size
 Resuscitation trolleys
 Exam coaches
 Syringe pump
 Endotracheal tubes
 Wheel chair
 Patient transport stretcher
 Sphygmomanometer, with adult and pediatric cuffs,
 Stethoscopes: pediatric and adult,
 Electrical suction machine
 Suction machine
 Nasal CPAP
 Bed pan, plenty in number
 Pacing boxes
 Wall clock
 Soiled cloth hampers
 Patient screen per bed and
 IV stands

K. Mental Healthcare Services

 Practices
 Psychiatry service have written policies and procedures on:
o Admission and discharge criteria specific to the service;
o Visitors policy
o Infection control
o Transfer and referral of patients
o The management of the psychiatry conditions in the hospital
o Monitoring and follow-up of patients
 Psychiatric patients receive all medical, surgical, diagnostic and treatment
services as ordered by a physician psychiatry professional.
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  There is an integrated psychiatry emergency service for 24 hours a day and 365
day a year in the hospital.
 There is psychiatry OPD & follow-up service during working hours
 There is pharmacotherapy service
 There is a dedicated outpatient and inpatient services for mental health services
 Complete psychiatric evaluation and care plan is documented in the medical
record.
 The multidisciplinary care plan is discussed with the patient and/or the patient’s
next of kin and implemented accordingly.
 Written discharge plan is developed for each patient
 There is Infection control practices
 There is Safety and security precautions for the prevention of suicide, assault,
elopement and patient injury.
 Every care is as per the protocol.
 There is a pediatric and adolescent psychiatric care and service
 Premises
 A private setting is available for interviewing patients.
 There is separate psychiatry emergency room within the general emergency
service.
 There is psychiatric ward dedicated for psychiatry service with slight adjustment.
 All the service areas are equipped with necessary & basic materials &
instruments.
 Professionals
 The Psychiatry service is directed by a licensed psychiatry professional or
psychiatrist.
 The psychiatrist or licensed practitioner is available all the time.
 There is adequate number, type and skills of clinicians and support staff that
ensure quality care.
 A licensed psychiatry nurse is available at all times
 Products
 The restraint equipment

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 Recreational and therapy equipment and supplies needed for psychiatry care
 The psychiatric OPD have the following supplies and functional equipment in
addition to office furniture’s:
o Torch
o Weighing scales for adults and/or children
o Thermometer, Stethoscopes, Sphygmomanometer, Examination couch
o Hand washing basin
o Spatula, disposable gloves, cotton, gauze
o Prescription, certificate, and appropriate referral forms, request forms for
laboratory, X-ray and other imaging investigations
 The inpatient service have the following supplies and functional equipment:
o ECT machine, gags, electrode application rubbers, electrodes, gel for
electrode placement
o Torch,
o Weighing scales
o Tape meter, thermometer, patella hammer, Stethoscopes and
Sphygmomanometer
o Examination couch, medicine trolley, Cupboard
o EKG machine
o Computerized EEG mach with at least 18 channels
o Suction machine
o Drip counters/Infusion pump, Tourniquets and IV stands
o Oxygen cylinder, Flow-meters for oxygen, Nasal prongs catheters
o Self-inflating bags for respiratory support, Masks, endotracheal tubes,
o Cannulas, Nasogastric tube
o Beds for patients and hand washing basin
o Glucometer
 The service have follow-up clinic that is equipped like other service areas.
 There is locked storage available for supplies and the safekeeping of the
individual

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  Psychotropic medications and other drugs are available.

L. Dentistry Services
 Practices
 The dental service is available during working hours.
 There is written protocols and procedures for the management of dental
conditions as well as consultation, referral and transfer of inpatients/outpatients to
other services inside/outside the hospital.
 The dental unit is functional for dental, oral and maxillofacial emergency cases
over 24hrs
 Non-emergency dental, oral and maxillofacial surgery services are available
during the regular working hours.
 Adequate & complete dental records are kept for each patient
 Informed Consent (written/verbal) is complete for every dental procedure in
addition to minor & major surgery.
 The dental service is provided in accordance with infection prevention standards
 Premises
 The dental service is located in the outpatient service unit of the hospital.
 There is an arrangement for in-patient service sharing with surgical department.
 There is one room with one dental unit or set up.
 The number and size of the is adequate for our patient load
 There is a waiting area
 There is an X-ray mounted dental unit
 The rooms of dental services have the following rooms:
o Sterilization area/ Store room with shelves
o Staff office
o Room for mini pharmacy
o Staff toilets, showers and changing room
o Guarded place or room for air compressor
o Store.
o The dental service use the hospital operation theatre, ICU & anesthesia
services.
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 Professionals
 The dental service is directed by a licensed dental surgeon
 There is adequate qualified dental and auxiliary personnel in the dental service
unit available at all times
 There is adequate support staff available as per the service need.
 Products
 The dental services have the following equipment and instrument:
o The dental unit
 Air-water syringes
 Operating light
 Saliva ejector (oral evacuator system)
 Dental Chair
 Operator’s stool
 Assistant stool
o Instruments for examination
 Dental mirror, Cotton pliers & Spoon excavator
 Explorers (different types, numbers)
 Periodontal pocket probe
 Instrument for filling treatment
 Condenser (serrated & plain, Medium, and big size)
 Beaver tail
 Burnisher (ball type, football type, interproximal type)
 Carve (Hollenback, tanner, ward, and discoid-cleoid).
 Trimmers
 Knife (interproximal, finishing gold foil)
 Amalgam carriers (doubled ended, gun type)
 Matrix retainer (different types tofflemire, ziqueland)
 Proximal trimmer
 Plastic instruments for filling treatment
 Carriers for restorative materials
 Carvers

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  Condenser Beaver tail
o Materials & instruments to keep the area free from moistures & to
improve visibility
 Rubber dam equipment
 Clamps (different type, posterior & anterior, mandibular &
maxillar)
 Universal rubber-Dam clamps forceps
 Rubber- dam punch
 Holder young frame
 Automation
o Complete Dental hand pieces with Rotating instruments & hand cutting
instruments
o Instruments and Materials for root canal treatment
o Instrument for Oral Surgery
o Forceps for Dental Extractions (Deciduous teeth)
o Mandibular forceps for posterior teeth
o Right-angled forceps for mandibular Extraction
o Maxillar Forceps for anterior & posterior teeth extraction
o Forceps for Maxillary and mandibular root extraction
o Periodontal instruments
o Basic Dental Laboratory Equipments
o Equipment for Radiology Department
o Equipments for sterilization
o Equipment used for amalgam restoration:
o Different operatory cabinets
o Central Air compressor
o Other rotating instruments:
o Hand cutting instruments:
o Other surgical instruments
o Orthodontics instrument

39
 o Periodontal instruments
o Prosthodontics Instruments
o Other medications and instruments
o Consumable materials for root canal treatment

M. Ophthalmology Services
 Practice
 The Ophthalmology service has written policies and procedures including:
o Admission and discharge criteria specific to the service;
o Visitors policy
o Transfer and referral of patients
o Monitoring and follow-up of patients
o Infection prevention and control
 The Ophthalmology service provide at least the following services
o Visual acuity testing
o Slit lamp examination
o Visual field examination
o Minor ophthalmologic surgical procedures
o Medical management of glaucoma
o Optometry service (optional)
 The ophthalmology service have protocols and procedure on:
o Penetrating eye injury
o Glaucoma management
o Red eye
o Corneal laceration
o Surgical interventions
 The Ophthalmology OPD service is available during the regular working hours.
 Integrate emergency ophthalmology service is available at all times.
 Information contained in the medical record are complete and sufficiently detailed.
 For admitted patients the service is over 24hrPremises
 The ophthalmology OPD has:
o Examination rooms
o Nurse station

40
 o Physicians room
o Minor OR room with washing basin

 Professionals
 The Ophthalmology Service is directed by a licensed ophthalmologist.
 Nursing service is the responsibility of licensed ophthalmic nurse
 Anesthesiologist or nurse anesthetist or anesthetist or BSc in anesthesiology is available,
as appropriate.
 Optometrist
 Supporting staff such as cleaners
 All staffs are available the whole time.
 Products
 The ophthalmology service have the following functional equipment:
o Diagnostic Equipment/Instrument
o Therapeutic Equipment/Instrument
o Diagnostics
o Consumables
o Both emergency and non-emergency medicines and supplies

N. Otorhinolaryngology (ORL), Dermatology, Oncology, Rehabilitation and Pathology

Services
 Practice, Premises, Professionals and Products are on the way to be developed and
fully functioned.

O. Radiology Services
 Practices
 The radiology service have written policies and procedures on:
o Safety practices
o Emergencies
o Adverse reactions
o Management of the critically ill & emergency patient
o Infection control
o Timeliness of the availability of diagnostic imaging procedures and the
results
o Quality control program of all equipment

41
  Policies and procedures for radiology services are available to all staff
 Radiologists supervise and interpret all radiological procedures
 The radiology service of the hospital have the following services at all times:
o Digital X-Ray service
o Ultrasound service
o Certain interventional procedures.
 There is means of ease of patient transfer to & from the radiology units.
 The radiology service unit is free of hazards to patients and personnel.
 Proper safety precautions are maintained against fire and explosion hazards,
electrical hazards, and radiation hazards.
 Radiation workers are checked periodically for amount of radiation exposure
 Signed complete reports written by the radiologist are filed with the patient's
medical record and duplicate copies kept in the service unit.
 Complete requests by the attending physician are written.
 All services are expected to be delivered in line with the protocols.
 Premises
 Design of radiology rooms is according to Ethiopian Radiation Protection Authority
guidelines standard.
 The hospital have policies and procedures for the availability of digital image archiving
and printing
 The radiology service have necessary rooms and equipment.
 Professionals
 The radiology service is directed by a licensed radiologist or radiology
technologist.
 A licensed professional nurse is available
 A receptionist, cleaners are available in radiology service
 All the staff are available all the time.
 Products
 The following Equipment are available for radiology services:
o Color duplex ultrasound machines for general purpose
o Dedicated echocardiography ultrasound machine with cardiac probe

42
 o Simple gray scale ultrasound machine.
o Digital x-ray machine
o Resuscitation equipment
o Quality control kits
o Lead gloves
o Lead aprons
o Gonadal shield
o Dark room with accessories as appropriate
o Procedure sets
 All diagnostic equipment are regularly inspected, maintained, and calibrated, and
appropriate records are maintained.

P. Medical Laboratory Services

 Practices
 The laboratory have written policies and procedures on:
o Procedure manuals or guidelines for all tests and equipment
o Report times for results (Established turnaround time)
o Quality assurance and control processes
o Inspection, maintenance, calibration, and testing of all equipment
o Management of reagents
o Procedures for collecting, identifying, processing, and disposing of specimens
o All normal ranges for all tests stated
o Laboratory safety program, including infection control
o There is documentation of quality control data, calibration report, refrigerator
readings and so on.
 The hospital have standardized data collection instruments like:
o Laboratory request forms
o Laboratory report forms
o Laboratory specimen and results registers
o Quarterly/monthly reporting forms
o Equipment and supplies inventory registers
o Quality assurance record forms

43
 o Referral forms
 The hospital developed monitoring and evaluation tools to assess whole activities
 The hospital have policies and procedures for:
o The availability of laboratory services including the emergency services for 24
hours a day and seven days a week
o Proper specimen collection
o Proper documentation and communication of policies to all personnel.
o Making amendments and corrections to laboratory procedures
 The laboratory follow standard operating procedures (SOP) and conduct routine quality
assessments
 Laboratory staff test quality control materials regularly.
 The right patient with the right request form is identified during collection and delivery of
result.
 There is complete requests for testing expected to be filled properly
 There is SOP or criteria developed for acceptance or rejection of clinical samples.
 Laboratory monitors the transportation of samples to the laboratory
 The laboratory maintains a record of all samples received.
 The Laboratory have a procedure for storage of clinical samples if it is not immediately
examined.
 Patient samples shall be stored only for as long as necessary to conduct the designated
tests
 Once a sample is used, it is maintained in the laboratory for a specified period of time
 Laboratory report is complete with copies and well documented.
 Safe disposal of samples is in line with standards of infection prevention.
 No eating, drinking, smoking or other application of cosmetics in laboratory work areas
or in any area where workplace materials are handled.
 Wearing of protective clothing of an approved design (splash proof)
 The medical laboratory have safety guideline.
 The laboratory keeps a complete record of the complaints.
 Premises
 The hospital have a well-organized, adequately supervised and staffed
clinical laboratory with the necessary space, facilities and equipment to perform
those services commensurate with the hospital's needs for its patients.

44
  The laboratory working environment is always kept organized and clean, with safe
procedures for handling of specimens and waste material to ensure patient and
staff protection from unnecessary risks at all time.
 The laboratory have adequate space and a safe environment to perform testing.
 All the rooms are designed and practiced in according to the standard
 The laboratory facilities meet the following:
o Have a reliable supply of running water
o Continuous power supply
o Working surface covered with appropriate materials
o Suitable stools for the benches.
o Internal surfaces are standard based designs
o Standard laboratory furniture
o Lockable doors and cupboards
o Closed drainage from laboratory sinks (to a septic tank or deep pit)
o Deep pit to discard contaminated material or access to a simple incinerator
o Separate toilets/latrines for staff and patients
o Emergency of safety services such as deluge showers and eye-wash stations, fire
alarm systems and emergency power supplies are included in the laboratory
services design specifications
 Professionals
 All laboratory services are directed by a licensed medical laboratory technologist
 Medical Laboratory staff are present at the hospital at all times.
 Students and other staff on attachment will work under the direct supervision of a
registered medical laboratory technologist.
 The Laboratory service have and maintain job descriptions, including
qualifications to perform specific functions.
 The Laboratory management provide adequate training, continuing education or access to
training for technical staff, and assess staff competency at regular intervals.
 Laboratory staff at all times, perform their functions with adherence to the highest ethical
and professional standards of the laboratory profession.
 Adequate type and number of staffs are available
 Products
 Laboratory is furnished with all items of equipment required for the provision of services.

45
  All equipment are always in good working order, routinely quality controlled, and precise
in terms of calibration.
 Equipment is maintained in a safe working condition.
 There is a written chemical hygiene plan that defines the safety procedures to be followed
for all hazardous chemicals used in the laboratory6.21.4.8. The following minimum
equipment and consumables shall be required
 All necessary type of tests and equipment per the standard are available.

Q. Pharmaceutical Services
 Practices

 Dispensing and Medication Use Counseling

o Standard operating procedure for dispensing and medication use counseling is
established to ensure patients’ safety and correct use of medications.
o Dispensers usually make sure that prescriptions are legible, written by authorized
prescriber and complete.
o The pharmacist usually check the correctness of prescriptions in terms of
appropriateness for the patient, dosage, and medicine interactions based on
approved standard treatment guidelines before use.
o All medicines are dispensed with adequate and appropriate information and
counseling to patients for correct use of their medications.
o All medicines to be dispensed are labeled clearly.
o Filled prescriptions are signed and accountability is accepted by the dispensing
pharmacist.
o Established and implementing policies, guidelines and procedures for reporting
any errors or any suspicion in administration or provision of
prescribed medications.
o The counseling of patients or their caregivers shall be undertaken to promote the
correct and safe use of medicines
o The pharmacist usually assess each patient's ability to understand the information
imparted by question and answer
o Cautionary instructions and ancillary information about medications is
communicated in writing to the personnel responsible for administering
medications.
 Control of Drug Abuse, Toxic or Dangerous Drugs

46
 o Our hospital established Policies and procedures to control:
 Administration of narcotic drugs and psychotropic substances
o A record of the stock on hand and of the dispensing of all these drugs is
maintained
o All controlled substances (narcotic and psychotropic drugs) are dispensed to the
authorized health professional
o The controlled substances are maintained in a securely locked, substantially
constructed cabinet or area.
o The administration of all controlled substances to patients are carefully
recorded into the standard record
 Clinical Pharmacy Services
o Our hospital through drug and therapeutic committee established policies and
procedures for the provision of clinical pharmacy services
o We have in patient pharmacy
o Clinical pharmacist is assigned that can have access to patient specific
medication therapy information
o Patient-specific medication therapy information is evaluated and a medicine
therapy plan is developed by the pharmacist mutually with the patient, the
prescriber and nurse.
o The pharmacist review, monitor and propose for modification of the therapeutic
plan in case of adverse effects, patient noncompliance, evidence based efficacy
problem and as appropriate, in consultation with the patient, prescriber and nurse.
o Through prescription and medication history monitoring, the pharmacist identify
problems or opportunities for optimizing treatment and hence safeguard the
patient and ensure the optimal use of medicines
o The processes of prescribing, dispensing and administering medicines are
inherently risk-laden and hence the clinical pharmacy services shall take
responsibility for ensuring safe, appropriate and effective use of medicines
o Medication education is delivered to patients or their caregivers upon discharge
by the clinical pharmacist.
o The pharmacist always make sure that the patient has all supplies, information
and knowledge necessary to carry out the medicine therapy plan.

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 o The pharmacist is expected to attend and participate at multidisciplinary ward
rounds/morning meetings and contribute to patient care through the provision of
medicine information, dose calculations and adjustment, assisting in the rational
prescribing decision, alternative regimens and reducing the frequency and
duration of medication errors.
o Emergency pharmacy service is open for 24 hours
o The responsible pharmacist take the duty to coordinate and prepare emergency
medicines lists and ambulance kits for the hospital
o The emergency pharmacy, in addition to supply of medicines, record patient
medication information and ensure correct use of medications
 Adverse Drug event, ADE/ Pharmacovigilance
o Our pharmacy appointed an ADE (adverse drug event) focal person responsible
for the collection, compilation, analysis and communication
of adverse drug reaction, medication error and product quality defects related
information to the DTC and then to FMHACA.
o Health professionals of the hospital are also responsible to report suspected ADE
cases to the ADE focal person.
o DTC discuss and make necessary recommendations to the hospital management
for decision on adverse drug event reported within the health facility.
o We consistently update the safety profile of medicines included in the formulary
list for immediate medicines use decisions and consideration during the revision
of the list.
o Adverse medication effects is noted in the patient’s medication record.
o All the ADE reports, patient identity, reporters and medicine trade names are
kept confidential.
o The reporting of ADE is done by the national ADE prepaid yellow form prepared
by FMHACA
 Medicine Supply and Management
o A drug and therapeutics committee (DTC) representing different service units of
the hospital is in place for selection of pharmaceuticals and other medical items
and developing the formulary list as well as policies and guidelines on managing
medicines based on the general hospitals medicines list.

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 o The hospital have written policies for the procurement of medicines from
government and private suppliers, which has details of SOP.
o The hospital central medical store is responsible to display or disseminate new
arrivals or alternative medicines to each service delivery points.
o The hospital introduced and maintained stock control system
o There is a pharmacist assigned as medicine Supply Management Officer
o The responsible pharmacist usually ensure that all areas where medicines are
stored are of acceptable standards
o Special storage conditions is maintained for pharmaceuticals requiring cold chain
system, controlled substances, radiopharmaceuticals and medical gases.
o Firefighting equipment or system is installed to medicines storage places
o Distribution of medicines within a hospital is under the direction and control of a
pharmacist and is in accordance with the policy developed by DTC.
o All issuing activities are made using official and serially numbered vouchers.
o There is written SOPs on how supplies of stock are to be obtained from the
medical store.
o There is written procedures for the return of expired, damaged, leftover
and empty packs from outlets to medical store to prevent potential misuse.
o Daily medicine consumption at different outlets of the hospital is recorded,
compiled and analyzed for the appropriate supply and use of medicines.
o We make every attempt to minimize the amount of medicines waste
generated in the hospital.
o The DTC is responsible for developing policies and guidelines on how to
organize and conduct medicine use studies.
 Medicine/Drug Information Services
o The hospital established a medicine information system and is directed by a
licensed pharmacist trained in the provision of medicine information services.
o The medicine information pharmacist is member of the hospital DTC
o The medicine information service is part and parcel of the day-to-day activities of
our hospital and provide objective and unbiased information
to health care professionals and the public.
o Provision of medicine information services to patients and is in accordance with
the SOP

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 o The medicine information center provide reference materials such as medical and
medicine related books, journals, medicines profiles, electronic
information, CD-ROM, relevant formularies and manufacturers' information and
updated list of drugs available in the hospital central medical store to health care
professionals
o The service is available during normal working hours.
 Medicine Waste Management and Disposal
o The disposal of medicine wastes is in compliance with the medicines
waste management and disposal directives issued by FMHACA.
o Hospital pharmacy takes responsibility, through supportive policies and
procedures for efficiently managing the medicine wastes.
o All personnel involved in medicines waste handling are trained
o All the procedure associated with disposal is per protocol
 Recording
o Each hospital maintain records to assure that patients received the
medications prescribed by a prescriber and maintain records to protect
medications against theft and loss.
o There is standardized Prescription Registration Book
o Controlled and non-controlled prescriptions are documented and kept in a secure
place that is accessible only to the authorized personnel for at least five and three
years respectively.
o Patient and medication related records and information are also documented and
kept in a secure place that is easily accessible only to the authorized personnel
 Billing
o Medicines are received and issued using standard receiving and issuing
vouchers with serial number registered by the appropriate finance bureau of the
government following & fulfilling every component of the process per protocol.
o All medicines issued from the dispensary are dispensed/sold using standard sales
ticket with serial number registered by the appropriate finance bureau. Sales
tickets are signed and stamped.
o The hospital respects the right of the consumer and functions according to the
standard.
 Premises

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  The design and layout of the pharmacy and all other premises are fulfilled as to the
standard
 The area(s) of counseling and dispensing counter are designed, and functions in such a
way that can satisfy the right & privacy of the consumer
 All parts of the premises are maintained in an orderly and tidy condition.
 Entrances, dispensing counters and doorways are accessible to persons with disability.
 The is adequate waiting area
 The location of the pharmacy premises took into account patient convenience and ease of
loading and unloading of medicines.
 A security policy is implemented which is designed to ensure the safety of both staff and
medicines, and take account of local crime prevention advice.
 A procedure is in place to ensure access to pharmacy premises in an emergency situation.
 Compounding premise usually maintained adequate, clean and ventilated.
 Ceilings and walls of dispensaries and store are constructed to protect safety of medicines
from burglary, rodents, direct sunlight, moisture and damages.
 Medicines are shelved a minimum of 20cm above the floor, 1m wide between shelves
and 50cm away from the wall and ceiling.
 The pharmacy premises have all the necessary rooms designed for every type of
activities to be done.
 Professionals
 The overall hospital pharmaceutical service is directed by a licensed pharmacist
 Our pharmacy has adequate number and experienced pharmacists according to our load
 The hospital have written policies and procedures for pharmacy workforce determination
 The hospital pharmacy have an accountant from finance division, pharmacy clerks,
cashiers, cleaners and porters.
 Written job descriptions are prepared for all staff and that all staff are acquainted with
their job descriptions and responsibilities.
 The staff are given reqular capacity building trainings
 All activities are done per the standard guidelines.
 All the pharmacists behave in line with the rule and regulation of the hospital
 The general pharmacy gives the service for 24hr a day and 7 days a week.
 Products

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  The hospital have its own medicine list within the framework of the general
hospital’s medicine list prepared by the FMHACA.
 There is adequate, suitable dispensing equipment in the dispensary.
 Each service areas have fire extinguisher, refrigerators, deep freezers, security alarms and
racks/shelves.
 Equipment used for measuring and weighing
 Hand basin, water sources that has a source of hot and cold tap water and a closed
drainage system, Toilet facilities, consistent electricity, telephone, internet services and
office facilities such as computers, furniture and other necessary supplies.

R. Blood Transfusion Services

 Practices
 Our hospital has blood transfusion services 24 hours a day and 365 days a year
 Transfusion of blood and blood products is per our level.
 There is a policy and procedure for donation, storing, requesting, processing, transporting
and transfusing blood within the hospital.
 The hospital maintain a minimum stock of blood supply at all times
 The whole activities related to blood transfusion are recorded.
 There is a hospital transfusion committee responsible to handle transfusion related issues
 Written Consent is signed before blood transfusion by the recipient or care giver
 Request, transfusion, follow up and disposal are all done in line with standard guidelines
and documented fully.
 Premises
 Blood storage room that can accommodate the cold chain facilities
 Consistent electricity, telephone and water supply
 Toilet facilities
 Hand-washing facilities
 Professionals
 A licensed laboratory technologist
 A licensed laboratory technician
 Cleaner
 Products
 We have:
o Refrigerators designed for blood storage

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 o A deep freezer
o Incubator
o Thermometer, Timer, Pipette, Reagent dispenser, Cold boxes
o Anti A antisera, Anti B antisera, Anti D (RH Typing), Antihuman globulin
o One heating block, One water bath for cross-matching

S. Ambulance Services
 Practice
 The ambulance service is provided to every emergency patient who needs the service
without any prerequisite and discrimination
 The ambulance service is available 24 hrs a day and 365 days a year
 The ambulance service provides the following services:
o Transportation service to the hospital and from the hospital
o Clinical examinations including brief history, vital signs, very pertinent physical
examination and glucose test when needed
o Clinical lifesaving support
 The ambulance service comply with the patient rights standards and ethics of care
 Ambulances of the hospital serve only for designated emergency medical services
 The ambulance kit is checked every time after providing a service
 Premise
 Parking area
 Telephone/radio communication means
 Labelled Ambulance car with adequate space and siren

 Medical items needed for providing immediate lifesaving support

 Professional
 Nurses
 Licensed drivers
 Telephone operator
 Products
 Medicines, supplies and medical equipment
 Log book (stating time of call, time of arrival, time of return)
 Bed (couches)

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  Wheelchair,
 Emergency light
 Standby ambulances

6. Other Hospital Services

I. Infection Prevention
 Practices
 All activities performed for infection prevention comply with the national infection
prevention guidelines.
 IPC effectively and efficiently governed and managed.
 The hospital identify the procedures and processes associated with the risk of infection
and shall implement strategies to reduce infection risk.
 The following policies and procedures are maintained
o Hand hygiene
o Transmission-based precautions
o Post-Exposure Prophylaxis programs (PEP)
o Environmental infection prevention
o Waste management
 All precautions are practice as to standard
 The hospital provide regular training on infection prevention and control practice to all
stake holders
 Premises
 Working Office for IP officer
 Meeting rooms for IP-committee
 Sterilization room
 Professionals
 IP committee coordinated by a full-time infection prevention and control officer.
 The officer shall be a licensed infectious diseases specialist or IP trained health
professional
 The IP committee is composed of:
o Nursing care
o Medical services
o Environmental health
o Housekeeping

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 o Administration
o Pharmacy
o Laboratory
o Laundry
o Kitchen
o Instrument sterilization and supply
o Occupational health and safety
o Quality management
 The infection prevention committee has written policy on annual plan, quality assurance
and SOP
 Products
 The hospital has all equipment, supplies and spaces necessary for infection prevention are
available

II. Medical Recording

 Practices
 Medical record is maintained in written form for every patient seen at all points of care.
 The hospital has policy and procedure on:
o Maintain individual medical records
o A patient shall have only one medical record in the hospital.
o The medical information of a patient during ambulance service shall be
documented and attached into the medical record
o Complete legible documentation, easy retrieval and access to records.
o Confidentiality of the records
o Can be prepared in line with national or state regulation
 Premises
 There is a separate medical record room with standard premises
 The medical record room have adequate space to accommodate all services
 The medical record room has necessary supplies, environment and design.
 Professionals
 Full time medical record personnel with basic computer skill and ability to organize
medical records responsible for medical records management
 Card sorter and runner
 Products

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  The Medical record room shall have:
o Shelves
o Master patient index boxes
o Computer
o Cart
o Ladder
o Patient folder
o MPI Cards
o Log book
o Fire extinguisher

III. Food and Dietary Services

 Practices
 The hospital provide nutritionally adequate meals, food supplemental supplies for
inpatients
 The dietary service is available for 24 hours a day and 365 days a year based on schedule.
 The dietary service have written policies and procedures for all dietary services like:
o Participation in multidisciplinary patient assessment
o Each patient's diet should be recorded in the medical record.
o Records of diet instructions
o All diets should be prepared in conformity with the hospital's dietary manual.
o Effecting changes in physician orders for diets
o Follow the policies and procedures developed by the drug and therapeutics
committee
o A mechanism for evaluating patients on each nursing unit to ensure they are
being adequately nourished.
o A mechanism for the dietary service to be informed if the patient does not receive
the diet that has been ordered
 Nutrition consultations
 All necessary processes are done per protocol
 Premises
 Food preparation room with necessary equipment
 Storage room
 Cart storage.

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  Dietitian's office.
 Janitor’s closet
 Personnel toilets with hand washing facilities
 Approved automatic fire extinguisher system in range hood.
 Continuous electricity (power) supply
 Safe and adequate water supply
 Professionals
 The dietary service is directed by catering chef or food science personnel.
 Meal distributor
 Chef cook
 Kitchen workers
 Store keeper
 Bakers
 Dishwashers
 Products
 The following products are available for dietary services:
o Refrigerator
o Kitchen utensils
o Pots, Jars, Carts, Dishes, Oven, Knives, Detergent materials, Pressure cooker,
Stoves.
o Working closes (like apron, boots, hair cover, gown, hand gloves)
o Barrel (garbage containers) for kitchen rest handling
o Lockers convenient to, but not in the kitchen proper

IV. Sanitation and Waste Management

V. Housekeeping, Laundry and Maintenance Services
VI. Social Work Services
VII. Morgue Services
 We have these services as well with their own Practices, Premises, Professionals, and Products as
per the standard set by ESA.

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The End!!!

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