Ministry of Health

Ethiopian Hospital Alliance for Quality

(EHAQ) 3rd Cycle Audit

Auditors Quick Guide

CSD/MSGD/FMOH
Feb./2020

05/04/2025 1
OUTLINES
• Background
• Introduction
• CATCH IT
• KPI
• Quality
 Background
• General Hospital which found 112km to the north of the capital in
Fitche town.
• The Hospital emerged in January 1991 E.C and currently serves
catchment population estimated to be 1.5 million.
• The Hospital starts to improve quality health service since 2000
E.C by incorporating business process re-engineering.
• The Hospital is governed by Hospital Board since September 2000
E.C.
• Since 2006 E.C Fiche Hospital is a lead hospital in EHAQ system,
supporting, one general and five district hospitals.
• Currently the hospital Established CGQIU and working
courageously to give quality health service to its patients and
clients
 Introduction
• EHAQ Launched on April 2012 G.C

• Designed to create a network of hospitals that are committed to helping

one another, improve services, with an initial cycle focusing on Patient
Satisfaction and the second cycle on Maternal, Neonatal and Child
Health and CASH
EHAQ cycles
•.
1st cycle 2nd cycle 3rd cycle

MNC
Patient
HEALTH
satisfaction/EH CATCH-IT
RIG &
CASH
CATCH-IT .

Cleanliness
(CASH audit score )
CATCH-IT • EHSTG
• SaLT
• DHIS2
Timeliness • PFHI
• OPD consultation time
• EOPD triaged within 5 minutes
• Delay in elective surgical
admission
• ALOS
• Mean duration of in hospital pre-
operative stay
EHAQ LEARNING COLLABORATIVE AND PARTNERSHIP PACKAGE

1. EHAQ Mentorship
2. Supportive supervision (SSV)
3. Cluster meeting
4. Regional review meeting
5. National review meeting
6. Benchmarking
7. Quality bulletin and
8. Quality summit
Name Of The Facility:
Fitche Hospital –Lead
St Peters Specialized Hospital-Covid 19 Rx
center
 Kuyyu Hospital –Member
 Gundo Meskel Hospital –Member
Mukaturi Hospital-Covid 19 Rx center
Chancho Hospital-Member
Sendefa Bake-Member
Qinbibit Shano Hospital..Member
EHAQ AUDIT TOOL OBJECTIVES
The key objectives of the cycle :
To assess the level of health facilities on cleanliness of
care and timeliness of care and provide onsite support
for identified areas of improvement.
To select regionally and nationally best performing
health facilities based on selected cleanliness and
timeliness standards and recognize their achievement.
To provide a standard of service that brings a positive
image for the hospital and realize socially acceptable
environment for patients, visitors and staff.

05/04/2025 9
EHAQ AUDIT TOOL SCOPE

• This audit is designed to address system, practice, and performance

towards quality focusing Cleanliness and Timely Care and
Institutional Transformation initiatives.

• This audit tool assesses 6 different areas with a number of standards

under each theme.

05/04/2025 10
 AUDIT FOCUS AREA
• This audit tool assesses 6 different areas with a number of standards
under each theme.
S. No Focus area initiative Score 100% (Percentage)

1. Cleanliness of care and timeliness of care/CATCH/ 120 (40%)

2. EHSTG 60 (20%)
3. Data quality and DHIS 2 30 (10%)

4. SaLTs 45 (15%)
5. Pain free Hospital Initiative (PFHI) 15 (5%)
6. Cluster activity (EHAQ networking and 30 (10%)
engagement)

Grand Score 300 100%

05/04/2025 11
EHAQ AUDIT approach

• Hospitals are expected to be evaluated once they are ready for the
assessment.

• This audit will be carried out first by the Hospitals internally self-
assessment.
• This audit will be carried out by RHB for support at Region level.

• Audited externally by trained assessors authorized by the

ministry.
12
 INSTITUTIONAL TRANSFORMATION INITIATIVES
[Link] Hospital Service Transformational Guidelines implementation

[Link] quality and DHIS 2 implementation

[Link] implementation

[Link] free Hospital Initiative

[Link] activity (EHAQ Networking)

13
Overview of
Quality
definition&
HSTQ
The Ethiopia Health Care System
• A health system is the organization of people, institutions and
resources that deliver health care services to meet the health needs of
target populations

• And as such, with the vision “To see healthy, productive and
prosperous Ethiopians” the Ethiopian health care system is currently
arranged in a three tier system
The Three Tier System
Ethiopian Health Tier System

Specialized Hospital Tertiary level health care

(3.5-5.0 million people)

General Hospital
Secondary level health care
(1-1.5 million people)

Primary Hospital
(1-1.5 million people)

Health Centre Health Centre

(40,000 people) (25-40,000 people) Primary level health care

Health Post
(3-5,000 people)

Urban Rural
 Transforming The Ethiopian
Health Care System
• The Health Sector Transformation Plan (HSTP) 2015/16 – 2019/20
(2008-2012 EFY) is currently being implemented across the health
sector
• There are four transformation agendas outlined
1. Quality and Equity
2. Woreda Transformation
3. Information Revolution
4. Compassionate and Respectful Care (CRC)
The Ethiopian National Health Care
Quality Strategy
• The Ethiopian NHCQS, launched in 2016, builds on the plan laid out
in HSTP to further align key stakeholders across 5 prioritized
interventions, which are:
• Maternal and Child Health
• Nutrition
• Communicable Diseases
• Non-communicable Diseases
• Clinical Services
QUALITY & EQUITY
The key to accelerate
the country’s effort
and close the
remaining gaps

Ministry of Health
 DEFINING QUALITY
What Does Quality Mean to
the Health Service??
• Doing the right thing
• At the right time
• In the right way
• To achieve the best possi7ble results

- US Agency for Health Care Research and

Quality (AHC
RQ)
 DEFINING QUALITY

Quality is the extent to which health services:

• Improve desired health outcomes
• Are based on clinical evidence
• Are provided in a technically and culturally competent
manner, with good communication and shared decision
making

- US Institute of (IO
Medicine
M)
definition
”Comprehensive care that is measurably safe, effective, patient-
centered, and uniformly delivered in a timely way that is a ffordable to
the Ethiopian population and appropriately utilizes resources and
services efficiently”
(NQS 2016
Six Dimensions

1. Safe
• avoiding injuries to patients from the care that is intended to
help them
2. Timely
• reducing waits and sometimes harmful delays for both those
who receive and those who give care
3. Effective
• providing services based on scientific knowledge to all who
could benefit, and refraining from providing services to those
not likely to benefit
Dimensions
4. Efficient
• avoiding waste, including waste of equipment, supplies, ideas
and energy
5. Equitable
• providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location
and socioeconomic status
6. Patient-centered
• providing care that is respectful and responsive to individual
patient preferences, needs and values, and ensuring that patient
values guide clinical decisions
 DEFINING QUALITY
(PATIENTS/CLIENTS)
• Patients/clients may not
always define quality in the
same way as clinicians and
policy makers
• Priorities often include:
– Technical competence
– Respectful treatment
– Availability of medications
Patient/Client Definition of Quality in
Healthcare
How does patient/client define quality?

“Don’t Harm Me”

“Heal Me”

“Be nice to me”

The reality we may not believe but
we have to!
CROS
SING
THE
QUALI
TY
CHAS “Between the health
M care we have and the
health care we can
IOM have lies not only a
2001 gap but a chasm…”
 The Quality Chasm
Scarce resources?
Lack of
knowledge/skills?
Lack of
What
accountability?
Causes it? Health system
complexity
Health system
complexity!!
Health care system is
not a simple system

Rather a complex
system
Commonly used QI Models

Kaizen Model for

Improvement
Timeliness of care

1. Better Appointment system is in place

• All admission go through the liaison office
• All inpatient appointments go through the liaison office
• The hospital has updated admission discharge protocol
• OPD appointed clients directly go to specific service areas without
being triaged
• Divide the appointment day into blocks of time
• Use of phone calls or reminder text to already appointed patient to
remind specific appointment day and time
Timeliness of care
2. Early initiation of hospital service and service time recorded
• Ensure early initiation of triage and medical record (at least one hour a head of
service time)
• All OPD started at 2:30 local time
• All emergency patients triaged within five minutes of arrival
• Check early disposition of patients to respective destinations is implemented
( EOPD )
• Emergency department lay out and preparedness
• Senior physicians make round at ED 2x daily ( EOPD )
3. Discharge plan is well documented and communicated
for every admitted patients
• Availability of SOP for discharge planning
• Discharge plan for every admitted patient is well documented
and communicated based on the SOP
• The hospital implements a minimum of daily
multidisciplinary team patient rounds and visit services
4. Better queue management systems
• The hospital introduced smart/manual queue management system is in
place
5. Optimum capacity for liaison service
• The hospital provides liaison services 24 hours in a day and 7 days a
week throughout the year.
• all referral out service are properly communicated to the receiving facility
• The hospital has bed monitoring system
• Documentation of elective admission waiting list with clear appointment
date
6. Increase OR efficiency
• Elective surgeries started at the beginning of the working hour.
• All patients planned for elective surgical admission are pre
communicated one week before surgery
• Elective surgery are scheduled in all working days
7. Avoid/Minimize cancellation
• Pre-operative evaluation and investigation were completed before
admission of patient
• Blood is available in their stock
• Supplies and equipment checklist filled for all procedure before a day
of surgery
CLEANLINESS OF CARE
1. CASH performance Audit
• Quarterly CASH Audit performed.
• Written feedback is given for specific departments
• Action plans are developed based on audit findings and
implementations are monitored by CASH/IPC committee and SMT
2. Monthly cleaning campaign is performed.
• The hospital has assigned a monthly cleaning day that is known by all
staff.
• The hospital has conducted monthly cleaning campaigns
3. Hospital compound is clean and tidy.
• Hospital internal grounds are visibly clean and tidy.
• Presence of clean designated green areas/parks with seating
facilities
• Wastebaskets are placed for nonmedical waste and
appropriately used.
4. Adequate Cleaning equipment and supplies are availed
and used
• Equipment and supplies, needed for cleaning, are available for the last
three months.
• All cleaners/housekeeping staff receive capacity building/orientation.
• All cleaners/housekeeping staff uses cleaning equipment and supplies
• All cleaners/housekeeping staff use personal protective equipment
while they are on duty.
5. All wards and corridor are visibly clean.
• Floors, walls and ceilings of wards and corridors are regularly cleaned
based on their schedule.
• Ward masters are assigned to oversee cleanness of their respective
service areas/ward.
• Presence of quarterly recognition scheme for clean wards
6. All OPD and IPD toilets are visibly clean and have
functional hand washing facility
• All toilets are visibly clean
• All toilets have a functional hand washing facility and soap is
available at all times
7 .Kitchen room visibly clean and staff are dressed
appropriately
• The kitchen and food making appliance are clean.
• Food transportation and covering material are in place.
• Staff wear clean cooking dresses, cover their hairs
• Functional shower is available in the kitchen.
• Food raw materials are appropriately sorted, labeled and
shelved
• Kitchen has an exhaust outlet and is well ventilated
8. The hospital has a functional laundry services.
• Hospital laundries have a functional machine (washing, drying and ironing) with
back up
• The laundry have separate areas for clean and soiled linen storage.
• The laundry have separate carts for clean and soiled linen transportation
• Equipment and supplies needed for laundry services are available for the last three
months
• Presence of preventive and corrective maintenance by from Biomedical
engineering team
• Laundry staffs dressed personal protective equipment
9. Optimum instrument processing
• Functional and consistent operation of autoclave and Sterilization
equipment
• Sterilized items are kept in a clean, separate, labeled and enclosed
storage area
• Sterilized and wrapped packages are dated and labeled with autoclave
indicator tape
• All Health workers are aware on 0.5% chlorine solution preparation
10. Hand hygiene practice (HH)
• Five moments of hand hygiene practice is in place
• Functionality of hand washing sinks equipped with liquid
soap/soap and water availability with backup
• Alcohol based hand sanitizer availability(Inpatient,
Emergency and Laboratory)
11. Improve health care waste management practice
• The hospital should have functional color coded and covered waste bins at each
service area
• Areas for storage of waste awaiting removal from the hospital should be fenced
and protected
• Clean and functional placental pit is available.
• Functional incinerator is available.
• Domestic waste pit for burning of non-infectious waste and burial pit for the
burial of non-combustive waste are available
• Hospital has proper liquid waste management system.
• Liquid wastes generated from the hospital is treated
FITCHE HOSPITAL MONTHLY CLEANING CAMPAIGN
Cobblestone at the gate of Fiche
Hospital
Fiche Hospital green area
Selected EHSTG
HOSPITAL LEADERSHIP, MANAGEMENT AND
GOVERNANCE
• The hospital has a functional governing board (GB) meets regularly to oversee the overall
operations and service delivery of the hospital.
• The hospital has a functional SMT that meets regularly to manage and execute the overall hospital
operations.
• Hospital has a well-functioning Development army.
• The hospital governing board has a plan to mobilize resources from diverse sources and makes
sure resources are utilized effectively and efficiently
• There is a system and practice of measuring performance and results, appraisals and recognition
system for departments and individual best performers in the hospital
• The hospital SMT and GB has ethics violation reporting, complaint handling and
management/reporting system

• The hospital has a ongoing capacity building program both for GB members and SMT.
• The GB, SMT & CEO is evaluated every six months
EMERGENCY MEDICAL SERVICES

• The hospital has an emergency department led by an emergency director / case manager with customized JD
for the department and individuals
• The hospital has an Emergency Triage, staffed with necessary infrastructure.
• The hospital has easily accessible Emergency department with an ambulance parking area
• The hospital shall establish efficient flow of Patients in the emergency department.
• The Emergency Department/Unit shall use a triage system of screening and classifying patients to determine
their priority needs and to ration patient care efficiently.
• The hospital provides emergency medical service 24Hours a day .
• There is emergency response plan for both internal and external disasters with a system to alarm or
communicate personnel and other stakeholders.
• Emergency department or Unit has policies, protocols,flowcharts, consultation and treatment guidelines for
running ED/EU.
NURSING AND MIDWIFERY CARE SER VICES
MANAGEMENT

• The hospital has established nursing midwifery service management structures and job
descriptions that detail the roles and responsibilities of each nursing and midwifery
professional, including reporting relationships.
• The hospital has a nursing and midwifery workforce plan that addresses nurse
/midwife staffing requirements and sets minimum nurse /midwife to patient ratios in
each service area.
• The hospital has written policies describing the responsibilities of nurses and
midwives for the nursing/midwifery process including the admission
assessment, planning, implementation and evaluation of nursing/midwifery care
• All admitted Pts and mothers and emergency patients/clients have a
nursing/midwifery care plan that describes holistic nursing/midwifery
interventions to address their needs.
• All hospital nurses/midwives comply with the professional code of conduct and
ethics which governs their professional practice
• The hospital has established guidelines for verbal and written communication
about patient/client care
• The hospital has standardized procedures for the safe and proper administration of
medications.
• The hospital has established nursing/midwifery care practice audit program
• The hospital has a centralized nursing/midwifery station set-up in each ward with
adequate space,equipment and consumables
MATERNAL, NEONATAL AND CHILD HEALTH SERVICES
MANAGEMENT

• The hospital ANC unit provides individualized, client centered and evidence
based care to clients on all working days and high risk mothers should be seen in
the referral clinic.
• The hospital should ensure provision of Comprehensive Emergency Maternal and
Newborn Care (CEmONC) services.
• The hospital should ensure women and child friendly services at all MNCH units
including pain management.
• The hospital ensures all equipment, essential drugs, supplies and reference
materials are available in maternity and pediatric unit.
• The hospital should ensure the provision of intrapartal care as per national
protocols
• The hospital should provide comprehensive postnatal care in the facility as per
national standards.
• The hospital should ensure provision of family planning (with focus on long term
methods) and comprehensive abortion care services following the national
guideline and policies.
• Maternity and pediatric units should undertake CQI activities by conducting
regular review meetings and audit programs.
• Hospitals have established separate pediatric
OPD, emergency and triage services.
• Hospitals have comprehensive Neonatal Care service that includes NICU, KMC,
mother’s room and isolation rooms
• Hospitals have separate Pediatric Wards composed of separate critical, general,
SAM, isolation and procedure rooms.
• Midwives should implement the midwifery process at all hospitals for all admitted
patients
LABORATORY SERVICES
MANAGEMENT
• The hospital has a clear laboratory management structure and accountability arrangement.

• The hospital laboratory management has established system for management of documents and records that

are maintained, controlled, reviewed and approved to ensure the provision of

quality laboratory services.

• The hospital laboratory has established system to monitor the effectiveness of its customer service program.

• The hospital laboratory has and implements a proper management system for its equipment that includes the

calibration, maintenance and inventory to ensure the provision of accurate, reliable and timely test results.

• The hospital has a laboratory supplies management system.

• The hospital laboratory shall implement a process control system that
monitors the processes from pre analytical to post analytical phases of
testing, including an established internal quality control.
• The hospital laboratory has established incident handling and
reporting system which includes errors or near errors (near misses).
• The hospital has established laboratory management information
system.
• The laboratory shall design a backup laboratory Service through
availing back laboratory equipment or and through backup laboratory
facility.
• The hospital laboratory has appropriate storage
and stock management systems for blood and
blood products received from blood banks
• The HTC in collaboration with respective regional blood back service shall
have mobilization of blood donation strategy through community awareness
programs.
• The hospital laboratory blood bank service shall +have appropriate cold chain
system for blood and blood products received from blood bank service until
used by prescribers.
• The hospital laboratory blood bank services hall
report blood administration and patient safety
information to respective regional blood banks
PHARMACY SERVICES
MANAGEMENT
• The hospital provides quality pharmaceutical products and effective services in its outpatient,
inpatient, and emergency pharmacy
service unit.
• The hospital has a functional Drug and Therapeutics Committee (DTC) that develops and
implements interventions promoting the rational
and cost- effective use of medicine.
• The hospital has a Medicines Formulary listing all pharmaceuticals prioritized by VEN that can be
used in the facility. The Formulary is utilized and
updated annually.
• The hospital ensures execution of good dispensing practices at all dispensing outlets.
• The hospital implements auditable, transparent and accountable pharmaceutical transactions and
services(APTS).
• The hospital provides clinical pharmacy services
at inpatient, outpatient and emergency departments.
• The hospital provides drug information services to health care providers, patients
and the public.
• The hospital has a functional compounding service.
• The hospital has efficient and effective pharmaceutical logistics management
system that reduces the frequency of stock-outs, wastage, over supply and drug
expiry.
• The hospital has appropriate both paper and computer-based inventory
management system.
• The hospital has an established system for regular Monitoring medication use and
safety
• The hospital conducts continuous segregation, Documentation and safe disposal
of
pharmaceutical wastes.
CLNICAL GOVERNANCE and QUALITY
IMPROVEMENT

• The hospital has a Clinical Governance and Quality Improvement Unit that is led
by at least MPH/MSc or General Practitioner.
• The hospital should develop a clinical governance and quality improvement
strategy.
• Procedures are established to monitor clinical practices and standards through
services’ specific process and outcome measures to enable the hospital to address
any problems identified.
• The hospital implements a regular clinical audit program in each service area.
• Procedures are established to assess and minimize risk arising from the provision
and delivery of health care.
• The hospital adopts a statement of patient rights and responsibilities,
• The hospital continuously and systematically reviews and improves all
aspects of its activities that directly affect patient safety and apply best
practice in assessing and managing risks to patients, staff and other.
• The hospital monitors patients’ experiences with care through patient
and satisfaction surveys conducted on a quarterly basis.
• The hospital develops and implements a strategy to provide patient
focused care.
• The hospital participates in benchmarking activities to learn from and
share good practice with other hospitals
Data Quality and DHIS 2
• % of EHSTG standards meet
• ER attendances length of stay greater than 24 hours
• Delay for elective surgical admission
• Institutional Maternal mortality
• Bed occupancy rate
• Patient satisfaction
 KPI Performance of FITCHE GENERAL HOSPITAL, 2012EC
SN PERFORMANCE
KPI TARGET

Quarter 1 Quarter 2 Quarter 3 Quarter 4 Annual

1 % EHSTG standard met 80% 65.5% 65.7% 70.6% 70% 69.6%

2 % of Non-Functional Model 0 12% 14% 8.3% 4%

Medical Equipment
5.5%

3 Outpatient waiting time < 60 minute 16minute 18 minute 16 minute 17 minute 16.25 minute

4 Outpatient not seen on the 0 0 0 0 0 0

same day
5 Emergency room 100% 95% 95% 98% 94.6 % 95.56%
patients triaged within 5
minutes of arrival

6 Emergency room 0 0 9.5% 3.8% 1.1% 1.1%

attendances with length
of stay > 24 hours

7 Delay for elective <15days 32 days 10 days 14 days 14 days 17.5 days
surgical admission

8 Pressure ulcer incidence 0 0 0 0 0.005% 0.0003%

9 Surgical site infection 0 0.02% 0.01% 0.02% 0.02% 0.017%

rate (SSI)
10 Completeness of 100% 60% 56% 65% 70% 62.75%
inpatient medical records

11 Peri-operative mortality 0 0.003% 0 0 0 0.00075%

rate

12 Rate of safe surgery 100% 70% 70% 90% 95.6% 81.4%

checklist utilization

13 Major surgery 193 187 207 218 805

14 OPD VISIT 20410 21459 15873 13822 71,564

15 IPD admission 1091 1105 921 1004 4,121

16 Total delivery 534 644 700 609 2,487

17 Proportion of women 100% 100% 100% 100% 100% 100%
Survived from PPH

18 CASH Audit Score 90% 65% 65.5% 62.5% 64.5% 64.375%

19 Patient satisfaction score 90% 77% 78% 73% 73.5% 75.4%

20 Staff satisfaction 69% 69% 69%

21 BOR 81% 83% 58% 64% 71.5%

22 Essential lab availability 100% 80% 82% 78% 80% 80%

23 Percentage of Clients 100% 68% 72% 72% 80.6% 73.15%

with 100% prescribed
drugs filled
24 Institutional maternal 0 01 mother 01 mother 02 mother 0 04 mother
mortality

25 Major Surgery Per 10.7 10.3 11.5 12.1 11.22

surgeon( Monthly)

26 OPD patient per 567 596 440 384 496

physician( Monthly)

27 Proportion of SLIPTA 74% 74% 74%

standard met

28 HSTQ score 100% 85 % 85.5% 87% 90% 86.7%

29 GGI Not done Not done 79% 85% 78.5%

30 Emergency room 2280 1708

attendance
Saving lives through Safe
Surgery (SaLTs)
1. The Hospital has appropriate and functional working environment to
provide quality surgical services
• Continuous 24/7 electric supply with automatic backup generator is available.
• Continuous 24/7 water supply with back up source is available
• Minimum number of OR tables are present.
• Cleanliness of the OR room and Equipment’s.
• Demarcated 4 zones present
• Changing rooms with lockers present
• Recovery room is present
• Toilet and showers present
• OR Nurse station present
• Mini-store present.
• Safety of electrical establishment
• Windows/ ventilators if any in the OR are intact and sealed
• Privacy kept for all clients throughout all aspects of care.
2. Adequate staff is consistently available to provide routine care and manage
complications

• Number of minimum OR staff available based on the standard.

• A clear communication plat form is present to reach staff on duty at
all times.
• A written, up-to-date quality-of care improvement plan and patient
Safety program is present in OR and surgical ward.
3 Surgical service leadership and efficiency

• Leadership structure, indicating roles and responsibilities

• Availability of client compliant handling mechanisms
• Monitor Major surgeries per table per day in the facility
• Monitor Delay for elective surgery
• Monitor Rate of cancellation of elective surgery
4. Evidence-based care is provided for all surgical patients

• Protocols for transferring and consultation mechanisms are present.

• Antibiotics used for surgical prophylaxis are as per standard treatment Guidelines (STG)
recommendation
• Surgical safety checklist is used.
• Completeness of surgical patients’ clinical records
• Patient and/or attendant is informed about clinical condition, surgical finding and treatment
provided.
• Check post-anesthesia status is monitored and documented.
5. Availability of essential pharmaceuticals and diagnostic
surgical service

• Availability of vital, and essential drugs and supplies for anesthesia and
surgical care.
• Continuous availability of basic laboratory and pathology services for
surgical patients.
• Continuous availability of basic radiology service.
• oxygen is consistently and adequately available in the OR
Pain Free Hospital
Initiative
• Hospital has implemented pain as a 5th vital sign
• Pain score is integrated with patients vital
sign chart )
• Patients Pain assessment is performed, scored and managed.
• Hospital has written and approved Pain Management Protocol.
• Adult and pediatric Pain Management protocol is available
• Patient education is given on how to report pain and proper utilization of pain medication.
• Pain Medication included in the Vital List
• Hospital pharmacy department promotes Good Dispensing practice for pain medication
• Hospital conduct a Pain Assessment and
Pain Management Audi
CLUSTER ACTIVITY (EHAQ Networking and engagement)

1. Clusters have regular meeting

• There is approved TOR and shared with all members of the cluster
• There is agreed activity plan and performance report for cluster
• Cluster regular meeting is conducted, recorded and follow-up action plan is
developed
• Best practices are documented and shared among member hospitals
[Link] conducts regular mentorship and
supportive supervision

• Lead hospital conducted regular mentorship or supervision to

member hospitals
• Regular feedback is given to member hospitals
• Lead hospital regularly monitored member hospitals cluster
performance
3. Community discussion panel

• Quarterly community forum is conducted

• Community forum action plan developed, communicated and implemented
• Hospital conducted regular mentorship or supervision to catchment Lead health
centers.
• Hospital regularly monitored performances of Lead health centers
• Hospital regularly supported Lead health centers with human resource, medical
equipment and supply
 Fiche EHAQ activity performance of 2012EC
• Three supportive supervision/ mentorship conducted.
• Three cluster meeting was attended.
• Two regional meeting and national meeting.
• Participate in Regional Quality summit and send QI project for quality bulletin
• Win one national QI project grand award ( 300000ETB)
• Good referral linkage among Hospitals.
• Hospital has good relation with catchment HC
• Medical equipment and supplies sharing among Hospitals.
• Human resource sharing among Hospital
 Fiche CATCH IT performance
[Link] CATCH IT Score 100% Achieved Achieved
(Percentag score percentage
e)
1. Cleanliness of care and timeliness of 120 40%
care/CATCH/ 92.5 30.83%
2. EHSTG 60 20% 7.48%
22.45
3. Data quality and DHIS 2 30 10% 26.33
8.76%
4. SaLTs initiatives 45 15% 11.67%
35
5. Pain free Hospital Initiative (PFHI) 15 5%
3 1%
6. Cluster activity (EHAQ networking and engagement) 30 10% 8%
24
Total Score 300 100% 190.33 67.74%
Over all result of Hospital..CATCH IT
2012EC achievement
100.00%

67.74% 66.31%

55.50% 54.77%

36.70%

FITCHE KUYYU CHANCHO GUNDOMESKEL SENDAFA BAKKE TARGET

***HORAA
BULAA***