ministry of health of ethiopia national safe surgery

iNational Five-Year Safe Surgery Strategic Plan

Saving Lives Through Safe Surgery (SaLTS)Strategic Plan 2016-2020

Addis Ababa, 2016

Ministry of Health of EthiopiaNational Safe Surgery Strategic Plan

Ministry of Health

This document was developed and printed with funding from the GE Foundation through the Safe Surgery 2020 Initiative. The contents are the responsibility of the Ministry of Heath of Ethiopia and do not necessarily reflect the views of the GE Foundation and Safe Surgery 2020 Initiative.

National Five-Year Safe Surgery Strategic Plan

Ministry of Health of Ethiopia

National Safe Surgery Strategic Plan

Saving Lives Through Safe Surgery (SaLTS) Strategic Plan 2016–2020

Ministry of Health

i


Table of ContentsTable of Contents .........................................................................................................................................ii

Abbreviations .............................................................................................................................................iv

Foreword ......................................................................................................................................................v

Acknowledgments ..................................................................................................................................... vi

Background ..................................................................................................................................................1

Introduction .................................................................................................................................................2

Rationale for Saving Lives through Safe surgery .....................................................................................................2

Country Surgical and Anesthesia Care Assessment ..............................................................................3

Strengths and Weaknesses ............................................................................................................................................4

Stakeholders’ Analysis ...................................................................................................................................................8

Saving Lives Through Safe Surgery Aim and Objectives .......................................................................................9

Strategic Pillars and Strategic Results ........................................................................................................................9

Strategic Pillar One: Leadership, Management and Governance ...................................................10

Strategic Objectives .....................................................................................................................................................10

Strategic Results ...........................................................................................................................................................11

Structure ........................................................................................................................................................................11

Strategic Pillar Two: Infrastructure Development ...........................................................................14


Strategic Pillar Three: Equipment and Supplies Management ......................................................15

Strategic Objectives 1 ...................................................................................................................................................15

Strategic Pillar Four: Excellence in Human Resource Development ...........................................16


Strategic Pillar Five: Excellence in Advocacy and Partnership .................................................... 26


Components ..................................................................................................................................................................26

Structure ........................................................................................................................................................................26

Identified Interventions ..............................................................................................................................................27

ii


Measurement/Indicators ............................................................................................................................................27

Strategic Pillar Six: Excellence in Quality and Safety .................................................................... 30

Objective 1: Improve efficiency in surgical and anesthesia care. .........................................................................30

Objective 2: Improve effectiveness of surgical and anesthetic care using evidence-based clinical care. ...............................................................................................................31

Objective 3: Establish a culture of patient-centered care in the surgical system ..............................................31

Objective 4: Improve safety in surgical and anesthesia care. ...............................................................................32

Objective 5: Ensure the provision of timely surgical and anesthesia care for emergency conditions and elective procedures. ..............................................................................32

Objective 6: Ensure equity in surgical and anesthesia care. .................................................................................33

Strategic Pillar Seven: Excellence in Innovations ........................................................................... 34

Strategic Objective .......................................................................................................................................................34

Component ...................................................................................................................................................................34

Strategic Pillar Eight: Excellence in Monitoring and Evaluation ................................................ 38

References ...................................................................................................................................................45

Annex A. Tool for Situational Analysis to Assess Emergency and Essential ................................ 46

Surgical Care in Ethiopia ................................................................................................................................................

Annex B: Safe surgery checklist ............................................................................................................ 77

Surgical and Anesthesia Care Audit Tool ................................................................................................................79

Annex C. Procedure Lists .......................................................................................................................91

iii


AbbreviationsCOSECSA College of Surgeons of East, Central, and Southern Africa

CPD Continuous professional development

CRC Compassionate, respectful and caring

CRCP Curative and rehabilitative core process

CRCPT Curative and rehabilitative core process team

EHAQ Ethiopian Hospitals Alliance for Quality

FMOH Federal Ministry of Health

HEI Higher education institution

HMIS Health management information system

HSTP Health Sector Transformation Plan

IESO Integrated Emergency Surgical Officer

IST In-service training

KPI Key Performance Indicators

M&E Monitoring and evaluation

MOF Ministry of Finance

OR Operating room

RHB Regional health bureau

SaLTS Saving Lives Through Safe Surgery

TWG Technical working group

WHO World Health Organization

iv


Foreword The Ethiopia Federal Ministry of Health (FMOH) has launched the Health Sector Transformation Plan (HSTP) as part of the second Growth and Transformation Plan of the Ethiopian government. The HSTP has set ambitious targets toward realizing the sustainable development goals and identified four transfor-mation agendas: Quality and Equity, Woreda Transformation, Information Revolution and Compassionate, Respectful and Caring (CRC) health workforce.

In line with the quality and equity transformation agenda and as part of recognizing the key roles essen-tial and emergency surgical care plays in achieving universal health coverage, the FMOH has prioritized surgical and anesthesia care by launching the national flagship initiative-Saving Lives through Safe Surgery (SaLTS).

The SaLTS initiative was launched in response to the World Health Assembly resolution-68/15 and aims to make essential and emergency surgical and anesthesia care accessible and affordable as part of the univer-sal health coverage. It is expected that the SaLTS initiative will streamline all efforts toward defining a package of essential and emergency surgical care for Ethiopia: to be available at all levels of the health care delivery system so that they will be accessed equitably by all segments of the population.

The FMOH extends its firm commitment to improving the situation of surgical and anesthesia care in Ethiopia by launching this strategic plan. As a flagship initiative, SaLTS will receive the highest level of attention by the leadership of the health sector.

I would like to take this opportunity to extend our profound appreciation to all individuals and organiza-tions who have actively participated in the development of the SaLTS strategic plan.

Daniel Gebremichael Burssa (MD, MPH)

Director General, Medical Services General Directorate

v


Acknowledgments The Federal Ministry of Health would like to acknowledge the following individuals and their institutions for serving as core team members of the SaLTS plan development team:

Dr Daniel Gebremichael, FMOH

Mr. Esayas Melese FMOH

Dr Atlibachew Teshome FMOH

Dr Samuel Zemenfeskidus FMOH

Dr Andualem Deneke Surgical Society of Ethiopia

Dr Rediet Shimelis Ethiopian Society of Anesthesiologists

Dr Abebe Bekele Addis Ababa University/FMOH

Dr Abraham Endeshaw Jhpiego

Dr Samson Esseye Jhpiego/FMOH

Kaya Garringer PGSSC

Olivia Ahearn PGSSC

Additionally, the following individuals have provided various technical inputs to the development of the SaLTS strategic plan:

Alemayehu Berhanu CHAI

Dr Dereje Gulilat Surgical Society of Ethiopia

Professor Milliard Derebew COSECSA

Dr Tigistu Ashengo Jhpiego

Sr Teruwork Kebede Jhpiego

Alena Skeels Jhpiego

Erin Barringer Dalberg

Asha Varghese GE Foundation

Ashley Eberhart Dalberg

Cheri Reynolds Assist International

The Federal Ministry of Health is very grateful to the following organizations for actively supporting the SaLTS plan development process:

Safe Surgery 2020 and GE Foundation

PFSA: Pharmaceutical Fund and Supply Agency

Surgical Society of Ethiopia

Ethiopian Society of Anesthesiologists

Ethiopian Society of Anesthetists

Ethiopian Society of Obstetricians and Gynecologists

USAID/HFG (HEALTH FINANCE AND GOVERNACE)

SCMS: Supply Chain Management System

CHAI: Clinton Health Access Initiative

World Health Organization

AMREF Health Africa

St Paul Hospital Millennium CollegeAddis Ababa University School of Medicine

vi

1National Five-Year Safe Surgery Strategic Plan

BackgroundSafe surgery has been an essential component of health care for years. However, the increasing incidence of traumatic injuries, cancers and cardiovascular diseases continue to raise the impact of surgical interven-tion in public health systems. In fact, safe surgery is the second global patients’ safety challenge next to health care associated infections. Surgical safety is a concern because most institutions do not implement the standard World Health Organization (WHO) surgical checklist.

Disorders that could be managed by surgery constitute a significant portion of the global disease burden (Debas et al. 2015). Annually, injuries kill nearly 5 million people, and about 270,000 women die from complications of pregnancy. Many of these injury-related and obstetric-related deaths, as well as deaths from other causes (e.g., abdominal emergencies and congenital anomalies), could be prevented by im-proved access to surgical care (Debas et al. 2015).

An estimated 234 million major surgeries are performed around the world each year, corresponding to one surgery for every 30 people alive. Yet, surgical services are unevenly distributed with 30% of the world’s population receiving 75% of major operations. Lack of access to high quality surgical care remains a sig-nificant problem in much of the world despite the fact that surgical interventions can be cost effective in terms of lives saved and disability averted. Despite this large burden, surgical services are not being deliv-ered to many of the individuals who need them most. An estimated 2 billion people lack access to even the most basic of surgical care (WHO 2008).

This need has not been widely acknowledged, and, therefore, priorities for investment in health sys-tems’ surgical capacities have only recently been investigated. Indeed, until the 1990s, health policy in resource-constrained settings focused sharply on infectious diseases and under nutrition, especially in children. Surgical capacity was developing in urban areas, but was often viewed as a secondary priority that mainly served socio-economically advantaged people.

The number of surgeries done in Ethiopia is not more than 200,000 a year with 250 general surgeons, 300 gynecologists, 50 orthopedic surgeons, and 100 ophthalmologists, which is inadequate to reach the unmet need of 5,000,000 surgeries per year. The waiting time for surgery extends up to four years, especially in referral hospitals.

Surgical site infections remain one of the most common causes of serious surgical complications. Evidenc-es show that proven measures, such as antibiotic prophylaxis within the hour before incision and effective sterilization of instruments, are inconsistently followed often not because of cost or lack of resources but because of poor systematization. Antibiotics, for example, are given perioperative in both developed and developing countries, but they are often administered too early, too late or simply erratically, making them ineffective in reducing patient harm.

Mortality from general anesthesia alone is reported to be as high as 1 in 150 in parts of sub-Saharan Africa. Three decades ago, a patient undergoing general anesthesia had an estimated 1 in 5,000 chance of death. With improvements in knowledge and basic standards of care, the risk has dropped to 1 in 200,000 in the developed world—a 40-fold improvement. Unfortunately, the rate of anesthesia-associated mortality in developing countries appears to be 100–1000 times higher, indicating a serious, sustained lack of safe anesthesia for surgery in these settings. In addition, anesthetic complications remain a substantial cause of surgical death globally, despite safety and monitoring standards that have significantly reduced unnecessary deaths and disability in developed countries.

2 National Five-Year Safe Surgery Strategic Plan

IntroductionThe Ethiopian Federal Ministry of Health (FMOH) implemented the Health Sector Development Pro-gram 1–4 successfully that helped reform the nation’s health system in the last 20 years. Currently, the FMOH launched the fifth strategic plan, called the Health Sector Transformation Plan (HSTP), which is aligned with country’s second growth and transformation plan. The HSTP has identified quality and equi-ty as a cornerstone of the transformation agenda focusing mainly on essential and emergency safe surgical and anesthesia care, in addition to maternal, neonatal and child health; nutrition; chronic non-communica-ble diseases and infectious diseases.

Saving Lives Through Safe Surgery (SaLTS) is the FMOH’s flagship initiative that is designed to respond to the World Health Assembly resolution of A68/15 in making emergency and essential surgical and anesthesia care accessible and affordable as part of the universal health coverage. The SaLTS initiative was developed with the objective to ensure the delivery of quality, safe, essential and emergency surgery throughout the country to alleviate the national burden of diseases, disability and death that are prevent-able throughout safe surgery.

The development of the SaLTS initiative was informed by input from various stakeholders and it aims to build on the experiences of existing reform agendas including but not limited to the Ethiopian Hospitals Reform initiative and utilizes the Ethiopian Hospitals Alliance for Quality (EHAQ) as a platform for rapid scale up. As a flagship initiative of the HSTP under the quality and equity transformation agenda, it will be integrated into the newly revised the Ethiopian hospitals reform implementation guideline for rapid imple-mentation and scale up in all health centers, primary hospitals and tertiary hospitals.

Rationale for Saving Lives through Safe surgery The provision of essential surgical procedures ranks among the most cost effective of all health interventions and would avert about 1.5 million deaths a year, or 6%–7% of all avertable deaths in low-income and middle-income countries (Debas et al. 2015; Mock et al. 2015).

In general, the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. Full coverage of universal coverage of essential surgery applicable to first-level hospitals would require over an estimated US $3 billion annually of additional spending and yield a benefit–cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems (Mock et al. 2015).


Country Surgical and Anesthesia Care Assessment

A situational analysis was conducted on selected health centers, primary hospitals and tertiary hospitals using the WHO surgical and anesthesia needs and status assessment tool.

According to WHO, properly equipped primary hospitals in low-income countries such as Ethiopia are able to perform emergency surgery for a number of conditions, including obstetric complications; abdom-inal emergencies and basic surgeries and injuries; simple orthopedic care for extremity fractures, dislo-cations, and amputations; burn care and uncomplicated general surgery for hernias; and treatment and control of surgical infections (Debas et al. 2006). However, many primary hospitals in rural Ethiopia are not in a position to provide the mentioned services due to lack of appropriate human resources, supporting staff, equipment and supplies.

A total of 44 essential surgical procedures that have been recommended in the Disease Control Priorities will provide a reasonable starting point for an essential surgical package, although there will be coun-try-specific variations (Debas et al. 2015). Safe anesthesia and perioperative care are necessary components of all of these procedures.

The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures. Investing in this platform is also highly cost effective for the long term to expand access to surgery. Task sharing by health officers through short-term training has been shown to be safe and effective while the country made long-term investments in building the surgical and anesthesia workforces.

SaLTS focuses on availing a package of essential and emergency surgical and anesthesia care at all levels of the Ethiopian health care delivery system with special emphasis in strengthening primary care to provide essential surgical care. Feasible measures, such as WHO’s Surgical Safety Checklist, have led to improve-ments in safety and quality. (Debas et al. 2006).


Strengths and WeaknessesA thorough systematic analysis of the Ethiopian health system supporting the SaLTS prioirties.

Building Blocks

Strength Weakness

Leadership and governance

Leading and coordinating

• Use of technical working groups (TWGs)

• Establishment of partner’s forum at subnational level

• Health Extension Program (HEP) and Health Development Army (HAD) as a demand creation, improving access and community empowerment tool

• Improved integrated supportive supervision practice

• Institutionalization of service improvement ap-proaches like Balanced Score Card (BSC), EHAQ.

Controlling and monitoring

• Strengthening of regulatory system

• Actions for standardization and regulation (facility standard, licensing)

• Establishment of quality control of lab

• Essential surgical and anesthesia care were not classified as primary health care

• Donor dependent program designing, resource and funding allocation

• Inadequate focus for streamlined planning and implemen-tation among the directorates and agencies of FMOH, partners and regions.

• Low involvement of patients in decision-making/leadership level

• Inequity across regional capacity in leading and implemen-tation capacity among regions and health facilities

• Weak implementation capacities among agencies, FMOH and regional health bureaus (RHBs).

• Lack of structural review and adjustment along with stra-tegic plan

Human resources and infrastructure

• Rapid increase in the availability of human re-sources for health IESOs, surgeons

• New initiatives such as CPD, leadership programs, by Ethiopian Food Medicine Health Care Admin-istration and Control Authority (FMHACA) under FMOH

• Rapid expansion of health institutions with prima-ry health care to 100%

• Procurement of medical equipment including op-erating room (OR) tables and anesthesia machines

• Wide gap in the global indicator of surgical capacity per population

• Lack of clarity in implementation of national guidelines in big cities, including health center and primary hospital reforms

• Limited capacity to own and lead some program areas at national level

• Poor provider attitude and low commitment of various stakeholders

• High attrition rate and absence of human resources motiva-tion and retention strategy

• Weak institutional knowledge management

• Weak knowledge generation and utilization at national level

• Inequity in the distribution of skilled manpower

• Lack of motivation and retention strategy


Building Blocks

Strength Weakness

Information • Improvement of evidence generation and dissem-ination:

• Several surveys and assessments are/were con-ducted (Ethiopian Health Demographic Survey (EHDS), Service Provision Assessment Plus Survey (SPA+), STEP wise survey for non-com-municable diseases (NCDs),)

• Improvement of health management information system (HMIS) and initiation of HMIS in private health facilities, initiation of community-based information systems (CHIS)

• Documentation of best practices

• Regular and participatory review mechanism such as annual review meetings

• Suboptimal use of evidence generated for timely deci-sion-making (mainly at local level):

• Weak systematic documentation of evidences

• Inadequate triangulation of information (HMIS, surveys, safe surgery findings, operational research)

• Inadequate and /or incomplete data:

• Inaccuracy of data on surgical and anesthesia care

• Lack of comprehensive information on disease burden

• Limited implementation of logistics management informa-tion system (LMIS) and HMIS

• Parallel and multiple reporting system

• Weak joint planning and monitoring of surgical and anes-thesia service performances

• Inadequate capacity-building of regional public health research centers

Medical drug and product

• Improved commodity security

• Growth of revolving drug fund capital

• Increased availability of ambulance services

• Increased supply of medical equipment

• Initiation of telemedicine, tele-education

• Supply chain gap (No availability of essential medicines and supplies (weak pharmaceutical logistics information system)

• Weak ambulance service management and inadequate running cost

• Poor capacity of forecasting, quantification procurement and stock management of supplies and commodities

• Poor forecasting, quantification and stock management of supplies and commodities

• Weak maintenance capacity (medical equipment)

• Low utilization of technology and innovations



Building Blocks

Strength Weakness

Service delivery • Increase in construction of hospitals and health centers

• Steady increase in key diagnostic and radiological intervention coverage

• Health facility expansion particularly to primary health care facilities

• Increase in availability of ambulance services

• Storage and distribution capacity of pharmaceuti-cal supplies and services

• Experience in implementing large scale successful programs

• Efforts for preparation of minimum service standards

• Decentralized lab services

• Sub-optimal functionality of health facilities

• Sub-optimal service availability and readiness at health facilities

• Missed opportunities for essential health interventions due to limited focus on integrated service delivery

• Inadequacy in continuum of care:

• Potential tertiary care gaps - limited surgeons, gynecolo-gists, IESOs, anesthesia professionals, trained OR nurses/managers access to hospital care, with negative influence on the continuum of care

• Inequitable distribution of human resources

• Socioeconomic situations (gender, education, income)

• Service points are not user-friendly particularly for disabled people and women

• Sub-optimal quality of care

• Inadequate availability of clinical service protocols for health facilities

• Absence of surgical and anesthesia care standard operating procedures, clinical auditing guidelines, standardized service assessment tools/checklists, indicators

• Inadequate follow-up on implementation of strategies, guidelines and standard operating procedures

• Weak referral and feedback system

Laboratory and imaging

• Presence of national strategic plan for laboratory services and designated unit

• Decentralized laboratory services

• Presence of national laboratory services with referral network

• Presence of national quality assurance and accred-itation system

• Initiation of backup laboratory system in Addis Ababa

• Increasing investment in high tech imaging ser-vices

• Improving national blood transfusion services accessibility

• Frequent interruption of important laboratory services

• Lack of supplies and consumables

• Inadequate human resources for laboratory and imaging services

• Lack of safe blood in some parts of the country

• Poor medical equipment management

• Lack of strategic plan for imaging services

Health financ-ing

• Implementation of health care financing reform (such as fee retention, private wing, service fee revision, etc.)

• Establishment of health insurance

• Resource mobilization (Millenium Development Goals Pool Fund (MDG PF); Revolving drug fund capital is improving

• Encouraging multi-sectorial collaborative efforts National Nutrition Program (NNP), water and sanitation, non-communicable diseases, s, MoE-Ministry of Education)

• Gaps in mobilizing local resources

• Low utilization and liquidation at all levels

• Poor resource mapping capacity especially at sub-national level

• Weak financial utilization and timely liquidation



Challenges, Opportunities and ThreatsChallenges Opportunities Threats

• Delay in implementation of policies, guidelines and plans

• Sub-optimal public-private part-nership (coordination, mistrust, reporting)

• Regulatory weaknesses

• Gender mainstreaming not insti-tutionalized in planning and mon-itoring and evaluation (M&E) of health programs

• Less optimal buy-in for the three one’s principles

• Good governance challenges – weak accountability

• Variation in leadership and good governance

• Variation in fostering coordi-nation/partnership (inadequate resource mobilization and utilization capacity and sub-op-timal leadership of programs at sub-national level)

• Regulatory:

• Inadequate quality assurance actions

• Poor capacity to implement the regulatory framework

• Limited multi-sectorial response such as in the development corridor

• Determination and political commit-ment by the government

• Increasing engagement, determina-tion and commitment by professional associations

• Improving health care seeking behavior by community

• Safe surgery is a global and national priority

• Emerging of important national initia-tives like Ethiopian Hospitals Alliance for Quality (EHAQ), Clean and Safe Health Facilities (CASH), and Auditable Pharmaceutical Transactions and Ser-vices (APTS)

• Sustained national economic develop-ment

• Improving road infrastructure, telecom

• Increasing academic institutions intake

• Establishment of vital events registra-tion agency

• Settlement of pastoralist communities

• Health insurance schemes

• Existence of strong government struc-ture up to community level

• Industrialization (increase in local pro-duction of drugs and equipment, local manufacturers of food, etc.)

• Urbanization

• Acceptance of health insurance

• Geographic inaccessibility of many communities, including to ambu-lance services

• High donor source for health expenditure

• Low predictability of foreign funding

• Harmful traditional practices as bar-riers to essential health services

• Potential for community fatigue for referral and service preferences by community

• Perception that Had-Health Devel-opment Army (HDA)s are politically oriented rather than service quality improvement scheme

• Trade agreements such as importa-tion of sub-standard supplies

• Inadequate counterfeit control (sub-standard imports)

• High caliber health professional attrition

• Climate change

• Increasing pool factor for the health workers/brain draining

• Fragile neighborhood states

• Population growth


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Saving Lives Through Safe Surgery Aim and Objectives AimTo improve equitable access to high-quality and safe essential and emergency surgical and anesthesia care as part of the universal health coverage.

Objectives

¡ To implement a nationally coordinated national plan on surgical care.

¡ To define and implement essential surgery package for all levels of the Ethiopian health care delivery system.

¡ To create better awareness on surgical and anesthesia care with different stakeholders.

¡ To improve the safety of surgical care by implementing the surgical safety checklist and improving the safety culture.

¡ To implement a quality improvement and audit tool in surgical care.

¡ To proactively identify best practices and scale up rapidly through EHAQ.

Core Values:

¡ Accountability

¡ Transparency

¡ Compassion

¡ Respect

¡ Care

¡ Patient centeredness

¡ Quality focused

¡ Innovation

¡ Partnership

Strategic Pillars and Strategic ResultsA high-level professional workshop was conducted to develop the strategic pillars and plan documents on the pil-lars of essential and emergency surgical care based on mapping the development and the existing capacity, commit-ment and funding.

The SaLTS initiative has identified key strategic objectives in line with the commitment of approaching the initia-tive through the health system building blocks. Considering the vast undertakings in making essential surgical care available and accessible, innovative approaches and wider partnerships will be solicited. Accordingly, the following key strategic pillars were identified.

1. Leadership, management and governance

2. Infrastructure development

3. Equipment and supplies management

4. Human resources development

5. Partnership and advocacy

6. Quality and Safety

7. Innovation

8. Monitoring and evaluation


Strategic Pillar One: Leadership, Management and GovernanceEffective leadership and governance are key to the successful implementation of such an ambitious program. Accordingly, functional structures will be established at all levels of the health system to oversee the program. The initiative will be led at the national level by the Minister of Health. Regionally, the program implementations will be integrated within the Medical Services General Directorateand the Health Services Quality Directorate and curative and rehabilitative core process (CRCP)/health care quality process. Similarly, the SaLTS leadership and management structure extends below the RHBs in zones, woredas and health facilities.

Existing structures and staff have limited experience in safe surgery leadership and management to effectively address essential and emergency surgical issues in the country, so the executive leadership will be supported by a TWG at the national level and a technical advisory group at the regional level. Day-to-day activities will be led and managed by respective government structures (project management team) at all levels. Additionally, the initiative will be incorporated with the existing EHAQ structure.

Current budget allocation for safe surgery is inadequate to address specific problems such as medical equipment, supplies, surgical workforce availability, capacity-building, improvement of operational quality capabilities and infrastructural development. Therefore, the FMOH will work in partnership with professional societies, partners, senior service providers and universities that have responsibilities for overall SaLTS program implementation and management in the country.

Strategic Objectives1. Establish effective leadership and management system across all levels of the health system.

¡ Establish leadership and management structure at all levels.

• Identify potential members. • Invite participants.• Conduct regular meetings

¡ Develop guidelines/manual for leadership and management structure.

• Develop a draft guideline. • Incorporate feedback from national TWG. • Finalize the guidelines/manual. • Circulate the manual for RHBs and facilities.

¡ Preparation of tool kits (assessment tool, SaLTS leadership guidelines, and standard operating procedures).

¡ Designate individual champions and institutions for SaLTS.

¡ Monitor, report and evaluate leadership and management activities.

2. Strengthen leadership and management capabilities at all levels.

¡ Provide short-term trainings on leadership and management skills.

• Develop training packages. • Identify trainees. • Conduct the training.• Conduct supportive supervisions, mentorship and coaching (on team building, communication).• Identify mentors.• Develop mentorship guide.• Conduct mentorship.


¡ Seconded expertise to build the capacity of government.

• Identify and communicate partners. • Develop Terms of Reference (ToR).• Identify and assign the expert.

¡ International and local experience sharing

• Identify areas that have best practices. • Secure budget. • Conduct the experience sharing.

¡ Establish knowledge management center.

Strategic ResultsImproved leadership and management system, measured by the following components:

¡ Establishing safe surgery leadership structure at all levels including their respective ToR.

¡ Identifying major leadership gaps at all levels in leading safe surgery program.

¡ Designing leadership support/training package based on identifying gaps.

¡ Implementing leadership support/training package.

Structure Executive committeesThe SaLTS strategy should be implemented by the executive committee at all levels of the health system. This committee gives guidance as to how emergency and essential surgical care should be implemented through SaLTS. It approves plans and the necessary budget to operate the program. It takes an active part in the supervision and monitoring and evaluation of the activities and gives the necessary feedback.

It is composed of the high-level management team in all strata. It establishes an advisory or steering committee that helps involve stakeholders, promote the program, and strengthen networking and advocacy.

Project Management TeamsThe management teams for SaLTS will be established in the medical services general directorate under the quality directorate, or Curative and Rehabilitative Core Process (CRCP), according to the level of organization. This team acts as an engine in the implementation of SaLTS. In addition, the management team develops plans according to the directions from the executive committee and the guidelines of emergency and essential surgical care. It may establish a TWG to run the program effectively.


Technical Working Groups The Medical Services General Directorate or CRCP of the health structure will create the TWG, which will be comprised of management teams, various professional societies, and partners relevant to SaLTS.

Health Facility Structure Roles and responsibilities

Hospital/health center CEO/clinical director/Se-nior Management Team (SMT)

• Supervise overall SaLTS activities

• Conduct baseline and ongoing assessment

• Assign necessary surgical team and OR manager

• Engage senior professionals in leadership

• Allocate and mobilize resources

• Evaluate the progress of implementation

• Assess and reward champion provider

• Ensure availability of necessary supplies

• Ensure the availability and utilization of WHO safe surgery essential checklists

• Establish facility level taskforce that follows the implementation of SaLTS strategy by delegating authority

SaLTS program coordinating teams (surgical team) • Develop SaLTS specific action plan

• Support the implementation of the facility SaLTS plan

• Conduct ongoing assessment to advise SMT and provide feedback to service units

• Provide training to clinical and non-clinical surgical staff

• Plan and supervise the activity of respective unit

• Discuss with team to improve the quality of surgical activities

• Organize hospital wide advocacy and communications

• Involve in all surgical team meetings

• Document all activities and submit the report

Full-time OR manager • Act as a secretary of SaLTS implementing team

• Oversee day to day activity of OR

• Conduct daily supervision to key function units and give information to SaLTS coordinating team

• Participate on senior management team representing surgical team


Facility SaLTS teamThe facility SaLTS team will be organized by health workers from the different management bodies and facility health workers. It will be led by the surgical and anesthesia staff of the facility. The job descriptions should be de-signed by the specific health facilities based on need and relevance to SaLTS and emergency and essential surgical care. Strong OR management will be established.

Major Initiatives 2009 2010 2011 2012 2013

Establish safe surgery leadership structure at all level including their respective ToR X X

Identify major leadership gaps at all levels in leading safe surgery programs X X

Design leadership support/training package based on identifying gaps X X

Implement leadership support/training package X X X X X

Strengthen FMOH capacity in leadership and governance X X X X X

Assist and empower professional societies to positively contribute toward leadership and good governance in safe surgery

X X X X X

Provide supportive follow-up, identified in leadership capacity-building as requested by regions and hospitals

X X X X X

Identify and recognize champions, documenting and disseminating proven best practices X X X X

Finalize safe surgery leadership structure at health facilities including their respective ToR X X X X

Continue to implement the leadership support/training package X X X X X

Develop masters’ level training curriculum for OR managers and identifying potential train-ing sites

X

Provide follow-up, identified and need based leadership and capacity-building support requested by regions, hospitals, zonal, woredas and health centers

X X X X X

Enroll 25 OR managers for masters’ level trainings recruited from all regions X

Enroll 50 OR managers for masters’ level training recruited from all regions X

Develop incentive and retention package and professional career for masters’ level OR manager graduates

X

Develop a syllabus to integrate leadership course into the undergraduate and postgraduate programs of the different surgical workforces

X

Enroll 75 OR managers for masters’ level from all regions X

Ethiopian Calender


Strategic Pillar Two: Infrastructure DevelopmentInfrastructure development entails necessary health facility buildings that are critical for the smooth functioning of the OR. Standard ORs meeting the national requirements and conducive for the surgical team and patients need to be prioritized. Recovery and central sterilization services and other adjoining structures will be improved. Improv-ing the condition of the existing infrastructure through renovations and constructing additional facilities as per the standard will be implemented.

Additionally, this pillar will focus on improving key utility services for ORs including safe and adequate water ser-vices, uninterrupted power services with back up, and communication systems. Due consideration will be provided to innovative ways of fulfilling the utility services requirements. For example, the possible use of solar power will be explored.

Strategic Objectives1. To ensure availability of standards infrastructure and building of delivery room, minor OR, and major OR in

primary and tertiary level.

2. To ensure the construction of new or renovation of existing health facilities complies with the national stan-dard guidelines.

3. To ensure that functional uninterrupted utility services are available at the facility level. This includes services such as water, power supply and communication system.

Major initiatives 2009 2010 2011 2012 2013

Conduct surgical infrastructure gap assessment in all regions. X X

Mobilize financial, material, and technical resources X X X X X

Renovate and build surgical suites that were identified in all regions based on assessment findings and their priorities.

X X X X X

Devise a mechanism for timely preventive check up and maintenance of all the distributed equipment

X X

Ethiopian Calender


Strategic Pillar Three: Equipment and Supplies ManagementAvailability of essential equipment, supplies, and consumables are key for the provision of surgical and anesthe-sia care. The SaLTS initiative will identify a national package of essential surgical and anesthesia procedures, and standard lists of national supplies and consumables will be prepared. Similarly, essential medical equipment and package of surgical instruments will be developed in accordance with the nationally identified essential surgical ser-vices package. Using a standardized inventory checklist, an assessment will be conducted to estimate the capacity and identify the gaps in supplies and equipment.

Evidence-based quantification of the supplies and equipment will be used to procure these essential items. A close follow-up system will be established for procurement and distribution of these items. Appraisal of existing anesthe-sia drugs for safety and effectiveness will be performed and, as necessary, newer and safer anesthesia drugs will be introduced into the system. A number of standardized tools will be introduced to assist health facilities to conduct regular inventories of the critical supplies and medical equipment.

Strategic Objectives1. To ensure that health centers and hospitals are equipped with the standard list of surgical and anesthesia equip-

ment according to the SaLTS equipment list and standard operating procedures and protocols to enable the provision of essential and emergency anesthesia care.

2. To ensure that required consumables are available in a timely way at each level and that supply chain manage-ment for pharmaceuticals is in place for essential and emergency surgical and anesthetic care the standard for health centers and hospitals.

3. To ensure there are centers for medical equipment maintenance and innovation.

4. To ensure that safe anesthesia drugs and consumables are available in the health care delivery system.

5. To ensure that a standard audit tool and monitoring guidelines for quality SaLTS are used across the entire region.

Major initiatives 2009 2010 2011 2012 2013

Develop comprehensive package of equipment, medicine and consumables for national essential and safe surgery package.

X

Procure and distribute essential OR and related infrastructure and supplies to the already established and newly constructed hospitals.

X X X X X

Quantify, forecast and procure comprehensive package of equipment, medicine and consumables for national essential and safe surgery package.

X X X X

Establish national safe surgery and anesthesia procurement and supply technical advisory committee inclusive of all stakeholders including professional societies.

X

Provide need based capacity-building training for all regions on pharmaceutical chain management.

X X X

Mobilize financial, material, and technical resources. X X X X X

Encourage and support local investors to produce surgical and anesthetic supplies that can be manufactured in country.

X X X X X

Distribute procured pharmaceutical items in a timely manner. X X X X X

Conduct mid-project review meeting with stakeholders. X X

Conduct supportive supervision in the hospitals to audit the newly distributed equipment and gadgets

X X X X X

Ethiopian Calender


Strategic Pillar Four: Excellence in Human Resource DevelopmentThe surgical workforce is the most important component of the SaLTS strategy. The availability of a motivated and competent surgical workforce is key to the success of the SaLTS initiative. A rapid analysis of the existing work-force, including identifying opportunities and potential challenges, needs to be conducted.

To ensure equitable distribution of competent health workers, innovative approaches will be introduced. Strategies for maximizing the efficiency of the existing workforce will be developed and implemented.

Evidence-based approaches such as task sharing and task shifting will be utilized meticulously. Leveraging high-level hospitals to support lower-level health facilities under them will be structured and highly encouraged. There will also be frequent capacity-building trainings at all levels based on the gaps identified.

The concept of compassionate, respectful and caring health professionals will be the main agenda and, as such, mechanisms for continuous engagement with the surgical workforce at all levels will be designed, and a motivation and recognition system will be implemented. In areas where there is an acute shortage of a skilled surgical work-force, strategies such as medical campaigns and surgical missions will be strengthened in the interim.

Strategic Objectives1. To ensure availability of surgical team in all primary, general and tertiary hospitals.

2. To ensure the motivation and retention of workforce for SaLTS through effective and efficient mechanism of surgical taskforce.

3. To ensure that qualified and certified health care providers deliver essential and emergency surgical and anes-thetic care.

4. To ensure and support all efforts toward capacity-building for productivity of surgical team.

5. To ensure compassionate, respectful and caring surgical health workforce (CRC).

6. To ensure bottlenecks are adequately managed

Strategies for Objectives

1. Increase availability of essential surgical team (focusing on anesthesia, IESO and OR nursing professionals).

¡ Implement strategies to increase surgical specialties:

• Partner with the College of Surgeons of East, Central, and Southern Africa (COSECSA).• Support medical schools to increase trainee pool.• Explore the establishment of additional specialty training centers.• Pair institutions.

¡ Implement task shifting.

• IESO are trained in emergency obstetric and surgical conditions at the primary care level• Anesthesia technician/Level 5 will fill the significant anesthesia professionals gap• Clinical nurses - Perioperative nursing technical and non-technical update trainings

¡ Implement task sharing

• Integrate leadership competencies into existing curricula of key forces.


• Conduct induction training on NTS (inter-professional collaboration) before deployment.• Review OR nurses curriculum to integrate post-anesthesia care unit and central sterilization room (CSR) competencies –• Select OR managers short term training.

¡ Maximize current enrollment of key surgical taskforce through innovative solutions:

• Introduce simulation laboratory. • Encourage cognitive apprenticeship (expanding clinical practice site).• Improve partnership with private sector. • Avail required infrastructure and teaching and learning materials • Promote and advocate new cadre.

¡ Create new essential surgical cadre.

• Emergency surgery physician • OR managers (post-grad)• Anesthesia technicians• OR/perioperative nurse (post-grad)• IESO future career structure • OR technician

2. Improve motivation and retention of key surgical team.

• Conduct professional development activities.

• Conduct motivation and retention study.

• Design motivation and retention strategies for key SaLTS surgical teams

• Establish career and incentive packages for new cadres.

• Link the human resources motivation strategy with the CRC movement

• Support the accreditation of surgical workforce.

3. Build capacity of surgical task force.

• Provide short-term training, including OR leadership and management.

• Use technology for learning (online training, telemedicine)

• Conduct on-the-job training

• Establish a system of mentorship and coaching.

• Provide long-term training to advance the technical and managerial skills of the surgical team.

• Work collaboratively with professional associations to provide quality in-service training (IST) – sustain-ability.

• Ensure quality of IST-training package.

4. Increase productivity of surgical team.

• Conduct technical update trainings and experience sharing, including NTS.

• Implement day care surgery.

• Explore and implement multiple shift surgery.

• Utilize the private wing initiative to benefit the surgical team

• Conduct surgical campaigns

• Identify, officially recognize and award champions.

• Prepare and implement benefit and incentive packages.


5. Balance deployment by offering privileges and incentives for those assigned to remote areas.

6. Improve quality of surgical care.

• Create a simulation lab in lead hospitals.

• Establish educational standards for pre-service education.

• Develop and implement practice standards.

• Create a licensure examination.

• Use a facility quality improvement tool.

• Review anesthetist competencies addressed in the pre-service education curriculum.

• Implement an organized coaching and mentorship system at all levels

Bottlenecks• Critical shortage of key surgical team (IESO, anesthesia provider and OR nurses).

• Inadequate skill mix of existing professionals.

• Lack of systemic human resources management system.

• Flexibility in including additional cadres of health workers in to the surgical system for e.g. - OR manager

• Challenges in developing career structure.


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70

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Det

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1-

--

--

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ts

2016

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--

--

1.5

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500

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5 Y

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1,00

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Det

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impl

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ting

the

stra

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r. ta

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ts

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2017

2018

2019

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14-

14-

--

1.9

Prov

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cato

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f H

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sup

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5 Y

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ts

2016

2017

2018

2019

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5-

-2

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5 Y

r. ta

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Ann

ual t

arge

ts

2016

2017

2018

2019

2020

30-

1515

--

1.11

Con

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cato

r: N

o. o

f pr

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con

duct

ed

5 Y

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ts

2016

2017

2018

2019

2020

20-

55

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1.12

Ava

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stitu

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sup

port

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5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

144

44

2

1.13

Enc

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to s

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cato

r: N

o of

new

BSc

pro

gram

s st

arte

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

10-

43

3-

1.14

Supp

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sthe

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cato

r: N

o. o

f H

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sta

rtin

g pr

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m

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

51

22

-

1.15

Dev

elop

an

MSc

pro

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ricul

um in

OR

man

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ain

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Indi

cato

r: Ta

rget

ed c

urric

ulum

dev

elop

ed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

11

--

--


Det

aile

d Sa

LT

S H

uman

Res

ourc

e D

evel

opm

ent P

lan

Act

ivity

No.

Init

iativ

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1.16

Supp

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to s

tart

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pro

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anag

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t.

Indi

cato

r: N

o. o

f gr

adua

tes

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

150

-25

5050

50

1.17

Dev

elop

an

MSc

pro

gram

cur

ricul

um in

OR

and

per

iope

rativ

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trai

n O

R

nurs

es in

per

iope

rativ

e/O

R n

ursi

ng.

Indi

cato

r: Ta

rget

ed c

urric

ulum

dev

elop

ed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

1-

1-

--

1.18

Trai

n O

R n

urse

s in

MSc

in O

R n

ursi

ng/p

erio

pera

tive

nurs

ing.

Indi

cato

r: N

o. o

f gr

adua

tes

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

500

100

100

100

100

100

1.19

Enc

oura

ge th

e ex

istin

g an

esth

esio

logy

resi

denc

y pr

ogra

m fo

r int

ake.

Indi

cato

r: N

umbe

r of

trai

nees

enr

olle

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

3-

--

--

1.20

Dev

elop

a s

trat

egic

pla

n fo

r IE

SO fu

ture

car

eer.

Indi

cato

r: Ta

rget

ed c

urric

ulum

dev

elop

ed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

1-

-1

--

1.21

Exp

and

the

CO

SEC

SA b

ased

trai

ning

of

gene

ral s

urge

ons

in th

e co

untr

y.

Indi

cato

r: N

o. n

ew p

rogr

ams

open

ed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

152

33

34

1.22

Enc

oura

ge e

xist

ing

surg

ery

and

obst

etric

resi

denc

y pr

ogra

ms

to in

crea

se th

eir a

nnua

l in

take

.

Indi

cato

r: Pe

rcen

tage

of

incr

ease

in u

ptak

e

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

100%

20%

20%

20%

20%

20%

1.23

Enc

oura

ge n

ew H

EIs

to c

omm

ence

resi

denc

y pr

ogra

ms

in s

urge

ry a

nd o

bste

tric

s.

Indi

cato

r: N

umbe

r of

new

pro

gram

s op

ened

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

10-%


Det

aile

d Sa

LT

S H

uman

Res

ourc

e D

evel

opm

ent P

lan

Act

ivity

No.

Init

iativ

e/P

lann

ed A

ctiv

ity

1.24

Prov

ide

the

nece

ssar

y in

fras

truc

ture

and

fina

ncia

l sup

port

to H

EIs

that

are

exp

andi

ng

thei

r num

ber r

esid

ents

inta

ke b

ased

on

the

perc

enta

ge o

f in

crea

se.

Indi

cato

r: A

mou

nt o

f su

ppor

t pro

vide

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

-%-%

-%-%

%%

2Im

prov

e m

otiv

atio

n an

d re

tent

ion

of k

ey s

urgi

cal t

eam

.

2.1

Con

duct

mot

ivat

ion

and

rete

ntio

n st

udy

on s

urgi

cal t

eam

(ane

sthe

sia

of a

ll le

vels,

OR

nu

rses

, IE

SO, s

urge

ry a

nd o

b/gy

n).

Indi

cato

r: N

o. o

f st

udie

s co

nduc

ted

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

4-

4-

--

2.2

Des

ign

mot

ivat

ion

and

rete

ntio

n st

rate

gy fo

r sur

gica

l tea

m m

embe

rs u

sing

rete

ntio

n st

udy

findi

ngs

Indi

cato

r: Ta

rget

ed s

trat

egy

deve

lope

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

1-

-1

--

3B

uild

cap

acit

y of

sur

gica

l tea

ms.

3.1

Stre

ngth

en c

olla

bora

tion

with

pro

fess

iona

l ass

ocia

tions

/ so

ciet

ies

to p

rovi

de q

ualit

y IS

T

for s

urgi

cal t

eam

.

Indi

cato

r: N

o. o

f A

ssoc

iatio

ns c

olla

bora

tion

crea

ted

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

44

--

--

3.2

Intr

oduc

e te

chno

logy

in to

the

in-s

ervi

ce tr

aini

ng o

f es

sent

ial s

urgi

cal t

eam

(tel

emed

i-ci

ne, m

obile

bas

ed te

chno

logy

, web

-bas

ed le

arni

ng, e

-log

book

s, e-

lear

ning

).

Indi

cato

r: N

o. o

f te

chno

logi

es in

trod

uced

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

4-

4-

--

3.3

Prov

ide

outr

each

ser

vice

on

prim

ary

hosp

itals

with

mul

tidis

cipl

inar

y su

rgic

al c

are

team

.

Indi

cato

r: N

o of

faci

litie

s co

ache

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

100

-35

3530

-

3.4

Dev

elop

ane

sthe

sia

trai

ning

pac

kage

add

ress

ing

esse

ntia

l and

em

erge

ncy

surg

ery

anes

thet

ic c

ompe

tenc

ies

desi

gnat

ed to

prim

ary

Hos

pita

l lev

el (a

nest

hesi

a fo

r tra

uma,

ob

stet

rics

and

emer

genc

ies)

.

Indi

cato

r: N

o. o

f pa

ckag

es d

evel

oped

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

33

--

--


Det

aile

d Sa

LT

S H

uman

Res

ourc

e D

evel

opm

ent P

lan

Act

ivity

No.

Init

iativ

e/P

lann

ed A

ctiv

ity

3.5

Prov

ide

tech

nica

l upd

ate

trai

ning

on

anes

thes

ia fo

r tra

uma,

obs

tetr

ics

and

emer

genc

y pr

oced

ures

at p

rimar

y ho

spita

l lev

el.

Indi

cato

r: N

o. o

f an

esth

etis

ts tr

aine

d

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

200

-10

010

0-

-

3.6

Prov

ide

trai

ning

of

trai

ners

trai

ning

in m

ento

ring

and

coac

hing

for s

enio

r sur

gica

l tea

m

that

will

pro

vide

coa

chin

g an

d m

ento

ring

visi

ts (e

qual

pro

port

ion

of a

nest

hesi

a pr

ofes

-si

onal

s, su

rgeo

ns a

nd o

b/gy

n).

Indi

cato

r: N

o. o

f pr

ofes

sion

als

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

360

-12

012

012

0-

3.7

Prov

ide

coac

hing

and

men

torin

g tr

aini

ng fo

r sen

ior s

urgi

cal t

eam

pla

nned

to b

e in

volv

ed

in c

oach

ing

and

men

torin

g vi

sits

.

Indi

cato

r: N

o. o

f st

affs

ass

igne

d as

coa

ch

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

360

-12

012

012

0-

3.8

Prov

ide

SaLT

S le

ader

ship

and

man

agem

ent t

rain

ing

for n

atio

nal a

nd re

gion

al T

WG

m

embe

rs.

Indi

cato

r: N

o. o

f pr

ofes

sion

als

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

155

33

31

3.9

Prov

ide

SaLT

S le

ader

ship

and

man

agem

ent t

rain

ing

for n

atio

nal a

nd re

gion

al p

roje

ct

team

mem

bers

.

Indi

cato

r: N

o. o

f pr

ofes

sion

als

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

5010

1010

1010

4In

crea

se p

rodu

ctiv

ity

of s

urgi

cal t

eam

.

4.1

Perf

orm

ance

-bas

ed re

cogn

ition

for s

urgi

cal t

eam

mem

bers

exc

eedi

ng s

et ta

rget

pro

ce-

dure

num

ber.

Indi

cato

r: N

o. o

f te

ams

reco

gniz

ed e

xcee

ding

targ

et

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

160

-40

4040

40

4.4

Perf

orm

ance

-bas

ed re

cogn

ition

for b

est f

acili

ty in

impl

emen

ting

SALT

initi

ativ

e.

Indi

cato

r: N

o. F

acili

ty re

cogn

ized

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

4010

1010

10


Det

aile

d Sa

LT

S H

uman

Res

ourc

e D

evel

opm

ent P

lan

Act

ivity

No.

Init

iativ

e/P

lann

ed A

ctiv

ity

4.5

Dev

elop

com

preh

ensiv

e tr

aini

ng p

acka

ge o

n da

y ca

re s

urge

ry a

nd a

nest

hesi

a.

Indi

cato

r: Ta

rget

ed p

acka

ge d

evel

oped

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

11

--

--

4.6

Bas

ed o

n de

velo

ped

trai

ning

pac

kage

, pro

vide

trai

ning

for m

ulti-

disc

iplin

ary

surg

ical

te

am m

embe

rs o

n da

y ca

re s

urge

ry a

nd a

nest

hesi

a.

Indi

cato

r: N

o. o

f Pr

ofes

sion

als

trai

ned

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

500

-80

140

140

140

4.7

Supp

ort l

ead

hosp

itals

to in

itiat

e da

y ca

re s

urge

ry.

Indi

cato

r: N

o. o

f H

ospi

tals

pro

vidi

ng d

ayca

re s

urge

ry p

er s

tand

ard

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

103

34

-

5Im

prov

e qu

alit

y of

sur

gica

l car

e.

5.1

Ass

ist H

EIs

to d

evel

op s

imul

atio

n la

b in

lead

hos

pita

ls.

Indi

cato

r: N

o. o

f si

mul

atio

ns d

evel

oped

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

10-

43

3-

5.2

Supp

ort t

he S

SE in

dev

elop

ing

a B

oard

of

Surg

ical

Spe

cial

ties

unde

r the

FM

OH

.

Indi

cato

r: B

oard

est

ablis

hed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

1-

1-

--

5.3

Supp

ort a

nest

hesi

olog

y so

ciet

y in

sta

ndar

dizi

ng th

e tr

aini

ng o

f an

esth

esio

logi

sts

in th

e co

untr

y.

Indi

cato

r: St

anda

rd c

urric

ulum

dev

elop

ed

5 Y

r. ta

rget

Ann

ual t

arge

ts

2016

2017

2018

2019

2020

1-

1-

--


Planned number health professionals to be trained

Activity No. Initiative/Planned Activity 5 Year targetAnnual target

2016 2017 2018 2019 2020

1 General surgeon 750 150 150 150 150 150

2 OB/GYN specialist 750 150 150 150 150 150

3 Anesthesiologist 100 20 20 20 20 20

4 Anesthetist 2,000 400 400 400 400 400

5 Scrub nurse 2,000 400 400 400 400 400

6 Recovery room nurse 2,000 400 400 400 400 400

7 OR manager 200 40 40 40 40 40

8 IESO 500 100 100 100 100 100

9 Dental surgeon 100 20 20 20 20 20

10 Ophthalmologist 200 40 40 40 40 40

11 Ophthalmology nurse 1,000 200 200 200 200 200

12 Orthopedists 150 30 30 30 30 30

15 Chest surgeon 15 3 3 3 3 3

16 Pediatric surgeon 20 5 5 5 5 5

17 Neurosurgeon 50 10 10 10 10 10

18 ENT Surgeon 50 10 10 10 10 10

19 Urologist 50 10 10 10 10 10

20 Plastic surgeon 25 5 5 5 5 5

21 OR technician 250 50 50 50 50 50


Strategic Pillar Five: Excellence in Advocacy and PartnershipExcellence in advocacy and partnership signifies that all stakeholders, including leaders at the FMOH and MOF, health care professionals (via training centers, universities, professional societies, etc.), partners, and the public (via health workers and the media), are aware of SaLTS and the national priority around improving safe surgery, and that SaLTS has sufficient partner engagement for implementation alongside the FMOH.

Strategic Objectives1. To ensure increased awareness of SaLTS among FMOH and MOF staff, health care professionals (both inside

and outside of surgery) and the general public.

2. To mobilize the surgical workforce as part of this movement, with every surgical professional (including sur-geons, OBGYNS, anesthetists, and nurses).

3. To increase the number of partners as well as investment by each partner in surgery in Ethiopia.

ComponentsAwareness

• Promote advocacy to key stakeholders within the FMOH and Ministry of Finance (MOF) as well as to health care management to inform them of SaLTS.

• Build awareness through a campaign to target health care professionals both directly working in surgery as well as more broadly working on maternal, newborn and child health issues (i.e., health service managers, surgeons, health workers, health trainees, and professional associations)

• Conduct a mass media campaign to target broader public (i.e., communities, patients).

Partner Engagement

• Divide responsibilities across core partners to ensure appropriate support for each SaLTS pillar.

• Cultivate additional partners to ensure necessary support for SaLTS strategy.

• Establish institutional arrangement for partner engagement .e.g. strengthening of Technical Working Groups for SaLTS at national and regional levels.

Structure • Awareness: The project team at the FMOH will take ownership over executing the awareness building

campaign and mass media campaign. They will design these campaigns in close collaboration with the SaLTS TWG and with approval from the executive team. The campaigns will then be rolled out with key partners, including the professional societies, universities and the mass media, as well as via quarterly pub-lic forums.

Partner engagement: The SaLTS TWG will be the primary means of engagement for core safe surgery partners in Ethiopia. On an ongoing basis, this group will monitor levels of partner support relative to strategic priorities across the eight SaLTS pillars and determine if additional support is necessary in any


particular area. When significant gaps in support for SaLTS become apparent, members of the TWG alongside the executive team will seek additional funders or partners to fill the identified gaps.

Identified InterventionsAdvocacy to create and increase awareness on SaLTSThe FMOH will develop standard SaLTS communication materials to update people on the importance of safe surgery in Ethiopia, as well as SaLTS objectives, pillars and activities. This effort will be completed as soon as possible in 2016. These communication materials should include: a two-page overview document, a key message document for surgical leaders and the full strategy document.

• The FMOH, in collaboration with key disseminating bodies like the RHBs, societies, and universities, will disseminate communication materials via key channels, including but not limited to, RHBs, professional society networks and meetings (including societies for surgeons, anesthetists, emergency surgical officers, ob/gyn, ophthalmologists, plastic surgeons and nurses), and university teaching facilities, among others. This dissemination will be completed within the first six months of strategy in 2016.

• The FMOH in collaboration with societies and media, will identify key public meetings where SaLTS should be shared, most likely the Annual Review Meeting, regional public forums, and larger health meet-ings in the country and seek media coverage at these forums to ensure that articles are written and news coverage is televised. This activity will be completed as soon as possible in 2016 but then carried out as events occur.

Partner Engagement• The FMOH will convene partners regularly (i.e., monthly in the first six months of SaLTS, and then quar-

terly) as part of the TWG to discuss progress against the SaLTS strategy, and identify any gaps or areas for further work. The TWG is recommended to be composed of at least 1-2 partners from each level of work (e.g., global/regional, national and local), but likely should not include all partners given the large group. Partners that are investing the most amount of time and resources to SaLTS should be prioritized for for-mal representation on the TWG while other partners should be asked for input on an ongoing basis.

• The FMOH will convey through the TWG meetings the most important areas for additional partner sup-port based on shifting priorities and gaps and then helps attract partners to core areas.

• As of early 2016, the core partners working with the FMOH on SaLTS include: at the global/regional level, the GE Foundation, Safe Surgery 2020, the Lancet Commission for Safe Surgery, the Harvard Program for Global Surgery and Social Change, G4 Alliance, the World Health Organization, and COSECSA; at the national level, Jhpiego, CHAI, AMREF, MSH, the World Health Organization, and a number of relevant professional societies and associations (i.e., Ethiopian Surgical Society, Anesthesia Society, etc.); and, at the local level, RHBs and local universities. Many of the global and national partners are also engaging deeply at the regional level. The table below shows in more detail which partners will be working to support which pillars.

Measurement/IndicatorsMeasuring awareness and partner engagement is inherently more challenging than measuring other aspects of this SaLTS strategy. Thus, the indicators outlined below should be considered a starting point to understand relative progress in these areas, but other signals of increased awareness and partner engagement may also become relevant over time.

• Awareness: FMOH will track annually the number of SaLTS overview materials distributed; number of in-bound requests regarding SaLTS that come to the FMOH; number of public media mentions (in articles/TV shows).


• Partner engagement: FMOH will track the total resources committed across partners; number of new partners that join SaLTS TWG.

Monitoring and EvaluationThis area of the strategy only requires light monitoring and evaluation. It is recommended that the above indicators are tracked on a more continual basis. Once a year, when the broader SaLTS strategy is reviewed, progress on these indicators should also be reviewed.

Strategic Result • Federal: Increased awareness of SaLTS program and increased investment from partners to support the

program and to improve surgical outcomes more broadly across Ethiopia.

• Regional, Zonal and Woreda: Increased awareness of SaLTS program and increased investment from re-gions / zones / woreda as well as other partners to support the program and to improve surgical outcomes more broadly in the regions

• University: Increased awareness of SaLTS and increased investment by universities to train surgical profes-sionals

• Health facilities: Increased awareness of SaLTS and increased investment by facility leadership in surgical infrastructure and equipment


Maj

or I

niti

ativ

es20

0920

1020

1120

1220

13

Iden

tify

and

enga

ge k

ey lo

cal a

nd in

tern

atio

nal p

artn

ers

that

will

sup

port

the

safe

sur

gery

and

ane

sthe

sia

care

pro

gram

.X

XX

XX

Dev

elop

nat

iona

l adv

ocac

y an

d pa

rtne

rshi

p m

anag

emen

t gui

delin

es.

XX

XX

X

Supp

ort a

nd p

rom

ote

activ

e en

gage

men

t of

loca

l sur

gica

l and

ane

sthe

sia

prof

essi

onal

soc

ietie

s in

SaL

TS

impl

emen

tatio

n at

all

leve

ls.X

XX

XX

Rec

ogni

ze a

nd a

war

d be

st p

erfo

rmin

g lo

cal p

rofe

ssio

nal s

ocie

ties.

XX

XX

X

Mak

e “S

afe

surg

ical

and

ane

sthe

sia

care

dis

cuss

ion”

a s

tand

ing

agen

da it

em b

oth

in n

atio

nal a

nd re

gion

al p

erfo

rman

ce m

eetin

gs.

XX

XX

X

Est

ablis

h na

tiona

l and

regi

onal

par

tner

s fo

rum

that

will

sup

port

the

safe

sur

gery

and

ane

sthe

sia

care

pro

gram

. X

XX

XX

Stre

ngth

en in

tern

atio

nal p

artn

ersh

ips

with

sur

gica

l and

ane

sthe

sia

prof

essi

onal

soc

ietie

s, co

llege

s an

d do

nors

. X

XX

XX

Stre

ngth

en a

nd e

xpan

d th

e C

OSE

CSA

bas

ed tr

aini

ng o

f su

rgeo

ns.

XX

XX

X

Inte

grat

e a

natio

nal a

dvoc

acy

live

TV

and

radi

o pr

ogra

ms

XX

XX

X

Impl

emen

t the

nat

iona

l adv

ocac

y an

d pa

rtne

rshi

p gu

idel

ine

acro

ss th

e co

untr

y X

XX

XX

Supp

ort a

nd m

onito

r act

ive

enga

gem

ent a

nd fu

nctio

nalit

y of

pro

fess

iona

l soc

ietie

s an

d fo

rum

s X

XX

XX

Con

duct

qua

rter

ly n

atio

nal a

nd re

gion

al p

artn

er fo

rum

s X

XX

XX

Supp

ort a

nd e

ncou

rage

act

ive

enga

gem

ent o

f lo

cal p

rofe

ssio

nal s

ocie

ties

thro

ugh

build

ing

thei

r fina

ncia

l, m

ater

ial,

lead

ersh

ip a

nd m

anag

emen

t cap

aciti

es

XX

XX

X

Part

ner w

ith lo

cal p

rofe

ssio

nal s

ocie

ties

and

part

ners

for e

ffec

tive

and

effic

ient

impl

emen

tatio

nX

XX

XX

Part

icip

ate

in in

tern

atio

nal p

rofe

ssio

nal s

ocie

ties

conf

eren

ce/m

eetin

g an

d sh

arin

g E

thio

pian

exp

erie

nces

of

safe

sur

gica

l and

ane

sthe

sia

care

pro

gram

impl

e-

men

tatio

n an

d br

ing

new

inte

rnat

iona

l exp

erie

nces

X

XX

XX

Stre

ngth

en in

tern

atio

nal p

artn

ersh

ips

with

sur

gica

l and

ane

sthe

sia

prof

essi

onal

soc

ietie

s, co

llege

s an

d do

nors

X

XX

XX

Org

aniz

e na

tiona

l ann

ual s

umm

it on

“E

thio

pian

Saf

e Su

rgic

al a

nd A

nest

hesi

a C

are

Prog

ram

”X

XX

XX

Eth

iopi

an C

alen

der


Strategic Pillar Six: Excellence in Quality and SafetyQuality and safety are essential components of the provision of surgical and anesthesia care.

Patient safety issues in Ethiopia include: death, disability (uncontrolled disability, seizure,) infection, fall injury, wrong site, wrong limb, and wrong person surgery, theft of personal materials during death care, psychological trauma, wrong medication. Of all medical errors reported, the largest proportion happened in in OR. Safety of surgical team (PEP, Hepatitis, physical protection) is also an important issue.

The national health care quality strategy has identified six dimensions of quality. These include Safety, efficiency, effectiveness, person-centered care, timeliness of care and equity .Relevant activities will be implemented in accor-dance with the dimensions of quality in health care. SaLTS will implement interventions to improve quality and safety outcomes.

Objective 1: Improve efficiency in surgical and anesthesia care.Major Activities:1. Plan surgical intervention for each procedure (cost, supplies, time of surgery, duration of stay and potential discharge time)

2. Prepare package of consumables for each procedure.

3. Establish and ensure adherence of national standards:

a. Set incision time in the morning.

b. Set first case start time-anesthesia.

c. Set time between two patients: turn over time.

d. Decision-to-incision time.

4. Implement a patient scheduling management system.

5. Establish interdepartmental and inter-specialty consultation and coordination mechanism.

6. Introduce shift work in surgery.

7. Improve OR management between departments.

8. Expand OR structure in tertiary hospitals.

9. Implement strategies to enhance productivity of surgical team: plan number of surgeries per surgeon and surgical team considering the case mix.

10. Expand day care surgery.

11. Implement consumption audit for each patient after procedure-checklist.

12. Establish preoperative evaluation clinic-joint evaluation by clinician and anesthetist before admission.

13. Set duration of validity for investigations and laboratory test (e.g., after how long should we order additional tests?).

14. Improve discharge management:

a. Introduce discharge lounge.

b. Set 24/7 discharge and set time after discharge decision within 2 hours.


Objective 2: Improve effectiveness of surgical and anesthetic care using evidence-based clinical care.

Major Activities 1. Develop and implement standard operating procedures for all surgeries.

2. Establish CPD systems.

3. Establish skill laboratory in major and lead hospitals.

4. Establish a system of clinical mentorship and coaching.

5. Conduct clinical auditing and quality improvement.

6. Develop and implement perioperative guidelines.

7. Develop and implement preoperative assessment guidelines, anesthesia care management

guidelines.

8. Improve patient information, procedure/data documentation.

9. Conduct operational research in surgical care at all levels.

Objective 3: Establish a culture of patient-centered care in the surgical system

Major Activities1. Improve health literacy in surgical and anesthesia care.

2. Strengthen public forums prioritizing surgical care; champions, training.

3. Enhance capacity-building on team building.

4. Implement interventions to improve communication.

a. Between the surgical team and the patient

b. Between the surgical team during difficult scenarios

c. Among colleagues

d. With management and other bodies

5. Develop and implement standard counseling guideline for informed consent and decision.

6. Develop and implement guidelines for person centered surgical care in Ethiopia to address issues like: facility improvement, confidentiality, and student-patient ratio.

7. Establish conflict management of surgical team prioritizing patient.

8. Conduct training on CRC in surgery: attitudinal training.

9. Establish immediate post-surgical briefing system for family and attendants

10. Develop Model of care for multidisciplinary cases: (grand round, clinical board, multidisciplinary specialty outpatient clinic so that patient patients will get all relevant professionals in the same clinic.)

11. Ensure presence of birth companion for cesarean section and consider having mothers close to babies for pediatric surgeries.


12. Develop patient transport policy: (who, how on what procedure: nurse to transport assisted by a trained porter.)

13. Implement national pain management guideline for all surgical patients.

14. Assign anesthesia professional and start anesthesia care starting in the outpatient department, inpatient department, preoperative and postoperative care.

15. Ensure clinical governance: authority with responsibility in the medical hierarchy.

16. Ensure the adherence to scope of practice by different professionals.

Objective 4: Improve safety in surgical and anesthesia care.Major Activities:

Improve communication between members of the surgical team

1. Implement safety checklist.

2. Introduce system safe design: transport stretcher improved, site marking, patient identification-name tag; time out: standard operating procedures for each surgery.

3. Introduce safe anesthesia drugs.

4. Use technology that reduces medical error: disposable drape, better transporting.

5. Introduce a system of independent check: verification.

6. Improve teamwork: training and HDA.

7. Establish a safety culture: Just culture establishment through awareness and training.

8. Conduct a clinical audit/death audit.

9. Develop and implement guidelines for medical error disclosure.

10. Capacity-building on medical error management-regular yearly patient safety forums.

11. Compile medical error-database and share with all professionals.

Objective 5: Ensure the provision of timely surgical and anesthesia care for emergency conditions and elective procedures.

Emergencies:

¡ Triage and prioritize cases and standard operating procedure for each case.

¡ Increase awareness on golden hour for injury.

¡ Strengthen pre-hospital care.

¡ Strengthen consultation process.

¡ Strengthen referral process.

¡ Designate ER table-back up.

¡ Set standard decision-to-incision for emergency conditions.

¡ Create a major incidence plan.


¡ Define critical pathway for each serious condition.

¡ Establish ER waiting list monitoring system.

Elective procedures:¡ Establish waiting list registration and management.

¡ Set time for each procedure-standards.

¡ Plan appropriate human resources, supplies, or tables.

¡ Conduct campaigns and weekend surgeries.

¡ Build capacity of lower facilities: networking and back referral and continuous support, clinical mentoring.

Set national time target for elective surgical procedure.

Objective 6: Ensure equity in surgical and anesthesia care.1. Establish social worker services.

2. Strengthen liaison services.

3. Avail interpretation service where necessary.

4. Improve labeling and sign posts.

5. Establish a system to prioritize people with disabilities.

6. Collect and utilize data on equity dimensions.

7. Develop and implement standards on what kind of cases to be seen by what level of physicians especially in referral cases in teaching facilities.

8. Conduct surgical campaigns.


Develop locally adoptable treatment guideline for the essential surgical and anesthesia pro-cedures included in the surgical and anesthesia care package.

X X X X X

Develop and standardize a nationally endorsed quality assurance and audit system in surgi-cal and anesthesia care.

X X X X X

Identify EHAQ LEAD hospitals and establish new hospital clusters. X

Conduct continuous onsite technical capacity-building and clinical mentorship for regional clinical support teams/committees and EHAQ LEAD hospitals and health centers on surgical and anesthesia care.

X X X X X

Develop support package for EHAQ LEAD hospitals and other surgical care facilities on surgical and anesthesia care.

X

Establish clinical support teams/committee on surgical and anesthesia care in all regions. X X

Identify and recognize champions, document and disseminate proven best practices/devel-opment of change package.

X X X X X

Strengthen and promote the national ethical practice guideline for surgical care providers. X X

Implement an adoptable WHO safe surgery checklist at hospitals. X X X

Provide continuous training regarding the ethical practice guideline and the rules and regu-lations regarding ethical and legal surgical and anesthesia care practice.

X X X X

Conduct clinical auditing and death reviews in selected hospitals and health centers. X X X X

Ethiopian Calender


Strategic Pillar Seven: Excellence in InnovationsEthiopia is seeking to develop new tools and processes or bring existing tools and processes that are not yet in Ethiopia to address some of the largest identified gaps to improve access to safe surgery in the country. Innovation in this context is defined quite broadly to include any product or tool, process, or item that is new to a particular setting and can help transform the way in which care is delivered in that setting.

Strategic ObjectiveTo increase use of innovations in Ethiopia related to improving safe surgery, either by locally developing these innovations or bringing them to Ethiopia from elsewhere.

ComponentsBased on existing data from hospitals performing surgery, input from a team drafting the SaLTS strategy, as well as extensive baseline assessments of five hospitals in the Tigray region conducted by the Harvard Program in Global Surgery & Social Change, the areas have been identified as priorities for innovation to improve surgical outcomes in Ethiopia. The partner that will be most closely overseeing each priority area is noted in brackets, with certain priority areas still in need of a specific overseeing partner. The table shows the year in which each innovation will be initiated, but these innovations are likely to carry across multiple years.


Tabl

e -P

riorit

ies

for i

nnov

atio

n to

impr

ove

surg

ical

out

com

es in

Eth

iopi

aP

illar

Pri

orit

y A

reas

Year

1Ye

ar 2

Year

3Ye

ar 4

Year

5

Nat

iona

l Lev

el

Lea

ders

hip,

mgm

t. an

d go

vern

ance

Form

con

sort

ium

[FM

OH

]

Supp

lies

and

logi

stic

s m

anag

emen

tC

ondu

ct b

iom

edic

al e

ngin

eer a

nd te

chni

-ci

an (

BM

ET

) Tra

inin

g [S

S202

0]Pr

ovid

e lo

w-c

ost a

m-

bula

nce

serv

ices

(and

br

oade

r ref

erra

l sys

tem

) [T

BD

]A

war

enes

s an

d pa

rtne

r en

gage

men

tE

stab

lish

netw

orks

of s

urgi

cal c

ham

pion

s [S

urgi

cal s

ocie

ties

/ as

soci

atio

ns]

Reg

iona

l Lev

elL

eade

rshi

p, m

gmt.

and

gove

rnan

ceC

reat

e tr

aini

ng a

nd m

ento

rshi

p pr

ogra

ms

for s

urgi

cal l

eade

rs re

gard

ing

lead

ersh

ip,

inno

vatio

n an

d pr

oble

m s

olvi

ng s

kills

[S

S202

0, J

hpie

go, E

thio

pian

Sur

gica

l Soc

i-et

y]

Scal

e tr

aini

ng a

nd m

ento

rshi

p pr

ogra

ms

for s

urgi

cal

lead

ers

rega

rdin

g le

ader

ship

, inn

ovat

ion

and

prob

lem

so

lvin

g sk

ills

[SS2

020,

Jhp

iego

, Eth

iopi

an S

urgi

cal

Soci

ety]

Impl

emen

t day

car

e su

rger

y [T

BD

]

Est

ablis

h w

eeke

nd a

nd

two

to th

ree

shif

t sur

-ge

ry [T

BD

]

Surg

ical

infr

astr

uctu

reC

ondu

ct d

emon

stra

tion

proj

ects

for a

ltern

a-tiv

e po

wer

/ e

lect

rici

ty s

olut

ions

(e.g

., so

lar)

in

Tig

ray

and

Am

hara

[SS2

020]

Con

duct

dem

onst

ratio

n pr

ojec

ts fo

r oxy

gen

plan

s, in

col

labo

ratio

n w

ith th

e ox

ygen

T

WG

, in

Am

hara

[SS2

020]

Hum

an re

sour

ces

for

heal

th d

evel

opm

ent

Incr

ease

nur

se a

nest

hetis

t tra

inin

gs in

T

igra

y an

d A

mha

ra [S

S202

0]C

reat

e pr

ogra

ms

to in

crea

se a

nest

hesi

olog

ists

in th

e co

untr

y [S

S202

0]

Est

ablis

h su

rgic

al s

kills

labs

(dry

and

wet

) and

ong

oing

tr

aini

ng in

thes

e la

bs [T

BD

]

Cre

ate

tele

med

icin

e pr

o-gr

ams

for o

ngoi

ng s

kills

bo

oste

rs [T

BD

]

Est

ablis

h si

m-

ulat

ion

cent

ers

for t

each

ing

and

inte

rven

tion

Loc

al L

evel

Qua

lity

assu

ranc

eIm

plem

ent W

HO

saf

e su

rger

y ch

eckl

ist [

TB

D]

Mon

itori

ng a

nd e

valu

-at

ion

Prov

ide

real

-tim

e da

ta c

olle

ctio

n de

vice

s an

d pr

ogra

ms

[TB

D]


Structure

The FMOH will oversee all work within innovation and will source innovation needs from the FMOH data, the TWG, as well as other core surgery partners on a semi-annual basis, which will allow the innovation priority areas listed in Table XX to be updated on an ongoing basis. As the list of innovation priorities is updated, the FMOH will identify appropriate partners to take responsibility for pursuing those innovations.

Identified InterventionFor each of the prioritized areas of innovation above, the FMOH will identify one or two core partners to begin to pursue the innovation and develop a specific plan. Innovations that already have selected partners are listed in the table next to the innovation. The first TWG will work to identify partners to carry forward innovations prioritized for year 1 for those that do not already have a clear owner. After a partner is identified to lead the activity on a specific intervention, they will manage their process in close collaboration with the FMOH and will report back to the TWG every six months.

Measurement/IndicatorsIndicators will be specific to the innovation itself. For example, an innovation that supports leadership training for surgical teams to improve their problem-solving, innovation and communication skills will have very different in-dicators than an innovation to support power and electricity solutions at specific hospitals. Thus, it is recommend-ed that each partner that is implementing a specific innovation intervention should determine their own metrics, in collaboration with the FMOH, at the beginning of implementation and track those metrics over the course of implementation.

Monitoring and EvaluationA specific monitoring and evaluation plan will need to be developed for each innovation intervention to account for variability in the target metrics, method for data collection and frequency of reporting.

Strategic Results ¡ Federal: Improved leadership, management and governance of surgery at a national level; strong asso-

ciations or networks of surgical resources; fewer broken machines (as a result of increased number of BMETs); and strengthened referral process.

¡ Regional, Zonal and Woreda: Improved leadership, management and governance at the regional level, as well as among surgical teams at the hospital level; increased volumes of surgeries being delivered (as a result of day surgeries and weekend shifts); uptake of power and oxygen solutions by government and local public-private partnerships; improved surgical outcomes (as a result of increased numbers and quality of nurse anesthetists and anesthesiologists, increased skills labs, increased simulation centers and uptake of telemedicine).

¡ University: Improved training capacity, including leadership training, nurse anesthetist training, anesthesi-ologist training, and hard skills training.

¡ Health facilities: Improved surgical volumes and outcomes as noted above.



Promote solar panel electric supply to improve electric supply to operating facilities.

X x x x x

Dig local water wells for hospitals. X x x x x

Develop a postoperative patient tracking system. X x

Assist teaching institutions in graduate tracking system. X x

Promote day care surgery in the country. X x x x x

Develop lists of day surgery and their management. X x x x x

Promote advanced anesthesia consultation throughout the coun-try (tele-anesthesia).

X x x x x

Utilize innovative ways of increasing the surgical workforce training capacity.

X x x x x

Establish continuous oxygen supply to selected hospitals. X x x x x

Support and promote day surgery and post-operative patient tracking system.

X x x x x

Support and monitor implementation of surgical and anesthesia graduates tracking system.

x x x

Support and promote effective networks of surgical champions. X x x x x

Low-cost ambulance services for broader referral system. X x x x x

Support and promote effective simulation centers for teaching and intervention.

X x x x x

Ethiopian Calender

Major intiatives for innovation pillar


Strategic Pillar Eight: Excellence in Monitoring and Evaluation

SaLTS project M&E FrameworkAim: To improve equitable access to quality and safe essential and emergency surgical and anesthesia care as part of the universal health coverage.

Objectives:

• Implement a nationally coordinated national plan on surgical care

• To define and implement essential surgery package for all levels of the Ethiopian health care delivery system.

• To create better awareness on surgical and anesthesia care with different stakeholders

• To improve the safety of surgical care by implementing the surgical safety check list and improving the safety culture

• Implement quality improvement and audit tool in surgical care

• Proactively identify best practices and scale up rapidly through EHAQ

Major contents of SaLTS M&E frameworkThe SaLTS M&E framework is developed as part and parcel of the national Framework for Hospital Performance

Monitoring and Improvement. The framework have four major components described in table 1 below.

1) The establishment, reporting and review of a core set of hospital KPIs on SaLTS.

2) The facilities will monitor additional site level indicators that are not part of KPI but necessary

for site level decision making

3) Supportive supervision site visits to surgical units of hospitals, led by the respective mentors at

each cluster hospitals and including other bodies such as RHB, MSD or partners as necessary; and

4) Review meetings:

• Regional (or cluster) review meetings between each RHB and all hospitals in the respective Region (or

cluster); and

• MSD and all Regional Curative and Rehabilitative Core Process Teams (CRCPTs) review meet-

ings.


Table. Key elements of the Hospital Performance Monitoring and Improvement Framework

Element Description

KPIs on SaLTS • A set of core hospital KPIs on SaLTS that meets the needs of Governing Boards, CRCPTs, MSD and the public will streamline reporting processes and prevent dupli-cation of efforts by the different stakeholders. The burden on hospitals will be mini-mized.

• A common set of KPIs on SaLTS will allow hospital performance on surgery to be tracked over time, and comparisons between hospitals and regions can be made

• The KPIs on SaLTS can be used by Governing Boards to monitor hospital perfor-mance. Problems will be identified at an early stage, allowing the Governing Board to take remedial action where necessary.

• KPIs on SaLTS should be reported by each hospital to the RHB CRCPT every month. Comparisons between hospitals can be made, identifying best practice as well as areas where improvement is needed.

• The SaLTS team at MSD can review cluster, regional and hospital performance and identify areas where additional support is needed

Supportive supervision site visits

• Supportive supervision site visits to hospitals should be conducted in order to check (validate) hospital performance in relation to the KPIs on SaLTS, to identify good practice, and to provide supervision and guidance to help surgical units of hospitals to improve areas that require strengthening

• Supervision should be conducted by a team of supervisors. The supervisors could in-clude cluster mentors, RHB CRCPT staff, MSD staff, staff from other hospitals (e.g. CEOs) and other partners such as SSE. It would not be necessary for all stakeholders to attend every supervision visit, rather the team for each visit can be drawn from the different stakeholders.

• All supervision should be under the direction of the respective CRCPT. No stakehold-er should conduct supervision without the approval?/awareness of the CRCPT.

Review meetings Regional

Review meetings between the CRCPT and hospitals (either region wide or in clusters) will allow for benchmarking and the dissemination of good practices At each review meeting hospitals should present a performance report based on their KPIs on SaLTS. Hospitals will have the opportunity to share successes and challenges in order to learn from each other.

Regional “all hospital” review meetings can also be used to discuss other relevant topics

National

Review meetings between MSD and all regional CRCPTs will allow for benchmarking and the dissemination of good practice between regions.

At each review meeting CRCPTs should present a regional performance report based on their KPIs. Regional CRCPTs will have the opportunity to share successes and challenges in order to learn from each other.

MSD/CRCPT meetings can also be used to discuss other relevant topics.


Logi

c mod

el fo

r SaL

TS p

rojec

t

• Su

rgic

al te

ams

of h

ospi

-ta

ls•

MO

H a

nd R

HB

sup

er-

viso

rs•

Part

ners

like

SSA

• Su

rgic

al th

eatr

es a

nd

othe

r inf

rast

ruct

ures

• E

ssen

tial e

quip

men

t, su

pplie

s an

d co

nsum

-ab

les

• Fu

ndin

g fr

om lo

cal a

nd

inte

rnat

iona

l sou

rces

• G

uide

lines

and

pol

icie

s on

sur

gery

and

hos

pita

l qu

ality

impr

ovem

ent

• C

ondu

ct S

ite re

adin

ess

asse

ssm

ent

• C

ondu

ct le

ader

ship

de

velo

pmen

t tra

inin

g •

Con

duct

men

tori

ng

visit

s at

clu

ster

leve

l•

Con

duct

sup

ervi

sory

vi

sit a

t eac

h ho

spita

l•

Con

duct

clu

ster

/reg

iona

l re

view

mee

ting

• C

ondu

ct in

tegr

ated

sup

-po

rtiv

e su

perv

isio

n•

Faci

litat

e b

ench

mar

k-in

g vi

sit b

etw

een

hoso

i-ta

ls

• D

evel

op o

r ada

pt fa

cilit

y de

velo

pmen

t che

cklis

t•

Con

duct

clin

ical

aud

it

• Im

plem

enta

tion

perf

orm

ance

gap

s id

entifi

ed a

nd p

ossi

ble

solu

tions

pro

vide

d•

Clin

icia

ns tr

aine

d,

supp

orte

d to

be

lead

-er

s in

saf

e su

rger

y•

Exp

erie

nce

of b

est

impl

emen

ting

hosp

i-ta

ls s

hare

d w

ith o

ther

ho

spita

ls•

Use

of s

tand

ard

prac

tices

and

tool

s in

trod

uced

• R

educ

tion

in p

erio

p-er

ativ

e m

orta

lity

• Im

prov

ed v

olum

e an

d qu

ality

of b

ellw

ethe

r su

rgic

al p

roce

dure

s•

Ens

ured

Saf

ety

in

surg

ery

• D

ecre

ased

in

mor

bidi

ty

and

mor

talit

y fr

om s

urgi

cal

cond

ition

s in

E

thio

pia

Inpu

t

Act

ivit

ies

Out

put

Out

com

eIm

pact


Key:

Natio

nal L

evel

Key I

ndica

tors

Indi

cato

rs fo

r Saf

e Su

rgic

al a

nd A

nest

hesi

a C

are

Prog

ram

S/N

oIn

dica

tor

Defi

niti

onF

orm

ula

Dat

a so

urce

Mea

suri

ng

unit

Cat

egor

yF

requ

ency

of

repo

rtin

g

1D

elay

for e

lect

ive

surg

ical

adm

issi

onT

he a

vera

ge n

umbe

r of d

ays

patie

nts

who

und

erw

ent m

ajor

el

ectiv

e su

rger

y w

aite

d fo

r ad-

mis

sion

dur

ing

the

repo

rtin

g pe

riod.

[Tot

al s

um o

f (D

ate

patie

nt is

ad

mitt

ed fo

r ele

ctiv

e su

rger

y –

Dat

e pa

tient

is a

dded

to th

e su

rgic

al w

aitin

g lis

t) /

(Tot

al

num

ber o

f pat

ient

s ad

mitt

ed

for e

lect

ive

surg

ery

duri

ng th

e re

port

ing

perio

d)]

Surg

ical

wai

ting

chec

klis

t; A

dmis

-si

on/

Dis

char

ge

Reg

istr

y

Num

ber

Qua

lity

Mon

thly

2Pe

ri-o

pera

tive

mor

-ta

lity

All-

caus

e de

ath

rate

prio

r to

disc

harg

e am

ong

patie

nts

who

un

derw

ent a

maj

or s

urgi

cal

proc

edur

e in

an

oper

atin

g th

eatr

e du

ring

the

repo

rtin

g pe

riod.

Str

atifi

ed b

y em

erge

nt,

and

elec

tive

maj

or s

urgi

cal

proc

edur

es.

[(Tot

al n

umbe

r of d

eath

s pr

ior

to d

isch

arge

am

ong

patie

nts

who

und

erw

ent a

maj

or s

urgi

-ca

l pro

cedu

re in

an

oper

atin

g th

eate

r) /

(Tot

al n

umbe

r of

patie

nts

who

rece

ived

maj

or

surg

ery)

] x 1

00

Patie

nt c

hart

s; A

dmis

sion

/

Dis

char

ge R

egis

-tr

y; O

R R

egis

try

Perc

enta

geQ

ualit

yM

onth

ly

3Su

rgic

al s

ite in

fec-

tion

rate

Prop

ortio

n of

all

maj

or s

urge

r-ie

s w

ith a

n in

fect

ion

occu

r-ri

ng a

t the

site

of t

he s

urgi

cal

wou

nd p

rior t

o di

scha

rge.

[(Num

ber o

f inp

atie

nts

with

ne

w s

urgi

cal s

ite in

fect

ion

aris

ing

duri

ng th

e re

port

ing

perio

d) /

(N

umbe

r of m

ajor

su

rger

ies

(bot

h el

ectiv

e &

non

el

ectiv

e) p

erfo

rmed

dur

ing

the

repo

rtin

g pe

riod

on p

ublic

pa

tient

s) +

(N

umbe

r of m

a-jo

r sur

gerie

s (b

oth

elec

tive

&

non-

elec

tive)

per

form

ed d

urin

g th

e re

port

ing

perio

d on

pri

vate

w

ing

patie

nts)]

x 1

00

SW R

egis

try

(SSI

); R

outin

e su

rvei

l-la

nce

(Sur

gica

l Site

In

fect

ion

Rep

ort

Form

s)

Perc

enta

geSa

fety

Mon

thly


4R

ate

of s

afe

surg

ery

chec

k lis

t uti

lizat

ion

Prop

ortio

n of

sur

gica

l cas

es

whe

re th

e W

HO

saf

e su

rger

y ch

eck

list w

as f

ully

impl

emen

t-ed

.

(Num

ber o

f sur

gica

l pat

ient

ch

arts

in w

hich

the

WH

O s

afe

surg

ery

chec

klis

t was

com

-pl

eted

/ T

otal

num

ber o

f OR

ch

arts

revi

ewed

) x 1

00

Ran

dom

revi

ew

of 2

0-25

sur

gica

l pa

tient

cha

rts;

OR

re

cord

s

Perc

enta

geSa

fety

Mon

thly

5M

ean

dura

tion

of

in-h

ospi

tal p

re-e

lec-

tive

oper

ativ

e st

ay

The

ave

rage

num

ber o

f day

s pa

tient

s w

aite

d in

-hos

pita

l (a

fter

adm

issi

on) t

o re

ceiv

e el

ectiv

e su

rger

y du

ring

the

repo

rtin

g pe

riod.

[Tot

al s

um o

f (D

ate

patie

nt

rece

ived

ele

ctiv

e su

rger

y –

Dat

e pa

tient

was

adm

itted

for e

lec-

tive

surg

ery)

/ T

otal

num

ber o

f el

ectiv

e su

rgic

al p

atie

nts

duri

ng

the

repo

rtin

g pe

riod]

OR

Reg

istr

y; A

d-m

issi

on/

Dis

char

ge R

egis

try

Num

ber

Qua

lity

Mon

thly

6Su

rgic

al b

ed o

ccu-

panc

y ra

teT

he a

vera

ge p

erce

ntag

e of

oc

cupi

ed s

urgi

cal b

eds

duri

ng

the

repo

rtin

g pe

riod.

[(The

sum

tota

l sur

gica

l pat

ient

le

ngth

of s

tay

(day

s) d

urin

g th

e re

port

ing

perio

d) /

(Ave

rage

nu

mbe

r of o

pera

tiona

l sur

gica

l be

ds d

urin

g re

port

ing

perio

d x

Num

ber o

f day

s in

repo

rtin

g pe

riod)

] x 1

00

Adm

issi

on/

Dis

char

ge R

egis

try

Perc

enta

geA

cces

sM

onth

ly

7R

ate

of fi

rst e

lect

ive

case

on

time

thea

ter

perf

orm

ance

The

per

cent

age

of fi

rst e

lect

ive

case

s th

at b

egan

on

or p

rior t

o th

e sc

hedu

led

time

per a

gree

d ho

spita

l pro

toco

l dur

ing

the

repo

rtin

g pe

riod.

(Num

ber o

f firs

t ele

ctiv

e ca

ses

com

men

ced

on ti

me

/ To

tal

num

ber o

f firs

t ele

ctiv

e ca

ses

perf

orm

ed) x

100

OR

Reg

istr

yPe

rcen

tage

Tim

eli-

ness

-qua

lity

Mon

thly

8R

ate

of c

ance

llatio

n of

ele

ctiv

e su

rger

yPe

rcen

tage

of e

lect

ive

surg

er-

ies

that

wer

e ca

ncel

led

on th

e pl

anne

d da

y of

sur

gery

.

(Num

ber o

f ele

ctiv

e su

rger

ies

canc

elle

d /

Tota

l num

ber o

f el

ectiv

e su

rger

ies

sche

dule

d) x

10

0

OR

Reg

istr

yPe

rcen

tage

Acc

ess

Mon

thly

Natio

nal L

evel

Key I

ndica

tors

Indi

cato

rs fo

r Saf

e Su

rgic

al a

nd A

nest

hesi

a C

are

Prog

ram


Natio

nal L

evel

Key I

ndica

tors

Indi

cato

rs fo

r Saf

e Su

rgic

al a

nd A

nest

hesi

a C

are

Prog

ram

9E

mer

genc

y su

rgic

al

acce

ssT

he p

ropo

rtio

n of

pat

ient

s w

hose

trav

el ti

me

from

whe

n th

ey fi

rst s

eek

care

to th

eir

arri

val a

t a fa

cilit

y pr

ovid

ing

AN

Y o

f the

sel

ecte

d B

ellw

eth-

er p

roce

dure

s (C

-sec

tions

, la

paro

tom

ies,

or o

pen

frac

ture

re

pair

s) is

less

than

or e

qual

to

2 ho

urs.

Stra

tified

by

each

of

the

thre

e pr

oced

ures

.

(Num

ber o

f em

erge

ncy

surg

ical

pa

tient

s w

hose

trav

el ti

me

from

w

hen

they

firs

t see

k ca

re to

th

eir a

rriv

al a

t a fa

cilit

y pr

ovid

-in

g ei

ther

C-s

ectio

ns, l

apar

oto-

mie

s, o

r ope

n fr

actu

re re

pair

s is

less

than

or e

qual

to 2

hou

rs

/ To

tal n

umbe

r of e

mer

genc

y su

rgic

al p

atie

nts)

x 1

00

Patie

nt s

urve

y; O

R

regi

stry

Perc

enta

geA

cces

sQ

uart

erly

10Su

rgic

al v

olum

eTo

tal n

umbe

r of m

ajor

sur

gica

l pr

oced

ures

per

form

ed in

op

erat

ing

thea

tre

per 1

00,0

00

popu

latio

n pe

r yea

r.

(Tot

al n

umbe

r of m

ajor

sur

gica

l pr

oced

ures

per

form

ed in

OT

pe

r yea

r / T

otal

pop

ulat

ion

of

catc

hmen

t are

a) x

100

,000

OR

Reg

istr

yN

umbe

rA

cces

sA

nnua

l

11Pr

opor

tion

of

budg

et s

pent

on

surg

ical

ser

vice

s

Prop

ortio

n of

recu

rren

t bud

-ge

t tha

t is

spen

t on

surg

ical

se

rvic

es.

(Am

ount

of r

ecur

rent

bud

get

spen

t on

surg

ical

ser

vice

s /

To-

tal h

ealth

faci

lity

budg

et) x

100

Hos

pita

l fina

nces

re

cord

Perc

enta

geFi

nanc

ing

Ann

ual

12B

lood

una

vaila

bilit

y ra

tioT

he p

erce

ntag

e of

maj

or s

urgi

-ca

l cas

es fo

r whi

ch b

lood

was

un

avai

labl

e up

on re

ques

t.

(Tot

al n

umbe

r of m

ajor

sur

gica

l ca

ses

for w

hich

blo

od w

as u

n-av

aila

ble

upon

requ

est)

/ (T

otal

nu

mbe

r of m

ajor

sur

gica

l cas

es

for w

hich

blo

od w

as re

ques

ted)

x

100

Lab

orat

ory

bloo

d re

cord

sPe

rcen

tage

Qua

lity

Mon

thly


13Pa

tient

sat

isfac

tion

Ave

rage

rat

ing

of

hosp

ital o

n a

scor

e of

0-1

0 fr

om T

he

Out

-Pat

ient

and

In

-Pat

ient

Ass

ess-

men

ts o

f Hea

lthca

re

Surv

ey (O

-PA

HC

&

I-PA

HC

sur

veys

) col

-le

cted

from

sur

gica

l pa

tient

s on

ly.

[(Sum

tota

l of O

-PA

HC

rat

ing

scor

es +

Sum

tota

l of I

-PA

HC

ra

ting

scor

es) /

(N

umbe

r of

O-P

AH

C s

urve

ys c

ompl

eted

+

Num

ber o

f I-P

AH

C s

urve

ys

com

plet

ed)]

Surv

eyN

umbe

rQ

ualit

yE

very

6 m

onth

s

14Pr

otec

tion

agai

nst

cata

stro

phic

exp

en-

ditu

re

Prop

ortio

n of

hou

seho

lds

prot

ecte

d ag

ains

t cat

astr

oph-

ic e

xpen

ditu

re fr

om d

irect

ou

t-of

-poc

ket p

aym

ents

for

surg

ical

and

ane

sthe

sia

care

.

Num

ber o

f pat

ient

s w

hose

ag

greg

ate

cost

for a

cces

sing

an

d re

ceiv

ing

care

is le

ss th

an

40%

of r

epor

ted

hous

ehol

d in

-co

me/

Tot

al n

umbe

r of s

urgi

cal

patie

nts

Patie

nt q

ualit

y su

rvey

(for

sel

f-re

-po

rted

inco

me

and

addi

tiona

l cos

ts

for a

cces

sing

and

re

ceiv

ing

care

)

Hos

pita

l cas

hier

re

cord

s (fo

r cos

t of

proc

edur

e)

Perc

enta

geFi

nanc

ing

Year

ly

15Su

rger

y, a

nest

hesi

a,

and

obst

etric

pro

-vi

der d

ensit

y

Num

ber o

f sur

gica

l, an

esth

et-

ic, a

nd o

bste

tric

phy

sici

ans,

in

tegr

ated

em

erge

ncy

surg

ical

of

ficer

s, a

nd a

nest

hetic

pro

vid-

ers

incl

udin

g B

Sc. a

nest

hetis

ts,

nurs

e an

esth

etis

ts a

nd ‘o

ther

s’ (n

urse

s, M

S an

esth

etis

ts a

nd

heal

th o

ffice

rs),

who

are

wor

k-in

g pe

r 100

, 000

pop

ulat

ion.

(Num

ber o

f sur

gica

l, an

es-

thet

ic, o

r obs

tetr

ic p

hysi

cian

s,

inte

grat

ed e

mer

genc

y su

rgic

al

offic

ers,

or a

nest

hetic

pro

vide

rs

incl

udin

g: B

Sc. a

nest

hetis

ts,

nurs

e an

esth

etis

ts a

nd ‘o

ther

s’ (n

urse

s, M

S an

esth

etis

ts a

nd

heal

th o

ffice

rs) w

orki

ng /

Tot

al

popu

latio

n of

cat

chm

ent a

rea)

x

100,

000

Surv

eyN

umbe

rQ

ualit

yYe

arly

16A

nest

hetic

adv

erse

ou

tcom

ePe

rcen

tage

of s

urgi

cal p

atie

nts

who

dev

elop

ed a

ny o

ne o

f th

e fo

llow

ing:

car

dio

resp

ira-

tory

arr

est,

faile

d in

tuba

tion,

or

faile

d sp

inal

ane

sthe

sia.

St

ratifi

ed b

y ea

ch o

f the

thre

e ad

vers

e ev

ents

.

(Num

ber o

f pat

ient

s w

ith

adve

rse

anes

thet

ic o

utco

me/

To

tal n

umbe

r of p

atie

nts

oper

-at

ed) x

100

Ane

sthe

sia

shee

t an

d lo

gboo

k Pe

rcen

tage

Qua

lity

and

Safe

ty

Mon

thly

Natio

nal L

evel

Key I

ndica

tors

Indi

cato

rs fo

r Saf

e Su

rgic

al a

nd A

nest

hesi

a C

are

Prog

ram


ReferencesDebas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. 2015. Disease Control Priorities: Es-sential Surgery. 3rd ed. Washington, DC: World Bank Group.

Debas H, Gosselin R, McCord C, Thind A. 2006. Surgery. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press; 1245–1259.

Mock CN, Donkor P, Gawande A, et al. 2015. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet. 385(9983): 2209-2219.

World Health Organization. 2008. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives. Geneva: WHO.


Annex A. Tool for Situational Analysis to Assess Emergency and Essential Surgical Care in Ethiopia Objective: To assess the gaps in the availability of Emergency and Essential Surgical Care (EESC) at hospitals in Ethiopia.

Key Category of Data

General Information

Infrastructure

Human Resources

Interventions

Emergency and Essential Surgical Care Equipment and Supplies

Financing

Information Management

Surgical Sets

Involvement of following providers is required to complete assessment:

1. Hospital Director or CEO

2. Surgeon/IESO

3. OB/GYN (Surgeon/IESO if not available)

4. Anesthetist/Nurse

If any of the providers listed above are not available, please direct all questions (where applicable ) to Hospital Director or CEO.


Facility Information

Fields marked with an asterisk (*) are mandatory REGION*

DATE OF DATA COLLECTION* (dd/mm/yyyy) NAME of person(s) filling out form*

PHONE NUMBER of person(s) filling out form*

EMAIL*

NAME and ADDRESS of health care facili-ty*

(include city, woreda or zone and region) Phone number of health care facility*

Data Collector

Type of health care facility be-ing evaluated

Primary

Hospital

General

Hospital

Specialized

Hospital

Private Hos-pital

NGO Hospital Mission Hos-pital


Hospital DirectorInfrastructure

Insert number.

1. Total population served by this health care facility #

2. Total number of hospital beds #

3. Total number of surgical beds (ENT, Trauma, GS, orthopedics and others) #

4. Total number of obstetric and gynecologic beds #

5. Total number of post-op recovery beds #

6. Total number of advanced care/ICU beds #

7. Total number of emergency area beds #

8. Total number of admissions in a year #

9. Total number of total surgical admissions in one year (ENT and orthope-dics included) #

10. Total number of obstetric and gynecologic admissions #

11. Total number of outpatients seen in one year #

12. What percentage of your patients can reach the hospital within 2 hours of travel?

* 0 (None) * 1-25% * 26-50%

* 51-75% * 76-99% * 100% (All)

13. Who is acting as OT manager?

OT Manager: defined as the person(s) responsible for the surgical and OB/GYN operating theatres

14. What is the average number of peri-operative, in-hospital deaths per month? #

Fill in with percentages.

15. Over the past month, how often do you have running water?

* 0 (Never) * 1-25% * 26-50% * 51-75% * 76-99% * 100% (Always)

16. Over the past month, how often do you have a regular, 24/7 electricity source?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

17. Over the past month, how often do you have a generator/back-up elec-tricity source?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

18. Over the past month, how often do you have internet?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


Hospital DirectorHuman Resources

Items Number of Full Time Workers.

19. Qualified radiologists? #

20. Qualified pathologists? #

21. Qualified biomedical technicians? #

22. Qualified X-ray technicians? #

23. Trained operating theater nurses? #

24. Pharmacists (including druggists)? #

25. Has any continuing medical education been provided to your staff?

� Yes � No

Financing

Health Financing and Accounting

26. What percentage of your patients have health insurance?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (All)

Budget Allocation

27. What is your total annual hospital budget? __________________________________ Birr

28. How much of your annual hospi-tal operating budget is allotted to surgery and anesthesia?

Including medications, consumables (gloves, etc.) and equipment bought for surgery.

� 0 (None) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (All)


Hospital DirectorInformation Management

Information Systems

29. What is the method of record keep-ing in your hospital?

None Paper Electronic Both

30. Are there personnel in charge of maintaining medical records?

� Yes � No

31. Are charts accessible across multiple visits for the same patient?

� Yes � No

32. How often is data prospectively collected for monthly peri-operative adverse events, such as unexpected return to OT or surgical site infec-tion?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

33. How often is data prospectively collected for monthly post-operative mortality rate?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

34. How often are you required to re-port information to the Ministry of Health or an equivalent agency? If applicable, may check more than one option.

� Never � Monthly � Quarterly � Yearly

35. Do you use telemedicine? � Yes � No

Research Agenda

36. How many quality improvement projects were done in the hospital in the past year?

#

37. How many ongoing research proj-ects are being done in the hospital?

Exclude resident, intern and student research projects.

#

38. How many papers have been pub-lished by hospital staff in the last year?

Exclude resident, intern and student research papers.

#


Surgeon or IESOInfrastructure

Items Insert number.

Minor: any procedure done under local anesthesia

Major: any procedure done in the operating theatre under general anesthesia or profound sedation (i.e. spinal anesthesia)

1. Total number of functioning operating rooms? Minor #

Major #

2. Total number of surgical procedures per year? Minor #

Major #

3. Total number of laparotomies (adult and pediatric) performed per month (on average in the past 6 months)?

#

4. Total number of surgical fracture repairs performed per month (on aver-age in the past 6 months)?

Minor #

Major #

5. Total number of pediatric (aged less than 15 years) surgeries per month? #

6. Total number of patients to this facility that you refer for surgical inter-vention to a higher-level facility per year?

#

7. How far do most patients travel to get to your health facility for surgical services?

If estimation is not possible, which woreda do a majority of patients come from?

(km)

8. When referred from your hospital, how far does the average patient travel to access surgical services?

(km)

Operating Room


9. How many OT tables do you have?

10. How many of those tables are regularly used?

11. If not in use, why?

(e.g. non-functional, surgical services not yet started)

#

#

12. How often do you keep surgery related records?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


Surgeon or IESOManagement Guidelines


13. Do you have management guidelines available for emergency care?

*Yes *No

14. Do you have management guidelines available for surgery?

*Yes *No

Laboratory

15. How often do you have access for blood?

16. How long does it take to get blood that is in stock after you place an order?

17. How long does it take to get blood that is not in stock after you place an order?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

18. How often is a Complete Blood Count available (including hemoglobin, hematocrit, WBCs, platelets)?

19. What do you have available often?

20. What do you not have available often?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

21. How often a full chemistry panel available (including BUN, creatinine, Na, K, etc.)?



� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

24. How often is the lab able to run all coagulation studies (including PT, PTT, BT, INR)?



� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

27. How often are you able to screen for an infectious panel (HIV, hepatitis virus, syphilis)?



� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

30. How often is the lab able to do a urinalysis? � 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


Surgeon or IESORadiology

31. How many X-ray machines do you have?

32. How many of those machines are reg-ularly used?



#

#

34. How many ultrasound machines do you have?

35. How many of those machines are regu-larly used?



#

#

36. How many CT scanners do you have?




#

#

39. How many MRI scanners do you have?




#

#

42. How often do you have 24-hour access to radiology imaging services?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

Supplies43. How many CSR machines do you

have?




#

#


46. How many autoclaves do you have?




#

#

49. How many ambulances do you have?

50. How many of those are regularly used?



#

#

Human ResourcesFull time Contracted

(short-term)

Residents/Interns/ Trainees

52. Surgeons? General #Ortho #IESO #Other spe-

cialties #

53. General Doctors providing surgery (including obstetrics)?

#

Surgeon or IESO

Select one.

54. How often is emergency surgical care available after hours/available 24 hours a day? (on average in the past month)

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


Surg

eon

or IE

SOIn

terv

entio

nsPl

ease

ask

quest

ions i

n po

int i

n tim

e con

text i

.e. w

hat i

s abl

e to

be d

one a

t tim

e of a

ssessm

ent.

Do

you

perf

orm

thes

e pr

oced

ures

?

Yes/

No

If Y

es,

How

man

y pr

oced

ures

pe

rfor

med

in

past

mon

th?

If N

o,

Why

not

?

Do

you

refe

r?

Lac

k of

ski

lls?

If y

ou re

fer,

is it

due

to…

(mar

k A

LL

that

app

ly)

Lac

k of

st

aff?

Non

-fun

c-tio

ning

eq

uip-

men

t?

Lac

k of

sup

-pl

ies/

dru

gs?

Oth

-er

?

Tra

uma

or in

jury

rel

ated

55. A

irw

ay p

roce

dure

s tr

ache

osto

my

and/

or

cric

othy

roid

otom

yY

N

#Y

N

56. T

ube

thor

acos

tom

y fo

r air

and/

or fl

uid

colle

ctio

ns in

the

pleu

raY

N

#Y

N

57. B

asic

wou

nd m

anag

emen

t inc

ludi

ng

thor

ough

sal

ine

was

hing

, irr

igat

ion

and/

or d

ebrid

emen

t

Y

N#

Y

N

58. R

epai

r of l

acer

atio

nsY

N

#Y

N

59. R

epai

r of f

acia

l and

/or s

calp

lace

ratio

nsY

N

#Y

N

60.

Em

erge

ncy

frac

ture

and

/or d

islo

catio

n m

anag

emen

t:

a. S

plin

ting

of fr

actu

res

(incl

udin

g PO

P)

b. D

islo

catio

n: tr

actio

n an

d/or

clo

sed

redu

ctio

n

c. E

xter

nal fi

xatio

n ap

plic

atio

n

d. I

nter

nal fi

xatio

ns o

f sim

ple

frac

ture

s an

d/or

dis

loca

tions

e. I

rrig

atio

n an

d/or

deb

ridem

ent o

f ope

n fr

actu

re

a) Y

N

b) Y

N

c) Y

N

d) Y

N

e) Y

N

# # # # #

a) Y

N

b) Y

N

c) Y

N

d) Y

N

e) Y

N


Surg

eon

or IE

SOIn

terv

entio

ns

61.

Initi

al m

anag

emen

t of b

urn

case

s lik

e re

susc

itatio

n, o

xyge

n de

liver

ing,

pai

n m

anag

emen

t

Y

N#

Y

N

62.

Adv

ance

d bu

rn m

anag

emen

t: es

-ch

arot

omy

and

fasc

ioto

my

Y

N#

Y

N

63.

Skin

gra

ft a

nd/o

r flap

Y

N#

Y

N

64. E

xplo

rato

ry la

paro

tom

y fo

r tra

uma

Y

N#

Y

N

65. C

ut-d

own

for v

ascu

lar a

cces

sY

N

#Y

N

66. T

raum

a re

late

d am

puta

tion

Y

N#

Y

N

67. B

urr-

hole

and

/or e

leva

tion

of d

e-pr

esse

d sk

ull f

ract

ure

for h

ead

inju

ries

Y

N#

Y

N


Do

you

perf

orm

thes

e pr

oced

ures

?

Yes/

No

If Y

es,

How

man

y pr

oced

ures

pe

rfor

med

in

past

mon

th?

If N

o,

Why

not

?

Do

you

refe

r?

Lac

k of

sk

ills?

If y

ou re

fer,

is it

due

to…

(mar

k A

LL

that

app

ly)

Lac

k of

st

aff?

Non

-fun

c-tio

ning

eq

uip-

men

t?

Lac

k of

su

pplie

s/

drug

s?

Oth

er?

68. V

ascu

lar e

xplo

ratio

n an

d/or

repa

ir/an

asto

-m

osis

for t

raum

a Y

N

#Y

N

69. N

eck

expl

orat

ion

for s

ever

e ne

ck in

jurie

sY

N

#Y

N

70. E

mer

genc

y th

orac

otom

y fo

r sev

ere

ches

t in

jury

Y

N#

Y

N

71. M

anag

emen

t of a

cute

han

d tr

aum

a (te

n-do

n an

d ne

urov

ascu

lar)

Y

N

#Y

N

72. M

anag

emen

t of m

uscu

losk

elet

al m

ulti-

ple

trau

ma

and

com

plex

frac

ture

s (e

.g. h

emi

arth

ropl

asty

, int

ra-a

rtic

ular

, spi

ne a

nd p

elvi

c fr

actu

re)

Y

N#

Y

N

Surg

eon

or IE

SOIn

terv

entio

ns


Non

-tra

uma

emer

genc

y an

d es

sent

ial g

ener

al s

urgi

cal c

ondi

tion

s

73. D

rain

ing

supe

rfici

al a

bsce

sses

Y

N#

Y

N

74. M

ale

circ

umci

sion

Y

N#

Y

N75

. Vas

ecto

my

Y

N#

Y

N76

. Exc

isio

n of

sm

all s

oft t

issu

e tu

mor

s lik

e lip

oma,

ga

nglio

nY

N

#Y

N

77. R

elie

ving

acu

te u

rina

ry re

tent

ion:

a) C

athe

teri

zatio

n

b) C

lose

d su

prap

ubic

cys

tost

omy

Y

N

Y

N

# #

Y

N

Y

N78

. Hyd

roce

lect

omy

Y

N#

Y

N79

. Rec

tal t

ube

defla

tion

for s

igm

oid

volv

ulus

Y

N#

Y

N

80. E

xplo

rativ

e la

paro

tom

y fo

r acu

te a

bdom

en

a. A

cute

app

endi

citis

b. A

cute

per

fora

tion

c. B

owel

Obs

truc

tion

a) Y

N

b) Y

N

c) Y

N

# # #

a) Y

N

b) Y

N

c) Y

N

Surg

eon

or IE

SOIn

terv

entio

ns


Do

you

perf

orm

thes

e pr

oced

ures

?Ye

s/N

oIf

Yes

,

How

man

y pr

oced

ures

pe

rfor

med

in

pas

t m

onth

?

If N

o,

Why

not

?

Do

you

refe

r?

Lac

k of

sk

ills?

If y

ou re

fer,

is it

due

to…

(mar

k A

LL

that

app

ly)

Lac

k of

st

aff?

Non

-fun

c-tio

ning

eq

uipm

ent?

Lac

k of

sup

-pl

ies/

dru

gs?

Oth

er?

81. M

anag

emen

t of G

allb

ladd

er P

atho

logi

es

a. C

hole

cyst

ecto

my

b. C

hole

cyst

osto

my

a) Y

N

b) Y

N

# #

a) Y

N

b) Y

N82

. Rep

air o

f her

nias

Y

N#

Y

N83

. Ana

l Pat

holo

gy M

anag

emen

t:

• H

aem

orrh

oide

ctom

y

• Fi

stul

otom

ies

and/

or d

rain

age

of p

eria

nal

absc

esse

s

Y

N#

Y

N

84. C

ompl

ex s

urgi

cal i

nfec

tion

man

age-

men

t:

a. S

eptic

art

hriti

s, o

steo

mye

litis

b. P

yom

yosit

is

c. S

urgi

cal m

anag

emen

t of h

and

infe

ctio

n

a) Y

N

b) Y

N

c) Y

N

# # #

a) Y

N

b) Y

N

c) Y

N

85. T

rans

vesi

cal-p

rost

atec

tom

y (T

VP)

Y

N#

Y

N

Surg

eon

or IE

SOIn

terv

entio

ns


86. C

ysto

litho

tom

y#

Y

N

87. C

omm

on b

ile d

uct (

CB

D) e

xplo

ratio

n,

bilia

ry b

ypas

s pr

oced

ures

and

/or T

-tub

e in

sert

ion

for h

epat

o-bi

liary

pat

holo

gies

Y

N#

Y

N

88. C

onst

ruct

ing

and/

or re

vers

al o

f col

osto

-m

ies,

col

on re

sect

ion

and/

or a

nast

omos

isY

N

#Y

N

89. M

odifi

ed r

adic

al m

aste

ctom

y Y

N

#Y

N

90. T

hyro

idec

tom

yY

N

#Y

N

91. P

edia

tric

em

erge

ncie

s:

Intu

ssus

cept

ion

Col

osto

my

for a

nore

ctal

mal

form

atio

n

Man

agem

ent o

f for

eign

bod

y sw

allo

win

g

Asp

irat

ion

a) Y

N

b) Y

N

c) Y

N

d) Y

N

# # # #

a) Y

N

b) Y

N

c) Y

N

d) Y

N

92. C

left

lip

Y

N#

Y

N

93. C

left

pal

ate

Y

N#

Y

N

Surg

eon

or IE

SOIn

terv

entio

ns

94. T

enot

omy

and/

or P

onse

ti ca

st fo

r clu

b fo

otY

N

#Y

N

95. N

eona

tal s

urge

ryY

N

#Y

N

96. G

astr

ic re

sect

ion

for c

ance

rs a

nd/o

r pe

rfor

atio

nY

N

#Y

N

97. E

soph

agea

l res

ectio

n fo

r can

cers

Y

N#

Y

N


98. E

soph

agea

l res

ectio

n fo

r per

fora

tion

Y

N#

Y

N

99. P

ulm

onar

y re

sect

ions

and

/or m

edia

sti-

nal p

roce

dure

s fo

r che

st p

atho

logi

esY

N

#Y

N

Oph

thal

mic

, Ora

l, D

enta

l Pro

cedu

res

100.

Ext

ract

ion

of p

rim

ary

and

perm

anen

t to

oth

Y

N#

Y

N

101.

Inc

isio

n an

d/or

dra

inag

e (p

erio

dont

al a

nd

dent

al a

bsce

ss)

Y

N#

Y

N

102.

Den

tal c

arie

s tr

eatm

ents

and

/or s

calin

g Y

N

#Y

N

103.

Rep

lant

atio

n of

avu

lsed

teet

hY

N

#Y

N

104.

Dis

impa

ctio

n Y

N

#Y

N

105.

For

eign

bod

y re

mov

al fr

om n

ose,

ear

s,

thro

atY

N

#Y

N

106.

Ear

and

/or e

ye ir

riga

tion

Y

N#

Y

N

107.

Red

uctio

n of

acu

te T

MJ d

islo

catio

nY

N

#Y

N

108.

Oro

faci

al in

fect

ion

man

agem

ent

Y

N#

Y

N

109.

Cat

arac

t sur

gery

Y

N#

Y

N

110.

Tar

soto

my

(upp

er e

yelid

)Y

N

#Y

N

111.

Eye

enu

clea

tion

Y

N#

Y

N

Surg

eon

or IE

SOIn

terv

entio

ns


112.

Man

agem

ent o

f fac

ial b

one

frac

ture

s an

d/or

inju

ry to

den

titio

n (in

terd

enta

l wir

ing,

ar

ch b

ar, I

MF

and

open

redu

ctio

n)

Y

N#

Y

N

113.

Myr

ingo

tom

y fo

r otit

is m

edia

Y

N#

Y

N

114.

Ton

sille

ctom

yY

N

#Y

N

115.

Sur

gica

l man

agem

ent o

f com

mon

ben

ign

and/

or m

alig

nant

tum

ors

and

cyst

of o

ral

& m

axill

ofac

ial r

egio

ns

Y

N#

Y

N

Surg

eon

or IE

SOIn

terv

entio

ns


Emergency and Essential Surgical Care Equipment and SuppliesPlease ask questions in point in time context i.e. what is able to be done at time of assessment.Capital Outlays

0

absent

1

available with

shortages or difficulties

2

fully available for

all patients all the time

Remark

116. Suction pump (manual or electric) with catheter117. Blood pressure measuring equip-ment118. Scalpel with blades119. Retractors120. Scissors121. Tissue forceps122. Gloves (sterile)123. Gloves (examination)124. Needle holder125. Sterilizing skin prep

Renewable Items

126. Nasogastric tubes127. Light source (lamp & flash light)128. Intravenous fluid infusion set129. Intravenous cannulas/scalp vein infusion set130. Syringes with needles (disposable)131. Sharps disposal container132. Tourniquet

133. Needles & sutures134. Splints for arm, leg135. Waste disposal container136. Face masks137. Eye protection138. Protective gowns/aprons139. Soap140 Electrocautery

Supplementary Equipment for use by skilled health professionals141. Adult Mcgill forceps

142. Pediatric Mcgill forceps

143. Chest tubes insertion equipment

144. Tracheostomy set


Surgeon or IESOFinancing

Cost145. What is the average out-of-pocket cost to a patient

for an open fracture repair (procedure only)? #

146. What is the average out-of-pocket cost to a patient for a laparotomy (procedure only)?

#

147. What is the average out-of-pocket cost to a patient for a CBC?

#

148. What is the average out-of-pocket cost to a patient for a chest X-ray?

#

149. What is the average out-of-pocket cost to a patient for surgery-associated lodging (e.g. bed, overnight stays) per visit?

Surgery-associated lodging: defined as in a single visit, before returning home (include lodging for patient and lodging for the caretaker)

#

150. What do the most patients pay out-of-pocket for patient and family transportation per visit?

a. Emergency visitsb. Elective visits

#

#

151. What is the average out-of-pocket cost to a patient for surgery-associated medication per visit (e.g. perfo-rated appendix)?

#

152. What is the average out-of-pocket cost to a patient for other necessities (e.g. laundry/food) per visit?

#


Research Agenda153. How many ongoing research projects does the de-

partment of surgery have?


#


Surgeon or IESOSurgical Sets

154. How many surgical sets are available for treatment of open fractures?

Missing: defined as any part of a surgical set that is absent or non-functional

a) Complete #

b) Incomplete #

c) If incomplete, what is missing?

155. How many surgical sets are available for laparoto-my?


a) Complete #

b) Incomplete #



OB/GYN (Surgeon/IESO if not available)Infrastructure

Items Insert number.

1. Total number of surgical OB/GYN procedures per month (on average in the past 6 months)?

Minor #

Major #

Management Guidelines


2. How often do you have management guidelines available for obstetrics?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

3. How often do you have management guidelines available for maternal delivery?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

Human ResourcesFull time Contracted

(short-term)

Residents/trainees

4. OB/GYNs? #

5. Midwives? #

6. How often are OB/GYN services available for 24 hours a day? (on average in the past month)

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


OB/G

YN (S

urge

on/IE

SO if

not

avail

able)

Inte

rven

tion

sPl

ease

ask

que

stio

ns in

poi

nt in

tim

e co

ntex

t i.e

. wha

t is

able

to b

e do

ne a

t tim

e of

ass

essm

ent.

Do

you

perf

orm

thes

e pr

oced

ures

?

Yes/

No

If Y

es,

How

man

y pr

oced

ures

pe

rfor

med

in

past

mon

th?

If N

o,

Why

not

?

Do

you

refe

r?

Lac

k of

sk

ills?

If y

ou re

fer,

is it

due

to…

(mar

k A

LL

that

app

ly)

Lac

k of

st

aff?

Non

-fun

c-tio

ning

eq

uipm

ent?

Lac

k of

su

pplie

s/

drug

s?

Oth

er?

Obs

tetr

ics

7. C

aesa

rean

Sec

tion

Y

N#

Y

N

8. A

bdom

inal

Hys

tere

ctom

yY

N

#Y

N

9. R

epai

r of U

teri

ne p

erfo

ratio

n or

rup

ture

(in

trac

tabl

e PP

H)

Y

N#

Y

N

10. N

orm

al d

eliv

ery

Y

N#

Y

N

11. M

anua

l rem

oval

of t

he p

lace

nta

Y

N#

Y

N

12. V

acuu

m-a

ssis

ted

deliv

ery

Y

N#

Y

N

13. R

epai

r of G

enita

l Lac

erat

ion/

Inju

ryY

N

#Y

N

14. C

ompr

ehen

sive

abo

rtio

n ca

re

Y

N#

Y

N

15. S

urge

ry fo

r ect

opic

pre

gnan

cyY

N

#Y

N


16. V

IAY

N

#Y

N

17. C

ryot

hera

py fo

r pre

canc

erou

s ce

rvic

al

lesi

ons

Y

N#

Y

N

18. C

ervi

cal b

iops

yY

N

#Y

N

19. E

ndom

etri

al b

iops

yY

N

#Y

N

20. T

ubal

liga

tion

Y

N#

Y

N

21. I

ncis

ion

of H

ymen

for i

mpe

rfor

ate

hym

en

with

hem

atoc

olpo

s an

d/or

hem

atom

ata

Y

N#

Y

N

22. S

urgi

cal m

anag

emen

t of p

elvi

c or

gan

prol

apse

Y

N#

Y

N

23. S

urgi

cal m

anag

emen

t of m

ajor

ben

ign

and/

or m

alig

nant

gyn

ecol

ogic

con

ditio

ns

Y

N#

Y

N

24. R

epai

r of o

bste

tric

fist

ula

Y

N#

Y

N

OB/G

YN (S

urge

on/IE

SO if

not

avail

able)

Inte

rven

tion

s


OB/GYN (Surgeon/IESO if not available)Emergency and Essential Surgical Care Equipment and SuppliesPlease ask questions in point in time context i.e. what is able to be done at time of assessment.

Supplemental Equipment for use by skilled health professionals0

absent

1

available with

shortages or difficulties

2

fully available for

all patients all the time

Remark

25. Vaginal speculum

FinancingCost

26. What is the average out-of-pocket cost to a patient for a C-section (procedure only)?

#

27. What is the average out-of-pocket cost to a patient for surgery-associated lodging (e.g. bed, overnight stays) per visit?

Surgery-associated lodging: defined as in a sin-gle visit, before returning home (include lodg-ing for patient and lodging for the caretaker)

#

28. What is the average out-of-pocket cost to a patient for surgery-associated medication per visit (e.g. perforated appendix)?

#

29. What is the average out-of-pocket cost to a patient for other necessities (e.g. laundry/food) per visit?

#


Research Agenda30. How many ongoing research proj-ects does the department of obstetrics have?


#

Surgical Sets

3.1. How many surgical sets are avail-able for caesarean delivery?


a) Complete #

b) Incomplete #



OB/GYN (Surgeon/IESO if not available)

InfrastructureQuality and Safety

1. For Anesthetist/Nurse to answer:

How often is the WHO surgical safety check-list utilized in the operating rooms?

2. For Data Collector (if able):

Calculate # of times the checklist is used in a random selection of 20 charts:

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

#

Operating RoomFill in with percentages.3. How many anesthesia machines do you have for the OT?

4. How many of those machines are regular-ly used?

5. If not in use, why? (e.g. machines not functional, surgical ser-vices not yet started)

#

#

6, How often do you have oxygen cylin-der or concentrator supply with mask and tubing?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

7. How often is a pulse oximetry used in the operating theater?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

8. How often do you keep anesthesia related records?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

Management Guidelines


9. How often do you have management guidelines available for anesthesia?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

10. How often do you have management guidelines available for pain relief?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

Supplies11. How often do you have a functioning adult pulse oximeter available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

12. How often do you have a functioning pediatric pulse oximeter available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

13. How often do you have adult blood pres-sure monitoring available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

14. How often do you have pediatric blood pressure monitoring available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)


15. How often do you have adult ECG moni-toring available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

16. How often do you have pediatric ECG monitoring available?

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

Human ResourcesFull time Part time Contract-

ed (short-term)

Residents/Interns/ Trainees

17. Anesthesiologist physicians?

18. Other anesthesia providers:

a) BSc. anesthetists #b) MS anesthetists #c) Level 5 anesthesia nurses #d) Nurses #e) Health officers #

19. General Doctors providing anesthesia?20. How often is anesthesia care available for 24 hours a day? (on average in the past month)

� 0 (Never) � 1-25% � 26-50% � 51-75% � 76-99% � 100% (Always)

OB/GYN (Surgeon/IESO if not available)


Inte

rven

tions

Plea

se a

sk q

uest

ions

in p

oint

in ti

me

cont

ext i

.e. w

hat i

s ab

le to

be

done

at t

ime

of a

sses

smen

t.

Do

you

perf

orm

thes

e pr

oced

ures

?Ye

s/N

oIf

Yes

, H

ow m

any

proc

edur

es

perf

orm

ed in

pa

st m

onth

?

If N

o,

Why

not

?D

o yo

u re

fer?

Lac

k of

sk

ills?

If y

ou re

fer,

is it

due

to…

(mar

k A

LL

that

app

ly)

Lac

k of

st

aff?

Non

-fun

c-tio

ning

eq

uipm

ent?

Lac

k of

sup

-pl

ies/

dru

gs?

Oth

er?

Ane

sthe

sia

and

Crit

ical

Car

e

21. B

asic

trau

mat

ic li

fe s

uppo

rt (

BT

LS)

tr

aini

ng

Y

N#

Y

N

22. A

dvan

ced

trau

mat

ic li

fe s

uppo

rt

(AT

LS)

, Ped

iatr

ics

adva

nced

life

sup

-po

rt (

PAL

S) tr

aini

ng

Y

N#

Y

N

23. L

ocal

ane

sthe

sia

Y

N#

Y

N

24. G

ener

al a

nest

hesi

a:W

ith in

tuba

tion

With

out i

ntub

atio

na)

Y N

b) Y

Na)

Y N

b) Y

N25

. Spi

nal a

nest

hesi

aY

N

#Y

N

26. E

pidu

ral a

nest

hesi

a (G

ener

al H

os-

pita

l)Y

N

#Y

N

27. P

erip

hera

l ner

ve b

lock

sY

N

#Y

N

28. P

roce

dura

l sed

atio

nY

N

#Y

N

29. L

MA

/adv

ance

d ai

rway

Y

N#

Y

N30

. Mec

hani

cal v

enti

latio

nY

N

#Y

N

31. F

iber

opt

ic in

tuba

tion

Y

N#

Y

N32

. Blo

od p

atch

Y

N#

Y

N33

. Cen

tral

ven

ous

cath

eter

inse

rtio

nY

N

#Y

N

34. A

rter

ial c

athe

ter i

nser

tion

Y

N#

Y

N


Emergency and Essential Surgical Care Equipment and SuppliesPlease ask questions in point in time context i.e. what is able to be done at time of assessment.

Capital Outlays0absent

1available with shortages or difficulties

2fully available forall patients all the time

Remark

35. Resuscitator bag valve & mask (adult)

36. Resuscitator bag valve & mask (pediatric)

37. Stethoscope

38. Thermometer

39. Oropharyngeal airway (adult size)

40. Oropharyngeal airway (pediatric size)

Supplementary equipment for use by skilled health professionals

41. Endotracheal tubes (adult)

42. Endotracheal tubes (pediatric)

43. IV infuser bags

44. Laryngoscope Macintosh blades with bulbs & batteries (adult) 45. Laryngoscope Macintosh blades with bulbs & batteries (pediatric)

Please check availability of following items.Items Yes No Remark 46. Functional Anesthesia Machine47. Anesthesia machine48. Ambu bag 49. Oral airways 50. Nasal airways51. Perfuser52. Patient monitor53. Patient monitor for transport54. Esophageal stethoscope55. Blood or Fluid pumper56. Warming blanket57. Mechanical ventilator for transport58. Suction machine 59. Capnogram60. Portable pulse oximeter61. Blood warmer62. Stethoscope


63. Manual BP apparatus64. Oxygen gauge65. Oxygen cylinder66. Bougie (Adult)67. Bougie (Pediatric)68. Stylet (Adult)69. Stylet (Pediatric)70. Anesthesia trolley71. Oxygen concentrator72. Double lumen tube 35- 4273. Suction tip74. Urinary Catheter75. Spinal needle 22-2676. Epidural set77. Tegaderm78. Insulated nerve block needles79. Central venous catheterization set80. Arterial line set with module81. Defibrillator

Items Yes No Remark


PharmaceuticalsLocal Anesthetics

82. Lidocaine 1% with adrenaline83. Lidocaine 2% with adrenaline84. Lidocaine 1% without adrenaline85. Lidocaine 2% without adrenaline86. Bupivacaine 0.5%

General Anesthetics87. Halothane 88. Isoflurane89. Sevoflurane

Paralytics90. Succinylcholine91. Rocuronium92. Vecuronium93. Pancuronium94. Atracurium95. Cisatricurium

Sedatives96. Thiopental


Items Yes No Remark

97. Ketamine98. Propofol99. Etomidate

Analgesic 100. Pethidine101. Fentanyl102. Sufentanil 103. Morphine10.4. Alfentanil

Benzodiazepines 105. Diazepam106. Midazolam

Diuretics107. Furosemide IV

Vasopressors108. Noradrenaline109. Dopamine 110. Dobutamine111. Phenylephrine112. Adrenaline113. Ephedrine

Beta-blockers114. Labetolol115. Metoprolol116. Propranolol117. Esmolol

Steroids118. Hydrocortisone119. Dexamethasone

Anti-emetics120. Ondansetrone121. Metaclopramide

IV Fluids122. Normal Saline123. Dextrose in Normal Saline124. 5% Dextrose125. Ringer’s Lactate

Miscellaneous



126. Naloxone127. Salbutamol inhaler128. Dantrolene129. Atropine130. Glycopyrrolate131. Neostigmine 132. Aminophylline133. Lidocaine IV134. Hydralazine 135. Amiodarone136. Intralipid137. 40% glucose

Information ManagementResearch Agenda

138. How many ongoing research projects does the department of anesthesia have?


#

Items Yes No Remark



Ann

ex B

: Sa

fe s

urge

ry c

heck

list

Patie

nt N

ame:

___

____

____

____

____

____

____

____

__

Med

ical

Rec

ord

Num

ber:

____

____

____

__

Bef

ore

indu

ctio

n of

ane

sthe

sia

Bef

ore

skin

inci

sion

Bef

ore

pati

ent l

eave

s O

R

Patie

nt h

as c

onfir

med

Con

firm

all

team

mem

bers

hav

e in

trod

uced

them

-se

lves

by

nam

e an

d ro

leN

urse

ver

bally

con

firm

s w

ith th

e te

am:

Iden

tity

Surg

eon,

ane

sthe

sia

prof

essi

onal

and

nur

se v

erba

l-ly

con

firm

The

nam

e of

the

proc

edur

e re

cord

ed

Site

Patie

ntT

hat i

nstr

umen

t, sp

onge

and

nee

dle

Proc

edur

eSi

teC

ount

s ar

e co

rrec

t (or

not

app

licab

le)

Con

sent

Proc

edur

eSp

ecim

en is

labe

lled

(incl

udin

g pa

tient

na

me)

Site

mar

ked/

not a

pplic

able

Ant

icip

ated

crit

ical

eve

nts

Any

equ

ipm

ent p

robl

ems

to b

e ad

dres

sed

Ane

sthe

sia

safe

ty c

heck

com

plet

edSu

rgeo

n re

view

s: cr

itica

l or u

nexp

ecte

d st

eps,

op

erat

ive

dura

tion,

ant

icip

ated

blo

od lo

ss?

Surg

eon,

ana

esth

esia

pro

fess

iona

l and

nur

se

revi

ew th

e ke

y co

ncer

ns fo

r rec

over

y an

d m

anag

emen

t of t

his

patie

nt

Puls

e ox

imet

er o

n pa

tient

and

fun

ctio

ning

Ane

sthe

sia

team

revi

ews:

any

patie

nt-s

peci

fic

conc

erns

?D

oes

patie

nt h

ave

know

n al

lerg

y?

•

No

•

Yes

Nur

sing

team

revi

ews:

has

ster

ility

(Inc

ludi

ng in

dica

tor r

esul

ts) b

een

confi

rmed

? ar

e th

ere

equi

pmen

t iss

ues

or a

ny c

once

rns?


Bef

ore

indu

ctio

n of

ane

sthe

sia

Bef

ore

skin

inci

sion

Bef

ore

pati

ent l

eave

s O

R

Diffi

cult

airw

ay/a

spir

atio

n ri

sk?

•

No

Ant

ibio

tic p

roph

ylax

is g

iven

with

in la

st 6

0 m

in-

utes

?

yes

•

Yes,

and

equ

ipm

ent/

assi

stan

ce a

vaila

ble

Not

app

licab

leR

isk o

f >50

0ml b

lood

loss

(7m

l/kg

in c

hild

ren)

?

Is e

ssen

tial i

mag

ing

disp

laye

d?

yes

•

No

Not

app

licab

le•

Ye

s, a

nd a

dequ

ate

intr

aven

ous

acce

ss

and

fluid

s pl

anne

d

Safe

sur

gery

che

cklis

t


Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

olSu

rgic

al a

nd A

nest

hesi

a C

are

Aud

it T

ool

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Surg

ical

Ser

vice

Sta

ndar

d 1:

The

hea

lth fa

cilit

y ha

s an

app

ropr

iate

wor

king

sys

tem

AN

D p

hysi

cal e

nviro

nmen

t with

ade

quat

e w

orki

ng g

uide

lines

, uti

litie

s, m

edi-

cine

s, s

uppl

ies

and

equi

pmen

t for

pro

vidi

ng q

ualit

y su

rgic

al s

ervi

ces.

SS 1

.1 W

ater

, ene

rgy,

san

itatio

n, h

andw

ash-

ing

and

was

te d

ispo

sal f

acili

ties

are

func

-tio

nal,

relia

ble,

saf

e an

d su

ffici

ent t

o m

eet

the

need

s of

sta

ff, c

lient

s an

d th

eir f

amili

es

(as

per n

atio

nal s

tand

ard)

.

Con

tinu

ous

elec

tric

sup

ply

with

bac

kup

gene

rato

r is

avai

labl

e.

1

In c

ase

of p

ower

cut

, gen

erat

or is

aut

omat

ic o

r can

be

star

ted

with

in 5

m

inut

es.

1

Con

tinu

ous

wat

er s

uppl

y is

ava

ilabl

e.

1

Ade

quat

e ba

ckup

wat

er s

ourc

e is

ava

ilabl

e w

hen

ther

e is

inte

rrup

tion

from

the

mai

n so

urce

. 1

Tank

ers,

roto

s

Func

tiona

l tel

epho

ne is

ava

ilabl

e in

liai

son

offic

e.

1

Tele

phon

e se

rvic

e is

ava

ilabl

e fo

r int

erna

l com

mun

icat

ion

(fixe

d or

m

obile

).1

Cen

tral

ope

rato

r or s

epar

ate

lines

in

labo

rato

ry, p

harm

acy

etc.

Lea

kpro

of c

over

ed a

nd la

bele

d w

aste

bin

s an

d im

perm

eabl

e sh

arps

co

ntai

ners

ava

ilabl

e to

seg

rega

te w

aste

into

3 c

ateg

orie

s.1

Ver

ify

in a

ll w

ards

/roo

ms

used

for

surg

ical

ser

vice

0 if

mis

sed/

non

func

tiona

l eve

n in

one

ro

om

At l

east

one

fun

ctio

ning

han

d hy

gien

e st

atio

n pe

r 10

beds

with

soa

p an

d w

ater

or a

lcoh

ol b

ased

han

d ru

bs in

all

surg

ical

war

ds (1

:6).

3

Ver

ify

in a

ll w

ards

/roo

ms

used

for

surg

ical

ser

vice

0 if

mis

sed/

nonf

unct

iona

l eve

n in

one

ro

om

Hea

lth c

are

staf

f dem

onst

rate

cle

anin

g th

eir h

ands

cor

rect

ly a

s pe

r the

W

HO

5 m

omen

ts fo

r han

d hy

gien

e (a

udit

tool

exi

sts)

.8

Staf

f Int

ervi

ew

Che

ck th

e sk

ills

of fo

ur h

ealth

car

e w

orke

rs


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Writ

ten,

up-

to-d

ate

prot

ocol

s an

d aw

aren

ess

rais

ing

mat

eria

ls (

post

ers)

on

cle

anin

g an

d di

sinf

ectio

n, h

and

hygi

ene,

ope

rati

ng a

nd m

aint

aini

ng

wat

er, s

anita

tion

and

hygi

ene

faci

litie

s, s

afe

was

te m

anag

emen

t are

ava

il-ab

le a

t all

area

s an

d ar

e vi

sibl

y po

sted

. 1

Ver

ify

in a

ll w

ards

/roo

ms

used

for

surg

ical

ser

vice

0 if

mis

sed/

nonf

unct

iona

l eve

n in

one

ro

om

Sani

tatio

n fa

cilit

ies

are

appr

opri

atel

y ill

umin

ated

at n

ight

, acc

essi

ble

to

peop

le w

ith li

mite

d m

obili

ty, g

ende

r sep

arat

ed fo

r sta

ff a

nd p

atie

nts,

in

clud

e at

leas

t one

toile

t tha

t mee

ts m

enst

rual

hyg

iene

man

agem

ent

need

s, h

andw

ashi

ng s

tatio

ns w

ith s

oap

and

wat

er a

dequ

ate

num

ber (

at

leas

t 1 la

trin

e pe

r 20

user

s fo

r inp

atie

nt s

etti

ngs)

.

6

1 fo

r eac

h bu

llet

Suffi

cien

t fun

ds a

re a

lloca

ted

to s

uppo

rt re

habi

litat

ion,

impr

ovem

ents

an

d on

goin

g op

erat

ion

and

mai

nten

ance

of w

ater

, san

itatio

n, h

ygie

ne

and

heal

th c

are

was

te s

ervi

ces.

3D

ocum

ent r

evie

w

Cur

ativ

e an

d pr

even

tativ

e ri

sk-m

anag

emen

t pla

n ex

ists

for m

anag

ing

and

impr

ovin

g w

ater

, san

itatio

n an

d hy

gien

e se

rvic

es.

1

Sugg

estio

n bo

x, re

gist

er, c

ompl

aint

han

dlin

g of

fice

is a

vaila

ble

for h

an-

dlin

g co

mpl

iant

of c

lient

s an

d th

eir f

amili

es.

1

Sugg

estio

ns a

nd c

ompl

aint

s ar

e re

view

ed in

the

day

to d

ay H

DA

and

ap

prop

riat

e m

easu

res

are

take

n w

hen

need

ed.

5

Clie

nts

and

fam

ilies

att

endi

ng th

e he

alth

faci

lity

wer

e sa

tisfie

d w

ith th

e w

ater

, san

itatio

n an

d en

ergy

ser

vice

s an

d w

ould

reco

mm

end

the

heal

th

faci

lity

to f

rien

ds a

nd fa

mily

.10

Clie

nt I

nter

view

All

heal

th c

are

staf

f are

sat

isfie

d w

ith th

e w

ater

, san

itatio

n an

d en

ergy

se

rvic

es a

nd b

elie

ved

that

suc

h se

rvic

es c

ontr

ibut

e po

sitiv

ely

to p

rovi

d-in

g qu

ality

car

e.8

Staf

f Int

ervi

ew

2 he

alth

car

e w

orke

rs a

nd 2

sup

port

st

affs

Clie

nts

and

thei

r fam

ilies

att

endi

ng th

e he

alth

faci

lity

wer

e sa

tisfie

d w

ith

the

pow

er a

nd li

ghti

ng s

ourc

e an

d w

ould

reco

mm

end

the

heal

th fa

cilit

y to

fri

ends

and

fam

ily.

10C

lient

Int

ervi

ew

Roo

ms

are

wel

l ven

tila

ted,

illu

min

ated

, reg

ular

ly c

lean

ed a

nd m

ain-

tain

ed.

1

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 1

.2 T

he O

R h

as a

dequ

ate

room

s fo

r pr

ovis

ion

of e

ssen

tial a

nd e

mer

genc

y su

rgi-

cal s

ervi

ces

(as

per n

atio

nal s

tand

ard)

.

Ade

quat

e nu

mbe

r of O

R ta

bles

are

pre

sent

. 4

(if 1

00%

)

3 (if

50-

100%

)

0 if

< 1

00%

•

2 fo

r pri

mar

y ho

spita

l

•

4 fo

r gen

eral

hos

pita

l (1

sept

ic)

•

7 fo

r spe

cial

ized

hos

pita

l

•

(1 s

eptic

)

Dem

arca

ted

4 zo

nes

pres

ent (

rest

rict

ed, s

emi r

estr

icte

d, tr

ansi

tiona

l, no

n re

stri

cted

).1

CSR

wra

p pr

esen

t with

a m

inim

um o

f 2 f

unct

iona

l aut

ocla

ves.

1

Cha

ngin

g ro

oms

with

lock

ers

pres

ent (

sepa

rate

d fo

r mal

e an

d fe

mal

e,

for a

min

imum

of 1

0 pe

rson

s).

1

Scru

b ar

ea p

rese

nt (d

irec

t acc

ess,

mul

tiple

sin

ks).

1

Rec

over

y ro

om is

pre

sent

. 1

Toile

t and

sho

wer

s pr

esen

t. 1

Cle

an a

nd d

irty

uti

lity

room

s pr

esen

t. 1

OR

equ

ipm

ent s

tora

ge.

Ster

ile s

uppl

y st

orag

e av

aila

ble.

Nur

se s

tatio

n pr

esen

t.

Cle

aner

’s ro

om p

rese

nt.

Ane

sthe

sia

stor

age

avai

labl

e.

Dut

y ro

om p

rese

nt.

1

Min

i-sto

re p

rese

nt.

1

SS 1

.3 T

he fa

cilit

y en

sure

s th

e ph

ysic

al

safe

ty o

f the

infr

astr

uctu

re (a

s pe

r nat

iona

l st

anda

rd).

Safe

ty o

f ele

ctri

cal e

stab

lishm

ent e

nsur

ed –

no

tem

pora

ry c

onne

ctio

ns

and

no lo

osel

y ha

ngin

g w

ires

1

Floo

rs o

f the

war

d ar

e no

n sl

ippe

ry s

urfa

ce a

nd e

ven.

1

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Win

dow

s/ v

enti

lato

rs if

any

in th

e O

R a

re in

tact

and

sea

led.

1

SS 1

.4 F

inan

cial

pro

tect

ion

give

n fr

om c

ost

of c

are.

Ove

rall

cost

of c

are

is n

ot e

xpen

sive

. 10

Clie

nt I

nter

view

Pres

crib

ed in

vest

igat

ions

are

ava

ilabl

e at

the

faci

lity.

10C

hart

Rev

iew

The

faci

lity

ensu

res

that

dru

gs p

resc

ribe

d ar

e av

aila

ble

at p

harm

acy

and

war

ds.

10C

hart

Rev

iew

Surg

ical

Ser

vice

Sta

ndar

d 2:

For

eve

ry s

urgi

cal p

atie

nt, c

ompe

tent

and

mot

ivat

ed s

taff

are

con

sist

ently

ava

ilabl

e to

pro

vide

rout

ine

care

and

man

age

com

plic

atio

ns.

SS 2

.1 E

very

sur

gica

l pat

ient

has

acc

ess

at

all t

imes

to a

t lea

st o

ne s

kille

d pr

ovid

er (a

s pe

r nat

iona

l sta

ndar

d).

Ade

quat

e nu

mbe

r of s

urge

ons

are

avai

labl

e ba

sed

on le

vel o

f hos

pita

l.•

5

•

5 if

100%

•

3 if

50-

100%

•

2 if

25-

50%

•

0 if

<

25%

•

Prim

ary

hosp

ital –

1 I

ESO

•

Gen

eral

hos

pita

l – 2

Gen

eral

su

rgeo

n, 2

OB

-GY

N a

nd 1

or

thop

edis

t

•

Spec

ializ

ed h

ospi

tal –

3 G

en-

eral

sur

geon

(1 s

ubsp

ecia

list),

2

orth

oped

ic s

urge

on, 3

obs

te-

tric

ians

, 1 a

nest

hesi

olog

ist,

10

anes

thet

ists

.

A c

lear

com

mun

icat

ion

chan

nel i

s pr

esen

t to

reac

h st

aff o

n du

ty a

t all

tim

es.

1

A ro

ster

is u

sed

whi

ch is

acc

essi

bly

disp

laye

d in

all

area

s, d

etai

ling

the

nam

es o

f sta

ff o

n du

ty, t

he ti

mes

of t

heir

shi

ft a

nd th

eir s

peci

fic ro

les

and

resp

onsi

bilit

ies.

1

All

surg

ical

pat

ient

s w

ere

satis

fied

with

the

heal

th c

are

rece

ived

.10

Clie

nt I

nter

view

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 2

.2 S

urgi

cal s

taff

wor

king

in O

R a

nd

surg

ical

war

d ha

ve a

ppro

pria

te c

ompe

ten-

cies

and

ski

lls m

ix to

mee

t nee

ds d

urin

g la

bor,

child

birt

h an

d th

e ea

rly p

ostn

atal

pe

riod

(as

per n

atio

nal s

tand

ard)

.

Hea

lth p

rofe

ssio

nals

kno

w h

ow to

pre

pare

0.5

% c

hlor

ine

solu

tion

(spe

c-if

y pr

ofes

sion

)8

Staf

f Int

ervi

ew

Sele

ct 4

hea

lth c

are

wor

kers

ran

dom

ly

and

veri

fy if

they

hav

e th

e kn

owle

dge

Hea

lth p

rofe

ssio

nals

kno

w h

ow to

pro

cess

use

d in

stru

men

ts (i

nstr

u-m

enta

l pro

cess

ing)

.8

Staf

f Int

ervi

ew

Sele

ct 4

hea

lth c

are

wor

kers

ran

dom

ly

and

veri

fy if

they

hav

e th

e kn

owle

dge

All

surg

ical

pat

ient

s w

ere

satis

fied

with

the

care

and

sup

port

fro

m th

e fa

cilit

y st

aff.

10C

lient

Int

ervi

ew

Mor

e th

an 8

0% o

f OR

and

sur

gica

l war

d st

aff h

ad a

sat

isfac

tory

per

for-

man

ce a

ppra

isal

on

the

prev

ious

mon

th a

ppra

isal

.5

All

OR

and

sur

gica

l war

d st

affs

repo

rted

to b

e “h

ighl

y sa

tisfie

d” w

ith

thei

r job

in re

latio

n to

the

wor

king

env

iron

men

t and

sup

port

of h

ospi

tal

man

agem

ent.

8

Staf

f Int

ervi

ew

Sele

ct 4

hea

lth c

are

wor

kers

ran

dom

ly

and

veri

fy

No

staf

f in

OR

and

sur

gica

l war

d is

act

ivel

y co

nsid

erin

g lo

okin

g fo

r a

new

job

beca

use

of p

oor w

orki

ng e

nvir

onm

ent a

nd p

oor h

ospi

tal m

an-

agem

ent s

uppo

rt.

8

Staf

f Int

ervi

ew

Sele

ct 4

hea

lth c

are

wor

kers

ran

dom

ly

and

veri

fy

A w

ritte

n, u

p-to

-dat

e qu

ality

-of-

care

impr

ovem

ent p

lan

and

pa-

tient

-saf

ety

prog

ram

is p

rese

nt in

OR

and

sur

gica

l war

d.

1

A w

ritte

n, u

p-to

-dat

e, le

ader

ship

str

uctu

re, i

ndic

atin

g ro

les

and

resp

on-

sibi

litie

s w

ith re

port

ing

lines

of a

ccou

ntab

ility

is p

rese

nt in

OR

and

su

rgic

al w

ard.

1

A m

echa

nism

is in

pla

ce fo

r reg

ular

col

lect

ion

of in

form

atio

n on

pat

ient

sa

tisfa

ctio

n (m

onth

ly) a

nd p

rovi

der s

atisf

actio

n (q

uart

erly

) in

OR

and

su

rgic

al w

ard.

1

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Surg

ical

sta

ff e

ffici

ency

is m

onito

red.

M

ajor

sur

geri

es p

er f

ull-t

ime

surg

eon

in th

e fa

cilit

y (la

st m

onth

)

10

•

10 if

mor

e th

an 4

5 or

less

than

45

but

0 s

urgi

cal w

aiti

ng li

st

•

7 if

30–4

5•

5

if 20

–30

•

2 if

10–2

0

•

0 if

less

than

10

Del

ay fo

r ele

ctiv

e su

rger

y (la

st m

onth

)

10

•

10 if

less

than

1 m

onth

•

7 if

b/n

1–3

mon

th•

5

if b/

n 3–

6 m

onth

•

2 if

b/n

6–9m

onth

•

0 if

mor

e th

an 9

mon

th

SS 2

.3 E

very

hea

lth fa

cilit

y ha

s m

anag

eria

l an

d cl

inic

al le

ader

ship

that

is c

olle

ctiv

ely

resp

onsi

ble

for c

reat

ing

and

impl

emen

t-in

g ap

prop

riat

e po

licie

s an

d fo

ster

s an

en

viro

nmen

t tha

t sup

port

s fa

cilit

y st

aff t

o un

dert

ake

cont

inuo

us q

ualit

y im

prov

emen

t (m

anag

eria

l and

clin

ical

lead

ersh

ip s

houl

d be

don

e by

the

righ

t pro

fess

iona

l as

per t

he

natio

nal s

tand

ard)

.

Mon

thly

mee

ting

is c

ondu

cted

to re

view

dat

a, m

onito

r qua

lity

impr

ove-

men

t per

form

ance

and

mak

e re

com

men

datio

ns to

add

ress

pro

blem

s id

entifi

ed, a

nd to

cel

ebra

te th

ose

who

hav

e pe

rfor

med

and

enc

oura

ge

staf

f who

are

str

uggl

ing

to im

prov

e.5

Ver

ify

if it

was

don

e in

the

prev

ious

m

onth

All

OR

and

sur

gica

l war

d le

ader

s ar

e tr

aine

d in

qua

lity

impr

ovem

ent

and

lead

ing

chan

ge (u

se o

f inf

orm

atio

n, e

nabl

ing

beha

vior

, con

tinu

ous

lear

ning

).5

Act

ion

plan

is d

evel

oped

and

impl

emen

ted

/ im

plem

enta

tion

in p

rog-

ress

for t

he g

aps

iden

tified

fro

m c

lient

s fe

edba

cks,

sta

ff fe

edba

cks,

dat

a re

view

, clin

ical

aud

it fe

edba

ck, e

tc.

10

Hea

lth fa

cilit

y le

ader

s an

d fr

ont l

ine

wor

kers

are

com

mun

icat

ed th

roug

h es

tabl

ishe

d m

echa

nism

s (e

.g.,

a da

shbo

ard

of k

ey m

etri

cs) t

hat t

rack

the

perf

orm

ance

of t

he d

epar

tmen

t. 5

See

last

mon

th’s

repo

rt a

nd m

anag

e-m

ent m

eeti

ng m

inut

e

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Surg

ical

Ser

vice

Sta

ndar

d 3:

Evi

denc

e-ba

sed

care

is p

rovi

ded

for a

ll su

rgic

al p

atie

nts.

SS 3

.1 T

he fa

cilit

y ha

s de

fined

and

est

ab-

lishe

d pr

oced

ures

for c

linic

al a

sses

smen

t an

d re

asse

ssm

ent o

f the

pat

ient

s.

Preo

pera

tive

asse

ssm

ent i

s do

ne fo

r all

surg

ical

pat

ient

s (P

/E, r

esul

ts o

f la

b in

vest

igat

ion,

dia

gnos

is a

nd p

ropo

sed

surg

ery)

. 10

Cha

rt R

evie

w

Min

imum

pre

oper

ativ

ely

need

ed la

b te

sts

are

done

.10

Cha

rt R

evie

w

All

lab

test

s w

ere

done

in th

e sa

me

faci

lity.

10

Cha

rt R

evie

w

SS 3

.2 F

acili

ty h

as d

efine

d an

d es

tabl

ishe

d pr

oced

ures

for c

onti

nuity

of c

are

of p

atie

nt

and

refe

rral

.

Prot

ocol

for t

rans

ferr

ing

and

cons

ulta

tion

mec

hani

sms

are

pres

ent.

1

Est

ablis

hed

proc

edur

e of

han

ding

ove

r is

pres

ent w

hile

rece

ivin

g pa

tient

fr

om O

R to

war

ds a

nd in

tens

ive

care

uni

t (tr

ansf

er fo

rm d

ocum

ente

d).

10C

hart

Rev

iew

Inte

rdep

artm

enta

l or i

nter

prof

essi

onal

con

sulta

tions

are

eff

ecte

d no

t m

ore

than

2 h

ours

. 10

Cha

rt R

evie

w

SS 3

.3 R

atio

nal u

se o

f dru

gs is

pra

ctic

ed.

Ant

ibio

tics

used

for s

urgi

cal p

roph

ylax

is a

re a

s pe

r sta

ndar

d tr

eatm

ent

guid

elin

es (S

TG

) rec

omm

enda

tion.

10

Cha

rt R

evie

w

Dru

gs a

re p

resc

ribe

d un

der g

ener

ic n

ame

only

10C

hart

and

Pre

scri

ptio

n R

evie

w

Ant

ibio

tics

used

for s

urgi

cal p

roph

ylax

is: d

ose,

fre

quen

cy, r

oute

and

nu

mbe

r of d

oses

, tim

ing

of a

dmin

istr

atio

n ar

e as

per

sta

ndar

d tr

eatm

ent

guid

elin

es (S

TG

) rec

omm

enda

tions

. 10

Cha

rt R

evie

w

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 3

.4 A

ll th

e ne

cess

ary

preo

pera

tive

prep

arat

ions

are

don

e be

fore

sur

gery

. A

nest

hetic

eva

luat

ion

was

don

e.

10C

hart

Rev

iew

Cro

ss m

atch

ed b

lood

pre

pare

d.

10C

hart

Rev

iew

Writ

ten

cons

ent t

aken

.10

Cha

rt R

evie

w

Patie

nt in

form

ed o

f the

clin

ical

con

ditio

n, tr

eatm

ent p

lan

and

poss

ible

ou

tcom

es.

10C

hart

Rev

iew

and

Clie

nt I

ntev

iew

Dat

e of

sur

gery

was

pre

plan

ned

at a

dmis

sion

and

info

rmed

to th

e pa

tient

. 10

Clie

nt I

ntev

iew

No

dela

y fr

om th

e pr

epla

nned

pro

cedu

re d

ay.

10C

lient

Int

evie

w

Surg

ical

saf

ety

chec

klis

t is

used

. 10

Cha

rt R

evie

w

SS 3

.5 F

acili

ty h

as d

efine

d an

d es

tabl

ishe

d pr

oced

ures

of s

urgi

cal s

ervi

ces.

The

re is

pro

cedu

re O

T s

ched

ulin

g.1

Surg

ical

site

is m

arke

d be

fore

ent

erin

g in

to O

R to

pre

vent

wro

ng s

ite

and

wro

ng s

urge

ry.

10C

lient

Int

evie

w

Spon

ge a

nd in

stru

men

t cou

nt p

ract

ice

is im

plem

ente

d.10

Cha

rt R

evie

w

Post

oper

ativ

e m

onito

ring

is d

one

befo

re d

isch

argi

ng to

war

d.10

Cha

rt R

evie

w

SS 3

.6 F

acili

ty h

as e

stab

lishe

d pr

oced

ures

fo

r mon

itori

ng d

urin

g an

esth

esia

.A

nest

hesi

a pl

an is

doc

umen

ted

befo

re e

nter

ing

into

OR

.10

Cha

rt R

evie

w

Food

inta

ke s

tatu

s of

pat

ient

is c

heck

ed.

10C

hart

Rev

iew

Patie

nts’

vita

ls a

re re

cord

ed d

urin

g an

esth

esia

.10

Cha

rt R

evie

w

Post

-ane

sthe

sia

stat

us is

mon

itore

d an

d do

cum

ente

d.10

Cha

rt R

evie

w

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

Surg

ical

Ser

vice

Sta

ndar

d 4:

The

hea

lth in

form

atio

n sy

stem

ena

bles

the

use

of d

ata

for e

arly

and

app

ropr

iate

act

ion

to im

prov

e ca

re fo

r sur

gica

l pat

ient

s.

SS 4

.1 A

ll su

rgic

al p

atie

nts

have

a c

ompl

ete

and

accu

rate

sta

ndar

dize

d m

edic

al re

cord

. T

he h

ealth

faci

lity

has

regi

ster

s, d

ata-

colle

ctio

n fo

rms,

clin

ical

and

ob

serv

atio

n ch

arts

in p

lace

at a

ll ti

mes

, des

igne

d to

rout

inel

y re

cord

and

tr

ack

all k

ey c

are

proc

esse

s fo

r sur

gica

l pat

ient

s (s

ee a

nnex

). 1

Obs

erva

tion

All

surg

ical

pat

ient

s ha

ve c

ompl

ete

reco

rd o

f all

info

rmat

ion

in th

e cl

ient

cha

rt a

nd re

gist

ered

on

the

HM

IS re

gist

er in

alig

nmen

t with

IC

D

code

. 10

Cha

rt R

evie

w

•

Ver

ify

if al

l inf

orm

atio

n is

re

cord

ed in

the

clie

nt c

hart

and

if

the

diag

nosi

s is

regi

ster

ed o

n th

e H

MIS

regi

ster

in a

lignm

ent

with

IC

D c

ode

The

hea

lth fa

cilit

y ha

s a

syst

em to

cla

ssif

y di

seas

es in

alig

nmen

t with

IC

D c

odes

at a

ll ti

mes

.

10

Cha

rt R

evie

w

•

Ver

ify

if th

e di

agno

sis

writ

ten

in th

e cl

ient

cha

rt is

doc

umen

t-ed

in th

e H

MIS

regi

ster

in

alig

nmen

t with

the

ICD

cod

es

SS 4

.2 F

acili

ty h

as d

efine

d an

d es

tabl

ishe

d pr

oced

ures

for m

aint

aini

ng, u

pdat

ing

pa-

tient

s’ cl

inic

al re

cord

s an

d th

eir s

tora

ge.

Rec

ords

of i

ntra

oper

ativ

e m

onito

ring

mai

ntai

ned.

10

Cha

rt R

evie

w

Ope

rativ

e no

tes

are

reco

rded

(dat

e, id

entifi

catio

n of

pat

ient

incl

udin

g M

RN

num

ber,

surg

ical

and

ane

sthe

sia

team

, pre

oper

ativ

e an

d po

stop

er-

ativ

e di

agno

sis,

type

and

des

crip

tion

of p

roce

dure

, typ

e of

inci

sion

s an

d us

ed s

utur

e m

ater

ials

, pos

tope

rativ

e pl

an).

10

Cha

rt R

evie

w

Ane

sthe

sia

note

s ar

e re

cord

ed.

Reg

iste

rs a

nd re

cord

s ar

e m

aint

aine

d.

10R

egis

ter R

evie

w

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 4

.3 E

very

hea

lth fa

cilit

y ha

s a

mec

ha-

nism

in p

lace

for d

ata

colle

ctio

n, a

naly

sis

and

feed

back

, as

part

of i

ts m

onito

ring

and

pe

rfor

man

ce im

prov

emen

t act

iviti

es.

OR

and

sur

gica

l war

d w

orki

ng h

ealth

car

e w

orke

rs re

gula

rly c

ondu

cts

revi

ews

of s

urgi

cal c

are

and

thei

r dat

a ev

ery

mon

th A

ND

dev

elop

s an

d im

plem

ents

a q

ualit

y im

prov

emen

t pro

ject

for a

ll th

e ga

ps id

entifi

ed.

40

40 (1

0 fo

r eac

h bu

llete

d cr

iteri

a’s) i

f the

fo

llow

ing

wer

e do

ne in

the

prev

ious

m

onth •

Surg

ical

car

e as

sess

men

t was

do

ne th

e pr

evio

us m

onth

•

G

aps

wer

e id

entifi

ed

•

Qua

lity

Plan

ning

(act

ion

plan

) fo

r the

gap

•

Impl

emen

tatio

n an

d fo

llow

up

in p

rogr

ess

The

hea

lth fa

cilit

y im

plem

ents

sta

ndar

d op

erat

ing

proc

edur

es a

nd p

ro-

toco

ls in

pla

ce a

t all

tim

es fo

r che

ckin

g, v

alid

atin

g an

d re

port

ing

data

5C

heck

pre

viou

s m

onth

min

utes

if th

e O

R a

nd s

urgi

cal w

ard

staf

f eva

luat

ed

thei

r dat

a be

fore

repo

rtin

g

Surg

ical

Ser

vice

Sta

ndar

d 5:

Com

mun

icat

ion

with

sur

gica

l pat

ient

s an

d th

eir f

amili

es is

eff

ectiv

e an

d in

resp

onse

to th

eir n

eeds

and

pre

fere

nces

.

SS 5

.1 A

ll su

rgic

al p

atie

nts

and

thei

r fam

-ili

es re

ceiv

e in

form

atio

n ab

out t

heir

car

e an

d ex

peri

ence

eff

ectiv

e in

tera

ctio

ns w

ith

staf

f.

Surg

ical

pat

ient

s ar

e gi

ven

the

oppo

rtun

ity to

dis

cuss

thei

r con

cern

s an

d pr

efer

ence

s.10

Clie

nt I

ntev

iew

Hea

lth c

are

staf

f dem

onst

rate

the

follo

win

g sk

ills:

activ

e lis

teni

ng,

aski

ng q

uest

ions

, res

pond

ing

to q

uest

ions

, ver

ifyi

ng c

lient

’s an

d th

eir

fam

ilies

und

erst

andi

ng, a

nd s

uppo

rtin

g cl

ient

’s in

pro

blem

- sol

ving

.10

Clie

nt I

ntev

iew

Surg

ical

pat

ient

s an

d th

eir f

amili

es c

ared

in th

e fa

cilit

y fe

lt th

ey w

ere

adeq

uate

ly in

form

ed b

y th

e at

tend

ing

care

pro

vide

r(s)

rega

rdin

g ex

am-

inat

ions

, any

act

ions

and

dec

isio

ns ta

ken

abou

t the

ir c

are.

10C

lient

Int

evie

w

Surg

ical

pat

ient

s an

d th

eir f

amili

es c

ared

in th

e fa

cilit

y ex

pres

sed

over

all

satis

fact

ion

with

the

heal

th s

ervi

ces.

10C

lient

Int

evie

w

Surg

ical

pat

ient

s an

d th

eir f

amili

es c

ared

in th

e fa

cilit

y re

port

ed th

at

they

wer

e sa

tisfie

d w

ith th

e he

alth

edu

catio

n an

d in

form

atio

n th

ey

rece

ived

fro

m th

e ca

re p

rovi

ders

.10

Clie

nt I

ntev

iew

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 5

.2 T

here

are

est

ablis

hed

proc

edur

es fo

r ta

king

info

rmed

con

sent

bef

ore

trea

tmen

t an

d pr

oced

ures

.

Writ

ten

info

rmed

con

sent

is ta

ken

befo

re a

ny s

urgi

cal p

roce

dure

and

in

duct

ion

of a

nest

hesi

a.

10

Clie

nt I

ntev

iew

SS 5

.3 I

nfor

mat

ion

abou

t the

sur

gica

l find

-in

g an

d tr

eatm

ent i

s sh

ared

with

pat

ient

s or

at

tend

ants

, reg

ular

ly.

Patie

nt a

nd/o

r att

enda

nt is

info

rmed

abo

ut c

linic

al c

ondi

tion,

sur

gica

l fin

ding

and

trea

tmen

t pro

vide

d.10

Clie

nt I

ntev

iew

Surg

ical

Ser

vice

Sta

ndar

d 6:

Sur

gica

l pat

ient

s re

ceiv

e ca

re w

ith re

spec

t and

dig

nity

.

SS 6

.1 A

ll su

rgic

al p

atie

nts

have

pri

vacy

ar

ound

the

tim

e of

clin

ical

eva

luat

ion,

and

th

eir c

onfid

entia

lity

is re

spec

ted.

The

phy

sica

l env

iron

men

t of t

he h

ealth

faci

lity

faci

litat

es p

riva

cy a

nd

prov

isio

n of

resp

ectf

ul c

are,

con

fiden

tial c

are

incl

udin

g th

e av

aila

bilit

y of

cur

tain

s, s

cree

ns.

10

Clie

nt I

ntev

iew

The

hea

lth fa

cilit

y ha

s w

ritte

n, u

p-to

-dat

e, p

roto

cols

to e

nsur

e pr

ivac

y an

d co

nfide

ntia

lity

for a

ll cl

ient

s th

roug

hout

all

aspe

cts

of c

are.

1

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Surg

ical

and

Ane

sthe

sia

Car

e A

udit

Too

l

Qua

lity

stat

emen

tQ

ualit

y m

easu

reSc

ore

Rem

ark/

veri

ficat

ion

crit

eria

SS 6

.2 N

o su

rgic

al p

atie

nt is

sub

ject

ed to

m

istr

eatm

ent s

uch

as p

hysi

cal,

sexu

al o

r ve

rbal

abu

se, d

iscr

imin

atio

n, n

egle

ct, d

e-ta

inm

ent,

exto

rtio

n or

den

ial o

f ser

vice

s.

The

hea

lth fa

cilit

y ha

s ac

coun

tabi

lity

mec

hani

sms

for r

edre

ss in

the

even

t of v

iola

tions

of p

riva

cy, c

onfid

entia

lity

and

cons

ent.

1

The

hea

lth fa

cilit

y ha

s w

ritte

n, u

p-to

-dat

e, z

ero-

tole

ranc

e, n

on-d

iscr

imi-

nato

ry p

olic

ies

rela

ting

to th

e m

istr

eatm

ent o

f clie

nts.

1

Any

clie

nt w

ho re

port

ed p

hysi

cal,

verb

al o

r sex

ual a

buse

, to

them

selv

es

or th

eir f

amili

es d

urin

g cl

inic

al e

valu

atio

n.

20

•

Sele

ct a

nd v

erif

y 5

clie

nts

exiti

ng

from

the

OR

regi

ster

•

4

for e

ach

clie

nt if

they

are

pr

otec

ted

•

0 fo

r eac

h cl

ient

if re

port

of

abus

e (s

ampl

ing

met

hod)

The

hea

lth fa

cilit

y ha

s w

ritte

n ac

coun

tabi

lity

mec

hani

sms

for r

edre

ss in

an

eve

nt o

f mis

trea

tmen

t.1

The

hea

lth fa

cilit

y ha

s a

writ

ten,

up-

to-d

ate

polic

y an

d pr

otoc

ols

out-

linin

g cl

ient

s ri

ght t

o m

ake

a co

mpl

aint

abo

ut th

e ca

re re

ceiv

ed a

nd h

as

an e

asily

acc

essi

ble

mec

hani

sm (

box)

for h

andi

ng in

com

plai

nts

and

is

perio

dica

lly e

mpt

ied

and

revi

ewed

.

4

•

4 if

pres

ent A

ND

per

iodi

cally

em

ptie

d an

d re

view

ed

•

1 if

only

pre

sent

All

clie

nts

wer

e sa

tisfie

d w

ith th

e fa

cilit

y m

eeti

ng th

eir r

elig

ious

and

cu

ltura

l nee

ds.

10C

lient

Int

evie

w

SS 6

.3 A

ll cl

ient

s ha

ve in

form

ed c

hoic

es in

th

e se

rvic

es th

ey re

ceiv

e, a

nd th

e re

ason

s fo

r int

erve

ntio

n or

out

com

es a

re c

lear

ly

expl

aine

d

All

clie

nts

repo

rted

to b

e tr

eate

d w

ith re

spec

t and

dig

nity

.10

Clie

nt I

ntev

iew

The

hea

lth fa

cilit

y ha

s a

writ

ten,

up-

to-d

ate,

pol

icy

in p

lace

to p

rom

ote

for o

btai

ning

info

rmed

con

sent

fro

m c

lient

s pr

ior t

o ex

amin

atio

ns a

nd

proc

edur

es.

1D

ocum

ent r

evie

w

Surg

ical a

nd A

nest

hesia

Car

e Aud

it To

ol


Ann

ex C

. P

roce

dure

Lis

ts Eth

iopi

an N

atio

nal L

ists

of

Ess

enti

al a

nd E

mer

genc

y Su

rgic

al a

nd A

nest

hesi

a C

are

Pro

cedu

res

S/ No

Spec

ialit

yPr

oced

ures

Ava

ilabi

lity

of P

roce

dure

s B

ased

on

Hea

lth

Faci

lity

Typ

es

Hea

lth

Cen

ter

Pri

mar

y H

ospi

tal

Gen

eral

H

ospi

tal

Spec

ializ

ed

Hos

pita

l

1G

ynec

olog

y an

d O

bste

tric

s C

aesa

rean

Sec

tion

2A

bdom

inal

Hys

tere

ctom

y or

Rep

air o

f U

teri

ne p

erfo

ratio

n fo

r rup

ture

(ass

ocia

ted

with

in

trac

tabl

e PP

H

3N

orm

al d

eliv

ery,

Man

ual r

emov

al o

f the

pla

cent

a, V

acuu

m D

eliv

ery

and

Rep

air o

f Gen

i-ta

l Inj

ury/

Lac

erat

ion

4C

ompr

ehen

sive

Abo

rtio

n C

are

5M

anag

emen

t of p

elvi

c or

gan

prol

apse

(Thi

s is

not

an

esse

ntia

l sur

gery

)

6R

epai

r of O

bste

tric

Fis

tula

7V

IA a

nd c

ryot

hera

py fo

r pre

canc

erou

s ce

rvic

al le

sion

s

8M

anag

emen

t of M

ajor

Ben

ign

and

Mal

igna

nt G

ynec

olog

ic C

ondi

tions

9Tu

bal l

igat

ion/

Vas

ecto

my

10Tr

aum

a an

d In

jury

R

elat

ed

Trac

heos

tom

y an

d cr

ico-

thyr

oide

otom

y

11Tu

be th

orac

osto

my

for a

ir or

flui

d co

llect

ion

in th

e pl

eura


12B

asic

wou

nd m

anag

emen

t inc

ludi

ng w

ound

toile

t, de

brid

emen

t rep

air o

f lac

erat

ions

and

sp

lintin

g of

frac

ture

s

13In

itial

man

agem

ent o

f bur

ns s

uch

as re

susc

itatio

n, e

mer

genc

y w

ound

man

agem

ent o

xy-

gen

deliv

erin

g, p

ain

man

agem

ent

14B

urn

man

agem

ent s

uch

as E

scha

roto

my,

Fas

ciot

omy

and

skin

gra

fts

15E

xplo

rativ

e la

paro

tom

y fo

r Tra

uma

16E

mer

genc

y th

orac

otom

y fo

r sev

ere

ches

t inj

ury

17B

urr-

hole

and

Ele

vatio

n of

Dep

ress

ed S

kull

Frac

ture

for H

ead

Inju

ries

18V

ascu

lar e

xplo

ratio

n an

d re

pair/

anas

tom

osis

for t

raum

a

19N

eck

expl

orat

ion

for s

ever

e ne

ck in

jurie

s

20C

ut d

own

for v

ascu

lar a

cces

s

21E

mer

genc

y fr

actu

re a

nd d

islo

catio

n m

anag

emen

t inc

ludi

ng p

ain

man

agem

ent,

imm

obili

-za

tion,

PO

P ap

plic

atio

n, tr

actio

n, d

islo

catio

n re

duct

ion

and

exte

rnal

fixa

tion

appl

icat

ion

22Tr

aum

a re

late

d am

puta

tion

23N

on tr

aum

a em

er-

genc

y an

d es

sent

ial

surg

ical

con

ditio

ns

Dra

inin

g su

perfi

cial

abs

cess

es

24M

ale

circ

umci

sion

and

adu

lt hy

droc

elec

tom

y

25E

xcis

ion

of s

mal

l sof

t tis

sue

tum

ors

like

lipom

a, g

angl

ion

etc)

(The

se c

anno

t be

esse

ntia

l or

em

erge

ncy)

Ann

ex C

. P

roce

dure

Lis

ts


Ann

ex C

. P

roce

dure

Lis

ts26

Rel

ievi

ng a

cute

uri

nary

rete

ntio

n by

cat

hete

riza

tion,

clo

sed

supr

a-pu

bic

cyst

osto

my

27Tr

ans

vesi

cal p

rost

atec

tom

y (T

VP)

, Cys

to-li

thot

omy

28R

ecta

l tub

e de

flatio

n fo

r sig

moi

d vo

lvul

us

29Pe

diat

ric e

mer

genc

ies

incl

udin

g in

tuss

usce

ptio

n, c

olos

tom

y fo

r ano

-rec

tal m

alfo

rmat

ion

and

fore

ign

body

sw

allo

win

g/as

pira

tion

man

agem

ent

30E

xplo

rativ

e la

paro

tom

y fo

r acu

te a

bdom

en (a

cute

app

endi

citis

, ect

opic

pre

gnan

cy, o

vari

an

tors

ion,

hol

low

vis

cus

perf

orat

ion

and

trau

ma)

31C

hole

cyst

ecto

my,

cho

lecy

stos

tom

y, C

BD

exp

lora

tion,

bili

ary

bypa

ss p

roce

dure

s an

d T-

tube

inse

rtio

n fo

r hep

ato-

bilia

ry p

atho

logi

es

32R

epai

r of a

bdom

inal

wal

l her

nias

33

Con

stru

ctin

g an

d re

vers

al o

f col

osto

mie

s, c

olon

ic re

sect

ion

and

anas

tom

osis

, Hae

mor

-rh

oide

ctom

ies,

Fis

tulo

tom

ies,

fiss

ure

surg

ery

and

drai

nage

of p

eria

nal a

bsce

sses

34M

odifi

ed r

adic

al m

aste

ctom

y an

d th

yroi

dect

omy

(all

form

s)

35G

astr

ic a

nd e

soph

agea

l res

ectio

n fo

r can

cers

and

per

fora

tion

36O

pera

tive

and

non

oper

ativ

e m

anag

emen

t of c

lub

foot

37M

anag

emen

t of S

eptic

Art

hriti

s, O

steo

mye

litis

, Pyo

myo

sitis

, and

han

d in

fect

ion

38

Com

plex

ort

hope

dic

trau

ma

care

incl

udin

g h

emi a

rthr

opla

sty,

intr

a-ar

ticul

ar fr

actu

res,

sp

ine

and

pelv

ic fr

actu

re m

anag

emen

t)

39A

nest

hesi

a an

d C

riti-

cal C

are

Gen

eral

ane

sthe

sia

40Sp

inal

ane

sthe

sia


41E

pidu

ral a

nest

hesi

a/an

alge

sia

(Not

an

esse

ntia

l pro

cedu

re)

42Pr

oced

ural

sed

atio

n

43

Adv

ance

d tr

aum

atic

life

sup

port

(AT

LS)

, Ped

iatr

ics

adva

nced

life

sup

port

(PA

LS)

(N

ot a

n es

sent

ial p

roce

dure

)

44B

asic

trau

mat

ic li

fe s

uppo

rt (

BT

LS)

45In

tuba

tion/

Ext

ubat

ion

(Not

an

esse

ntia

l pro

cedu

re)

46M

echa

nica

l ven

tila

tion

47O

phth

alm

ic, O

ral a

nd

Den

tal p

roce

dure

s E

xtra

ctio

n of

Pri

mar

y an

d Pe

rman

ent t

ooth

48In

cisi

on a

nd d

rain

age

(per

iodo

ntal

and

den

tal a

bsce

ss)

49D

enta

l car

ies

trea

tmen

ts a

nd s

calin

g

50

Man

agem

ent f

acia

l bon

e fr

actu

res

and

inju

ry to

den

titio

n (in

ter-

dent

al w

irin

g, a

rch

bar,

IMF

and

open

redu

ctio

n)

51

Man

agem

ent o

f com

mon

ben

ign

and

mal

igna

nt tu

mor

s an

d cy

st o

f ora

l & m

axill

ofac

ial

regi

ons

(

52C

atar

act s

urge

ry

53Ta

rsot

omy

54Fo

reig

n bo

dy re

mov

al fr

om n

ose

and

ears

55M

yrin

goto

my

for o

titis

med

ia

56To

nsill

ecto

my

Ann

ex C

. P

roce

dure

Lis

ts

ministry of health of ethiopia national safe surgery

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