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Contents
1. Facility Profile 2
2. GENERAL INFORMATION 3
3. Health centre reform guideline performance (average of the year for three years) 4
4. Service delivery organization readiness 6
5. Human Resources for Health (Staffing) 7
6. Facility general and clinical care readiness audit 8
7. Clinical care audit 17
8. Pharmacy audit checklist 18
9. Inventory and stock management audit 19
10. Referral audit tool 20
11. Quality improvement audit checklist 22
12. over all Comprehensive Audit score 24
Reference: 25

Comprehensive Audit Checklist for

health centers
Draft
 1. Facility Profile
Official Name of Health Facility

Region/ city administration

Zone/Sub city

Woreda/Towns

Telephone No.

P.o.box

Fax:

E-mail

Distance from the insurer to be contacted

Name of the insurer to be contacted

Type of facility o Health Centre

Year the facility established

 2. GENERAL INFORMATION
1 Catchment area population
2 Total number of outpatient visits including first and repeat visits in the last Ethiopian ____Non-insured ______________ insured
fiscalyear Other ______

3 Total number of admissions in the last Ethiopian fiscal year

4 Approved budget of health facility for the last Ethiopian fiscal year (treasury source)

Salary and related issues

Medical supplies

Capital (Construction and equipment)

Other
Total
5 Internal revenue generated by health facility in the last fiscal year
Sales of Medicines and Medical Supplies (1436)
Medical Examinations and Treatments (1437)
Other (1489)
Total
Revenue generated from health insurance (For renewal only, and new scheme) ***Keep in
mind double counting with other category
6 How much of retained revenue appropriated in the last fiscal year (total)
Appropriated for medical supplies specifically
7 How much of the retained revenue utilized in the last fiscal year (total)
 retained revenue utilized specifically for medical supplies
8 Approved budget of health facility for this fiscal year (treasury source)
Salary and related issues
Drug and Medical supplies
Capital (Construction and equipment)
Other
Total
9 Internal revenue collection by health facility for thisfiscal year
Sales of Medicines and Medical Supplies (1436)
Medical Examinations and Treatments (1437)
Other (1489)
Total
Revenue generated from health insurance (For renewal only, and new scheme)
***Keep in mind double counting with other category
1 How much of retained revenue appropriated in this fiscal year (total)
0
Appropriated for medical supplies specifically
1 Internal revenue to government allocation budget ratio for the last Ethiopian calendar year
1
1 Does the facility have an updated license?
2 Note:See and check the license. If not updated for the current year, stop the assessment

3. Health centre reform guideline performance (average of the year for three years- for
new)
Request for Health center Reform performance report for the last three years and capture the percentage score for each chapter.
Chapter Number of % of Standards Met for ______ Remark
 standards

Year 1 Year 2 Year 3

HEALTH CENTER LEADERSHIP, MANAGEMENT AND 12

GOVERNANCE

HEALTH POST SUPPORT AND COMMUNITY 9

PATIENT FLOW 8

MEDICAL RECORD 4

PHARMACY SERVICES 13

LABORATORY SERVICES 9

INFECTION PREVENTION AND PATIENT SAFETY 12

MEDICAL EQUIPMENT MANAGEMENT 10

HUMAN RESOURCE MANAGEMENT 7

PERFORMANCE MONITORING AND QUALITY 5

IMPROVEMENT

FINANCIAL AND ASSET MANAGEMENT 11

Total
 4. Human Resources for Health (Staffing)
Please tell me how many staff in each of the following occupational categories are currently assigned to or employed by this facility,
whether full-time or part-time. Please tell me how many staff in each of the following occupational categories are currently assigned
to, or employed by to this facility, whether full time or part-time, the health center shall have at least the following summary of
professionals:
Minimum Standard
Full par
Professionals required number Total Remark
time time Met in %
required
Health Officer 2

General Practitioner (optional) 1

Midwife 3

Nurse 5

Ophthalmic nurse 1

Psychiatry nurse 1

Environmental Health professional 1

Laboratory technician or technologist 2

Pharmacist or pharmacy technician 3

Cleaners (exclude if outsourced) 5

Archive workers 6

Maintenance officer 1

Morgue attendant 1

Other to be added as needed (not rated)

Total
 5. Service delivery organization readiness
Arrange a meeting with the Manager/ Medical Director and present the questions below.
24-HOUR STAFF COVERAGE
Self-assessment Validation Action
1 Is there a duty schedule or call list for 24-hour staff coverage? If no go to
#🡺4
2 May I see the duty schedule or call list for 24-hour staff coverage?

3 Does this facility have a functioning land line telephone that is

always available to call for outside client services?

4 Is there access to email or internet at the facility today?

AMBULANCE/TRANSPORT FOR EMERGENCIES
5 Does this facility have a functional ambulance or other vehicle for
emergency transportation for clients that is stationed at this facility
or operates from this facility?
6 Is fuel available today?
7 Does the ambulance have a dedicated driver?

6. Facility general and clinical care readiness audit

These are questions extracted from the Health center Transformation guideline relevant chapters. As these questions are critical to ensure
quality car e to the insurance beneficiaries, we are asking again the same questions.
 Result
S. No. Auditing components Self-Evaluation Validation

I. Leadership and government

Yes (1) No (0) Yes (1) No (0)

1. Does the facility have an updated license?

Note: Observe the license

2. Does the facility have a strategic plan?

3. Does the health center have a functional governing board that meets
regularly to oversee service delivery at the health center?
Note: board established according to relevant legislation, meets regularly
(quarterly), minutes taken at each meeting

4. Does the facility conduct at least one SMT meeting every month

5. Does the governing board mobilize resources from diversified sources?

Note: Mobilize from different sources (government, internal revenue,
donations), annual budget approval, check resources are mobilized based on
the plan

6. Does the health center have a functional SMT that meets regularly to
manage and execute the overall health center activities?
Note: Obtain a copy of the health center’s organogram and check it
against the SMT members, ToR is prepared and signed by all members;
and SMT meets every week

7. Does the SMT discuss the following agenda items:

(1) Reform initiatives (EHCRG and KPI),
(2) Health financing,
(3) Quality improvement projects?
Note: Observe SMT meeting minutes for the previous quarter and check
 Result
S. No. Auditing components Self-Evaluation Validation

whether these agenda items are discussed.

Yes- If all the three agenda items are raised in the SMT meeting minutes for
the previous quarter

8. Is the facility audited by external auditor?

Note: Check audit report of the previous year prior to the assessment

II. Human resource for health and administration

Yes (1) No (0) Yes (1) No (0)

9. Does this facility conduct routine monitoring of staff satisfaction (twice per
year)?

10. Do all facility staff have a renewed license?

Note: Take a sample of 5 random clinical staff files and check renewed
licence is attached in the personal record

III. Infrastructure availability (electricity, water, toilet)

Yes (1) No (0) Yes (1) No (0)

11. Is this facility connected to the central supply electricity grid?

12. Does this facility have any of the following other sources of electricity?
Such as: Fuel operated generator, Battery operated generator, Solar
system or other

13. Is this facility available 24/7 used source of water for the facility at time
from any source?
Such as: piped tap water, protected dug well, rainwater collection, tanker
truck

14. Is there a separate toilet (Latrine) for men and separate toilet for women in
the general OPD, laboratory, and labour and delivery service areas?
 Result
S. No. Auditing components Self-Evaluation Validation

15. Is there a toilet (Latrine) in functioning condition that is available for

inpatient client use? (optional)

16. Is this facility accessible to individuals with disabilities: Ramp or elevator,

Toilet, Sign language trained personnel at OPD
Y- If all the listed are available

17. Does this facility have a functioning computer?

IV. Medical record management

Yes (1) No (0) Yes (1) No (0)

18. Did the facility implement SMART Care/fully functional computerized

system for registration in the medical record unit? Y- If computerized
system for registration is implemented

19. Does the health center have a single unified medical registration unit for all
patients’ registration?
Note: Interview Head of Medical Records Department (or equivalent) and
confirm that only one registration system exists for ALL patients, including
inpatients, outpatients, emergency patients, and specialty clinic patients.

20. Does the health center utilize paper and computer-based systems to register
and retrieve medical records?
Note: Identify the Master Patient Index & view MR tracking system.

V. Patient flow
Yes (1) No (0) Yes (1) No (0)

21. Does the Health center has a Triage, staffed with appropriately trained
personnel and equipped with necessary equipment and supplies

Note: Check availability of necessary equipment and supplies

 Result
S. No. Auditing components Self-Evaluation Validation

22. Does the health center has Outpatient/client appointment systems are in
place for all disciplines provided by the health center.

23. Does the Health center has a Liaison and Referral Service guideline that the
health facility staff understand and implement

24. Are there sign posts at the compound of the health that directs
clients/patients to the desired health service units

25. Does the health center established maternity waiting room fulfilled with
essential utilities such as latrine, bathroom, electric power and water

VI. Infection prevention and patient safety

Yes (1) No (0) Yes (1) No (0)

26. Does the health center have Infection prevention and patient safety
committee

● Interview CEO/medical director to confirm that CASH/IPPS committee

is in place and functional (check updated and printed TOR of the
committee,)
●

27. Does Infection prevention and patient safety committee develop an action
plan and operational

Check regular monthly minutes of the committee

Is the committee operational?
Check if activities planned are implemented based on the schedule (check
performance reports)
 Result
S. No. Auditing components Self-Evaluation Validation

28. Does the health center has Standard practices to prevent, control and
reduce risk of HCAIs are in place and transmission based precautions (TBP)
are adequately addressed

● Check whether proper decontamination procedures are in place

● Check whether proper high-level disinfection procedures are in place

29. Does the health center have the necessary commodities and supplies of IPPS
routinely available in the designated service areas?
Note:
● Check the availability and adequacy of necessary PPE’s and utilization
of PPEs

30. Does the Health center provides health education to patients, caregivers
and visitors, as appropriate on infection prevention practices Note:

● Check the presence of health education program

31. Does the health center ensure the availability of adequate and functional
toilets, hand washing sinks, and showers?
Note:
● The number of functional toilets are adequate to clients (1 toilet for20-
24 clients)
● Hand washing facilities are available at all service units
● Functional showers at all wards
● Proper and separate storage of washed lines
● Presence of Hand washing facility

32. Does the health center have a client education system for IPPS
improvement?
 Result
S. No. Auditing components Self-Evaluation Validation

Note: Check
● The presence of client education schedule where relevant IPPS contents
is included
● Educational materials and supplies related to IPPS

VII. Pharmacy services management

Yes (1) No (0) Yes (1) No (0)

33. Does the health center have a functional Drug and Therapeutics Committee
(DTC) that develops and implements interventions promoting the rational
and cost-effective use of medicines?
Note:
● Presence of DTC annual plan for the fiscal year
● Presence of terms of reference (TOR)
● Presence of official letter of assignment for members
● Presence of at least 6 signed meeting minutes in the last 12 months
● Presence of performance report of DTC activities of the last fiscal year

34. The health center has a Medicines Formulary listing all pharmaceuticals
prioritized by VEN that can be used in the facility. The Formulary is
utilized and updated annually.
Note:
● Availability of annually updated pharmaceutical list or formulary
and the list is prioritized by VEN

35. Does the health center implement auditable, transparent, and accountable
pharmaceutical transactions and services (APTS)?
 Result
S. No. Auditing components Self-Evaluation Validation

Note:
● Presence of properly recorded and filed prescriptions, sales
tickets, and registers at dispensaries

● Adequate human resource is deployed in each pharmacy services

units (hint: based on workload analysis: number of prescriptions and
bed size)

● Pharmacy premises are arranged to keep patient safety and

privacy

● Implementation of coding to uniquely identify medicines

● Bin ownership is implemented

● Presence of monthly reports for products, finance and services

● Presence of audit report (internal)

● Wastage rate in monetary value is <2%

● Presence of annual report on ABC and VEN analyses

36. Does the facility have 24/7 functional pharmacies available in the
ward/inpatient or outpatient departments?
Note:
● Check the posted schedule and attendance of the professionals

37. Does the health center ensure execution of good dispensing practices at all
dispensing outlets?
Note:
 Result
S. No. Auditing components Self-Evaluation Validation

● Dispensing area workflow organized as: Evaluation & Billing

4Payment//Processing 4Counseling

● Presence of waiting area with seats in OPD pharmacies

● Presence of signed prescriptions by evaluator and counselor

Presence of records for identified DTPs and measures taken

38. Does the health center have an efficient and effective pharmaceutical
logistics management system that reduces the frequency of stock-outs,
wastage, over supply and drug expiry?
Note:
● Presence of procurement policy

● Presence of annual pharmaceutical quantification and supply

plan

● Report that shows percentage of procured items from the health

center list.

● Presence of updated bin card (use the specific audit tool)

● Good storage practice is being followed

39. Does the health center has policies and procedures for identifying and
managing drug use problems, including: Identifying and reporting adverse
drug reactions, and prescription monitoring

Note:
● Presence of semi-annual prescription monitoring report
● Presence of annual DUE Report
● Presence of ADE report
 Result
S. No. Auditing components Self-Evaluation Validation

● Presence of WHO drug use indicator study report

● Presence of update on (high alert medications,
● error prone abbreviations, look-alike, and sound alike

40. Does the health center have an appropriate inventory management system?
Note: see the Presence of properly recorded and filed Vouchers at store

● Availability of paper based or electronic inventory

management tool

● Presence of physical inventory report for dispensaries for stores

● Presence of stock status analysis report.

41. Does the health center ensures proper and safe disposal of pharmaceutical
wastes and expired drugs in line with national guidance?

Note:
● Presence of SOP for disposal for the health center
● Presence of list of disposed products with description
● Expired medicines are separately segregated
● Presence of certificate for disposed medicines (minutes during
disposal)

42. Does the health center provide drug information services to health care
providers, patients, and the public?
Note:
● Presence of properly filled query receiving and answering forms (see
the previous month records)
● Presence of recently prepared sample drug alert/newsletter, therapy
update, drug monograph
● Presence of updates on stock availability to the health center
community (ask health care team or see records)
 Result
S. No. Auditing components Self-Evaluation Validation

● Presence of medicine use education for patients (ask the appropriate

unit)

VIII. Laboratory services management

Yes (1) No (0) Yes (1) No (0)

43. Does the Laboratory management meet the needs and requirements of
customers making the laboratory results are discussed up on and
interpreted

44. Does the health center has Current list of laboratory tests provided by the
facility with the price of each test is accessible to all clinical staff and
patients. in all services areas, customer satisfaction survey report and View
presence of suggestion box to collect customers suggestions & posted
available test menu

45. Does the laboratory has a logistic management system to monitor the
procurement and use of laboratory materials that prevents unnecessary
storage or shortage

46. Does the laboratory has standard operating procedures (Rejection,

transport, retention and disposal) and follows it properly

47. The laboratory work environment is organized and clean at all

times that specimen handling mechanisms ensures safety for the
service providers and users

48. Does the laboratory has a health and safety manual with procedures that
include different types of actions (handling fire and chemical hazard etc?)

49. Does the laboratory have and implements a quality assurance policy that
covers all aspects of laboratory functions
 Result
S. No. Auditing components Self-Evaluation Validation

IX. Health Financing and Asset Management Yes (1) No (0)

50. Does the health center has Bilingual fee posters are displayed beside each
departmental reception desk, in all waiting areas and at all cash points?
Each poster shows the fees and exemptions and advises patients to obtain
and keep receipts for all payments.

51. Does the health center Accountant prepares a monthly report for the
Health Center Management with details of credit granted, credit repaid
and balance outstanding.

52. Does the health center conduct monthly reconciliation is undertaken for
every health center bank account and any donor grants.

53. Does the health center keep monthly and quarterly reports on revenue,
expenditures, receivables, payables, trial balance, the status of budget
utilization and others including the health center’s operating margin are
prepared by the Finance Department and submitted to the health center
management and Governing Body.

Note:
● Confirm that financial records of services kept and documented
● View most recent two quarters reports submitted to concerned bodies

54. Does the health center conduct Internal and external audit of health center
accounts is conducted as a minimum annually and audit reports are
reviewed by the Governing Body.

55. Does the health center has a Memorandum of Understanding with Waiver
Certificate Granting Authorities providing details on the type of service and
mode of conduct
 Result
S. No. Auditing components Self-Evaluation Validation

56. Does health center outsourced non-clinical services,

X. Performance monitoring and quality improvement

Yes (1) No (0) Yes (1) No (0)

57. Does the health center have established a structure (multidisciplinary

team) for performance monitoring and quality improvement

View TOR and list of members of Quality Committee.

● Check the minutes of the Quality Committee to ensure whether
regular meetings are being conducted and the content of meetings
● Receive a copy of the unit’s annual plan

58. Does the quality committee prepare an annual and quarterly plan

59. Does the health center implement quality improvement cycle for selected
priority problems

60. Does the health center monitor Client satisfaction survey and other quality
improvement assessments

Note:
● View results of last patient satisfaction survey.
● Confirm that survey conducted within last 6 months.
● Check and confirm that actions were taken as a results of patient
satisfaction survey
 Result
S. No. Auditing components Self-Evaluation Validation

61. Does the health center to collect, analyze and use for quality improvement
purposes and report reportable indicators to the respective body as per
HMIS standards

Total

7. Chart audit care audit

For new facilities applying to contract with the health insurance system, identify data sources from services provided in the last quarter. In case of
comprehensive audit for renewal of contract, use the Claims submitted by the facility to select 19 medical records randomly. Simple Random
sampling, Random number generator of calculators or Table of Random numbers can be utilized. The 19 medical record number and patient full
name will be recorded and forwards to the health facility for retrieval on the date of the visit. Upon receiving the medical records, the table below
will be utilized to capture data on each audit element. (If Yes=1, if No=0, NA= when non applicable) (Mixed method- should be narrated or SOP
should be prepared) - Recent visit per sheet (last visit) – observation while clerking for validation

Documentation for the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Total Average Remark

recent (last) visit
(sum of 1’s) (total/19)
includes

Patient’s full name on Full

each sheet of paper name
( Pt. &
farther
 name)

1. Patient information

1.1. MRN on each sheet

1.2. Date (for every visit)

1.3. Patient sex and age

per sheet of paper

2. History & physical examination

2.1. Chief complaint or

reason for visit

2.2. Pertinent medical

history

2.3. Vital signs

2.4. Pertinent physical

examination

3. Investigations

3.1. Lab and other

investigation ordered as
appropriate (if not
ordered NA)

Result documented (if

yes to #3.1.)

4. Diagnosis and treatment

4.1. Diagnosis consistent

with history, physical
 examination and
investigations

4.2. Treatment plans

are consistent with
findings/diagnosis as per
STG

4.3. Appropriate Patient

instructions (when to
return, when to stop,
what to watch out)

5. Legibility and authorization

5.1 Written notes are

legible

5.2. Providers signature

and name

5,3, No error or if
Errors, crossed with a
single line and signed

5.4. No local/personal
Abbreviation, or
Abbreviations are
contained within an
agreed glossary

Total score

8. Pharmacy audit checklist

1. Prescription audit: identify 19 prescription using the SOP and complete the form below. Write 1 if Yes and 0 if No
Prescri Pr Responses on review of prescriptions
ption e Medicine-related Prescriber- Dispenser-
number sc Patient-related information Prescription verification Cost verification
 ri information related related
pt ( excluding supply) information information
io
n
St D M Ful A O N D F Ro D N P S N P S Drugs on Drugs Prescr Cost of drugs
a a R l g P a o r ut u a r i a r i prescription on ibed in the
n t N Na e D m s e e r m o g m o g are similar to prescript and registration
d e me / e e q of a e f n e f n drugs ion dispen book
ar n of I D u ad t e a e a indicated on copied sed /prescription
A
d o (pa P i o e mi i s t s t medical similarly drugs is similar to
d
pr . tie D a f n nis o s u s u record with on are the updated
S d
e nt g c tra n i r i r the same pharmac simila pricelist for
e r
sc (pt n m y tio o e o e date y r the batch
x e
ri .& o e n n n registrat
s
pt fat si d ion book
s
io her s i
n na c
fo me i
r n
m e
1

10

11

12

13

14
 15

16

17

18

19

Total

Averag
e

9. Inventory and stock management audit

By using the list of drugs selected for clinical audit, visit the health facility pharmacy and compile the information below. All information
collected should pertain for the period under the audit. (Shewa add more, set criteria)
Product Units of Bin card Bin card Balance on Balance on Stock out Physical Stock product available at
count available? updated? bin card physical for the inventory - out Dispensing unit(s) the
(Y=1, N=0) (Y=1, N=0) (quantity) inventory most store room today? (Y=1, N=0)
(quantity) recent 6 (quantity) (Y=1,
months equals bin N=0)
(Y=1, card
N=0) balance
(Y=1, N=0)
Product1

Product 2

Product 3

Product 4

Product 5

Product 6
Product 7

Product 8

Product 9

Product 10

Product 11

Product 12

Product 13

Product 14

Total

Average

10. Referral audit tool

1. Referral system assessment audit:
Visit the Liaison office and check evidence for the following referral standards. All questions pertain only to the audit period.

s.no Criteria Yes (1) No (0)

1 Updated list of services for which the health facility refers clients is available at OPD and liaisons office.

2 Staff oriented/trained on the updated list of services for which the health facility refers clients

3 There is current /updated agreement with the health facility accepting referred clients

4 The liaison officer communicates with the accepting facility before sending referred patients

5 The health facility has a record-keeping system (referral registration) to track all referrals

6 The health facility updates the registration book by collecting feedback from receiving facilities
 7 Referral to the receiving facility done in accordance with the Primary Care Clinical Guideline (at PHC
facilities) and other relevant guidelines

2. Referral Letter verification and audit: Randomly select 19 referrals from the claim submitted from the facility using
table of random number. Capture the name of the patient, MRN and referral date to identify and scrutinize copy of the
referral letter at the facility.
3. Write 1 if yes and 0 if No
s.no check documentation of
the following on the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Total Average
referral letter
Pt & facility related information
1 Patient's name, age, &Medical
record number
2 Name of referring health
professional
3 Name of receiving health
facility
Clinical information
4 Description of chief complaint &
associated symptoms
5 Relevant clinical findings
6 Provisional diagnosis or clinical
impression
7 Reason for referral
Standard and completeness of referral sheet
8 Seal of the referring facility
9 Use standard referral format
Total
Average
Referral letter verification
1 Referral status mentioned on
the same date on the medical
record
2 Referral status documented on
the referral registration book of
the facility
3 Referral justified by the primary
care Clinical guideline or other
relevant guidelines

11. Quality improvement audit checklist

The clinical audit team will closely work with the quality unit of the facility to ascertain the following.

s.no Criteria Yes No

2 Is there evidence that the facility’s quality team identifies and evaluates safety and quality issues identified through
supervision, review meetings, clinical audit and client concerns? (verifying the implementation of quality improvement
cycle)

Look for: (rewrite, Eg. PDSA)

● Structured process of selection and prioritization of quality projects is in place

● Quality improvement projects are informed by data and are outcome related
● Staff is involved in quality improvement projects
● Findings from previous improvement projects are routinely shared with entire staff
● Findings from previous improvement projects are used to inform subsequent projects

4 Agreed gap 1 Review process is in place to evaluate quality improvement plans and assess performance data; findings are
generated for follow up and used to plan ahead; summary of findings are documented.

5 Agreed gap 2

Review process is in place to evaluate quality improvement plans, and assess performance data; findings are generated for
follow up and used to plan ahead; summary of findings are documented.
6 Agreed gap 3

Review process is in place to evaluate quality improvement plans, and assess performance data; findings are generated for
follow up and used to plan ahead; summary of findings are documented.

7 Agreed gap 4

Review process is in place to evaluate quality improvement plans, and assess performance data; findings are generated for
follow up and used to plan ahead; summary of findings are documented.

8 Is there evidence that staff and management know of the types of improvement activities that have been undertaken, i.e.
have these been communicated and celebrated?

9 Is there evidence that the facility has processes in place to track and improve client satisfaction?

● Look for: Comment and complaint forms are available for patients to complete?
● Secure patient comment and complaint boxes are in publicly accessible places?
● There is a current complaints register which includes responses and actions to address identified issues?
● There is evidence of regular/urgent meetings about client comments and complaints?

10 Does the facility monitor client satisfaction?

Look for:

● Facility conducts patient satisfaction surveys/ community score card?

● Facility reviews patient satisfaction/community scorecard data?
● Issues identified are incorporated into the facility's quality improvement system?

Does the facility monitor staff satisfaction?

Look for:

● Facility conducts staff satisfaction surveys

● Issues identified are incorporated into the facility's quality improvement system
● Mobilized resource for staff development/incentive

Total score
 12. over all Audit score (re-look)
s.no Audit type Total Score Weight Adjusted score
points

1 Hospital transformation guideline

performance (average of the year for three
years)

2 Service delivery organization readiness

3 Human Resources for Health (Staffing)

4 Facility general and clinical care readiness

audit

5 Clinical care audit

6 Pharmacy audit checklist

7 Inventory and stock management audit

8 Referral

9 Quality improvement

Total
1. Reference:
● Health facility readiness assessment tool; Ethiopian Health Insurance Agency (EHIA)
● Ethiopian hospital services transformation guidelines (EHSTG), September 2016; Ethiopia Ministry Of Health (FMOH)
● Health care audit, 2016 April 15; Food, Medicine and Healthcare Administration and Control Authority (FFMHACA)

1.