Addis Ababa city
Administration health bureau
Medical service Directorate
EBC Document Lists
5/11/2017 E.C
Addis Ababa
Guideline /Protocols and SOPs
Section Two: Mechanism to Avail high quality evidence (6)
Section Two(a):Scope Based practices Audit tool…4
1 Protocol for specific scope of practice (Facility level, Specilaity service
level and professional level
[Link] consultation protocol and consultation format
3 Triage protocol
4 Surgical service protocol
Section two(b):Standard based clinical Service Audit tool…2
[Link] practice protocol at least surgical service, OPD Clinic,
Emergency service and Neonatal ICU
2. protocol/policy/procedures for patient round and bedside teaching,
nursing procedures, patient transportation, bad news breaking,
surgical Scheduling and STG
Section Three: Evidence Generation and Utilization (26)
Section Three (a):Evidence generation and utilization … 2
[Link] for staff capacity building
[Link] for triangulation of selected data
Section three(b): System redesign and EHSTG boosters 23
[Link] protocol
[Link]-triage screening protocol
[Link] for patient channeling to the cough clinic
4 Air born and droplet precaution protocol on OPD clinic
[Link] Service protocol
[Link] for pediatric wards
[Link] for round and clinical care for pediatric ward
8. Vital sign protocol
[Link] and palliative care protocol
10 . Physiotherapy protocol
EBC Documents Cont…
[Link] equipment maintenance protocol
12. Calibration procedures
[Link] maintenance protocol
14. Notification protocol for facility and operating system
repair…..work order system for repair
[Link] Manual
[Link] monitoring protocol /checklist for food and
beverage service
[Link] and beverage service manual
17protocol for prioritized equipment list with an inspection
and preventive maintenance
18 Management guideline for selected prioritized health
conditions and drug lists
EBC Documents Cont.…
1 [Link] for prescribe, dispense and monitor appropriate
and rational use of drugs.
[Link] of clinical audit team
[Link] round (grand round) protocol…senior led
multidisciplinary round ,nursing care, IPC, client
education ,clinical pharmacy and client satisfaction
22. Handover protocols
23. Protocol for new admission audited and co-signed by day
and duty time senior physicians
Section three (c): Efficient use of health care resources (1)
[Link] /guide for staff incentive and recognition
EBC Documents
Guideline /Protocols and SOPs
Section Two: Mechanism to Avail high quality evidence (6)
Section Two(a):Scope Based practices Audit tool…4
1 Protocol for specific scope of practice (Facility level, Specilaity service
level and professional level
[Link] consultation protocol and consultation format
3 Triage protocol
4 Surgical service protocol
Section two(b):Standard based clinical Service Audit tool…2
[Link] practice protocol at least surgical service, OPD Clinic,
Emergency service and Neonatal ICU
2. protocol/policy/procedures for patient round and bedside teaching,
nursing procedures, patient transportation, bad news breaking,
surgical Scheduling and STG
Section Three: Evidence Generation and Utilization (26)
Section Three (a):Evidence generation and utilization … 2
[Link] for staff capacity building
[Link] for triangulation of selected data
Section three(b): System redesign and EHSTG boosters 23
[Link] protocol
[Link]-triage screening protocol
[Link] for patient channeling to the cough clinic
4 Air born and droplet precaution protocol on OPD clinic
[Link] Service protocol
[Link] for pediatric wards
[Link] for round and clinical care for pediatric ward
8. Vital sign protocol
[Link] and palliative care protocol
10 . Physiotherapy protocol
EBC Documents Cont…
[Link] equipment maintenance protocol
12. Calibration procedures
[Link] maintenance protocol
14. Notification protocol for facility and operating system
repair…..work order system for repair
[Link] Manual
[Link] monitoring protocol /checklist for food and
beverage service
[Link] and beverage service manual
17protocol for prioritized equipment list with an inspection
and preventive maintenance
18 Management guideline for selected prioritized health
conditions and drug lists
EBC Documents Cont.…
1 [Link] for prescribe, dispense and monitor appropriate
and rational use of drugs.
[Link] of clinical audit team
[Link] round (grand round) protocol…senior led
multidisciplinary round ,nursing care, IPC, client
education ,clinical pharmacy and client satisfaction
22. Handover protocols
23. Protocol for new admission audited and co-signed by day
and duty time senior physicians
Section three (c): Efficient use of health care resources (1)
[Link] /guide for staff incentive and recognition
Section Four: Focus Service Areas…20
Section four(a):Quality nursing care Audit tool ….8
1 Nursing care protocol
[Link] procedure
3 Nursing round protocol
4 Nursing Audit protocol
[Link] code of conduct
[Link] nursing care package/protocol
7. Capacity building protocol …regular need based
capacity building for nursing staff
[Link] orientation protocol …clearly understand
disease process
Section four(b):Surgical service efficiency and safety Audit tool……8
[Link] surgery protocol
[Link]-admission evaluation protocol
[Link]-operative workup protocol
[Link] elective and post operative hospital stay protocol
[Link] and post operative hospital stay protocol
[Link] and debriefing protocol….team briefing and debriefing
or binging and end of day
[Link] care surgery protocol ….define day care surgery clinical
condition for each department and ensure necessary
infrastructure
[Link] Protocol
Section 4 cont…
Section four(c):Improve neonatal intensive care audit tool …1
[Link] service protocol
section four (d): Improved emergency ,trauma and critical care Audite
tool ….2
[Link] protocol
2. protocol/guideline for referral, triage, burn, poisoning,trauma,
ED,ICU service
Section five .Patient Preferences and Value Audit Tool …4
[Link] for discharge planning
[Link] management protocol
[Link] pain and palliative care clinic guideline/protocol
[Link] service protocol
Section six: Cluster Activity..1
[Link] document for cluster activities
Total= 58 protocol/guideline and SOPs
Expected QI Projects
