2. Ethiopian Health Service Program and
Regulations
Learning objectives
• At the end of this topic, the learner should be
able to:
– Understand the Ethiopian health policy
– Describe health service program of the
country
– Identify health care system regulations
– Explain health information system policies and
procedures
1
Ethiopian health policy
• Policy: The set of basic principles and associated
guidelines, formulated and enforced by the
governing body of an organization, to direct and
limit its actions in pursuit of long-term goals
(management definition).
• Health Policies: According to world health
organization (WHO), health policy is defined as
decisions, plans, and actions that are undertaken
to achieve specific health care goals within a
society.
2
Ethiopian health policy…
• An explicit health policy can achieve several
things:– Defining a vision for the future which in turn helps
to establish targets and points of reference for the
short and medium term.
– Outlining priorities and the expected roles of
different groups.
– Building consensus and inform people.
3
Ethiopian health policy…
• Strategies: a method or plan chosen to bring about a
desired future, such as achievement of a goal or
solution to a problem.
• Regulation: a legal provision that creates, limits, or
constrains a right, creates or limits a duty, or allocates
a responsibility.
• Guideline: is a statement by which to determine a
course of action.
– aims to streamline particular processes according to a set
routine or sound practice.
– may be issued by and used by any organization
(governmental or private) to make the actions of its
employees or divisions more predictable, and of higher
quality actions.
4
Ethiopian health policy…
• Rule: Rule and ruling usually refers to
standards for activities.
• Procedure: is a document written to support
a policy.
– It is designed to describe Who, What, Where,
When, and Why by means of establishing
organization accountability in support of the
implementation of a policy.
5
Ethiopian health policy…
• Following the change of government in
1991(G.C), a number of political and socioeconomic reform measures were put in place.
1. the development and introduction of a new
National Health Policy in 1993
2. and, in 1997, the formulation of a
comprehensive rolling 20-year Health Sector
Development Plan (HSDP).
6
The National Health Policy
• The Government of Ethiopia formulated the
National Health Policy in 1993.
• The policy emanated from commitment to
democracy and gives strong emphasis to the
fulfilment of the needs of the less privileged
rural population that constitutes about 85% of
the total population in Ethiopia.
7
The National Health Policy
Policy linkages
MDGs
GTP
HSDP is
the
Health main
Policy vehicle
8
Ethiopian health policy…
• The 1993 policy principally focuses on fiscal
and political decentralization, expanding the
PHC services to all segments of the population
and encouraging partnerships and the
participation of nongovernmental actors.
9
Ethiopian health policy…
General theme of the policy
• Democratization and decentralization of the
health system;
• Prevention of disease and Promotion health
• Ensuring accessibility of health care to all
population;
• Promoting inter-sectoral collaboration
• Promoting and enhancing national self- reliance in
health by mobilizing and efficiently utilizing
internal and external resources.
• The health policy has also identified the priority
intervention areas and strategies to be employed
to achieve the health policy issues.
10
Ethiopian health policy…
• Assurance of accessibility of health care for all
segments of the population.
• Working closely with neighboring countries,
regional and international organizations to share
information and strengthen collaboration in all
activities contributory to health development
including the control of factors detrimental to
health.
• Development of appropriate capacity building
based on assessed needs.
11
Ethiopian health policy…
• Provision of health care for the population on a
scheme of payment according to ability with special
assistance mechanisms for those who cannot afford
to pay.
• Promotion of the participation of the private sector
and nongovernmental organizations in health care.
• Many of the national policies like: the Policy of
population, Women, Prevention and Control of
HIV/AIDS, Drug including the national health
policies are congruent to other Macro level policies
like the growth and transformation plan (GTP) and
the Agriculture led rural development strategy.
12
Ethiopian health policy…
Facts Considered during Ethiopian Health Policy
Development
• Life expectancy at birth is estimated 53 years due to
very high premature mortality.
• Despite this, the population is expected to double in
the next two decades leading to considerable
pressure on social services including health.
• Parasitic and infectious diseases account for high
mortality and morbidity.
• Health of children and mothers are affected by
harmful traditional practices besides diseases.
13
Ethiopian health policy…
• Malnutrition is prevalent particularly among
children and mothers.
• While workers in different production sectors are
exposed to accident and illness due to the nature
of their occupation, efforts to establish
occupational health standards and services are
very minimal.
• Environmental health problems attribute to the
occurrence of the great proportion of
communicable diseases in the country.
• The access to safe and adequate water supply is far
below the needs of the population.
14
Ethiopian health policy…
• The bulk of the people lack adequate sanitary facilities.
• The method used to dispose human excreta poses a threat
to public health.
• Modern health care delivery systems are inadequate and
remote to the wider population and characterized by ineffective organization, poor logistics and technological
support and infrastructure.
• Access to modern pharmaceutics is very limited.
• Indigenous health technologies have been widely used in
Ethiopia.
• The development of health in a country needs to be
supported by the development of Health Science and
Technology (HST
15
Ethiopian health policy…
• HST encompasses the scientific capability to undertake
studies in relevant fields such as Biomedical, Public Health,
Pharmaceutical, Clinical and Traditional Medicine.
• Moreover, the small number of health activities has been
uncoordinated resulting in unnecessary duplication of
efforts and wastage of insufficient resources.
• HST undertakings suffer from lack of adequate
infrastructure, limited access to scientific and technological
information and shortage of trained manpower.
• The negative effects of these problems are augmented by
inadequate funding and incentives as well as absence of
career development structure in HST institutions.
16
Health Service Development Program
• HSDP is considered as a policy implementation
strategic document that guides the
development of sub national plans and sets the
rule of engagement in the health sector.
• It responds to a number of problems identified
in the health service coverage and quality, and
some of the major objectives of the HSDP –I, II
and III were:
17
Health strategies/plans
Health strategies/plans
1. HSDP I
– Covered the first five years (1997/98–2001/02)
– Prioritized disease prevention
– Introduced a four-tier system for health service
delivery
– Characterized by a primary health care unit (PHCU),
comprising one health center and five satellite health
posts; the district hospital, zonal hospital and
specialized hospital.
18
Health strategies/plans…
2. HSDP-II (2002/03–2004/05)
– Introduced the Health Service Extension Program
– Innovative health service delivery system
– It is a community based health care delivery
system provided at kebele and household levels
with focus on sustained preventive health actions
and increased health awareness.
19
Health strategies/plans…
3. HSDP III (2005/6 - 2009/10)
– Directly aligned with the health-related MDGs
– Focuses on high-impact health system strengthening
interventions needed to accelerate scale-up and
increase coverage of key health services for HIV, TB,
malaria, as well as maternal and child health.
20
Health strategies/plans…
4. HSDP IV (2010 – 2015)
– Developed as part of the National GTP
– Renewed commitment to the achievement of MDGS
– Gives priority to maternal and child health,
nutrition, as well as the prevention and control of
major communicable diseases, such as HIV/AIDS.
– Emphasizes the strengthening HEP to improve the
quality of PHC, HRD and health infrastructure.
– Developed the three tier health delivery system
21
Health strategies/plans…
• Increase access and coverage to health care,
along with utilization
• Improve service quality through training and an
improved supply of necessary inputs
• Strengthen management of health services at
Federal and Regional levels
22
Health strategies/plans…
• key components of the method used to develop
the HSDP IV :
1. Policy framework
2. Health sector strategic assessment
– Strategy of HSDP
– Strategic Objectives
–Performance Measures and Strategic initiatives of
HSDP IV
3. Costing & Financing of HSDP-IV
23
Health strategies/plans…
1. Policy framework
• The Ethiopian health sector has set objectives for
the effective health interventions with the aim of
reaching every section of population and
meeting the health related MDG & targets
24
Health strategies/plans…
• The development of HSDP IV has taken into
account certain National health policy and other
national health related policies :– policy for HIV/AIDs prevention and control,
– national drug policy,
– population policy,
– national policy on women,
– national development and transformation plan and
– rural development policy and strategies
25
Health strategies/plans…
◊ international commitments like the MDG goals
and targets
◊ MDG 4, 5 and 6 are particularly falling under the
domain of the health sector.
◊ Each goal will be achieved through predetermined
targets.
26
MDGs
MDG 1: Eradicate extreme poverty and hunger
MDG 2: Achieve universal primary education
MDG 3: Promote gender equality and empower
women
MDG 4: Reduce child mortality
MDG 5: Improve maternal health
MDG 6: Combat HIV/AIDS, malaria and other diseases
MDG 7: Ensure environmental sustainability
MDG 8: Develop a global partnership for development
27
Targets for health related MDG
 Target1. Halve, between 1990 and 2015, the
proportion of people whose income is less than
one dollar a day.
 Target 2. Halve, between 1990 and 2015, the
proportion of people who suffer from Hunger
 Target 4. Eliminate gender disparity in primary and
secondary education
 Target5. Reduce by two thirds, between 1990 and
2015, the under-five mortality rate
 Target 6. Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio.
 Target 7. Have halted by 2015 and begun to reverse
the spread of HIV/AIDS.
28
Targets for health related MDG
 Target 8. Have halted by 2015 and begun to
reverse the incidence of malaria and other major
diseases.
 Target 9. Integrate the principles of sustainable
development into country policies and programs
and reverse the loss of environmental resources.
 Target 10. Halve by 2015 the proportion of people
without sustainable access to safe drinking water.
 Target 18. In cooperation with the private sector,
make available the benefits of new technologies,
especially information and communications.
29
Health strategies/plans…
2. Health sector strategic assessment
• Health sector organizations were assessed to
have clear picture on the power and duties of
each organization in the health sector.
• Mandates are formally defined in the Ethiopian
laws and regulations for public organizations such
as the FMOH and RHB by the legislative body.
30
Health strategies/plans…
Role of Federal ministry of Health:
Initiate policies and laws, prepare plans and
budget, and implement upon approval
Establishing and administering referral hospitals
as well as study and research centers.
Determining the qualifications of professionals
required to be engaged in public health services
at various levels
31
Roles cont’d …
Undertaking the necessary quarantine control
to protect public health.
 Determining standards to be maintained by
health services.
Devising strategies, means and ways for the
implementation of prevention, control and
eradication of communicable diseases
32
Health strategies/plans…
Role of Regional health bureau:
Prepare, on the basis of the health policy of the
country, the health care plan and program for
the people of the region, and to implement same
when approved.
Organize and administer hospitals, research and
training institutions that are established by the
regional government.
33
Health strategies/plans…
Issue license to health centers, clinics,
laboratories and pharmacies to be established by
NGOs and private investors and supervise
Cause the provision of vaccinations, and take
other measures, to prevent and eradicate
communicable diseases.
34
Health strategies/plans…
Participate in quarantine control for the
protection of public health.
Ascertain the nutritional value of foods.
35
Health strategies/plans…
Role of woreda health office:
Manage and coordinate the operation of the
primary health care services at woreda levels.
Providing political leadership for health.
Ensuring the community’s demand for health
care is properly addressed.
Planning, resource mobilization and allocation,
monitoring and evaluation of health programs
and the delivery of health services.
36
Health strategies/plans…
Facilitating inter-sectoral collaboration.
Provide guidance to enhance the partnership
with NGOs, CSOs and private sector.
Regional, zonal and district administrative council
will play crucial roles in the implementation of
HSDP IV.
37
Health strategies/plans…
• The other outcomes of the assessment of the
health sector are identifying its mission and
visions.
The mission of FMOH:
– to reduce morbidity, mortality and disability and
improve the health status of the Ethiopian people
through providing and regulating a comprehensive
package of promotive, preventive, curative and
rehabilitative health services via a decentralized
and democratized health system.
38
Vision of FMOH:– To see healthy, productive and prosperous
Ethiopian
Core values:– community first (customer), commitment,
change, collaboration, trust and continued
professional development as of any health
39
Health strategies/plans…
• The Strategy HSDP IV has three key elements:– Customer’s core values,
– strategic themes and prospective.
– The customer value proposition
• The strategic themes are key areas in which the
health sector must excel in order to achieve its
mission and vision.
40
Health strategies/plans…
• These strategic themes are:
– Excellence in Health Service Delivery and quality
of care
– Excellence in Leadership and Governance
– Excellence in Health Infrastructure and Resources
41
Health strategies/plans…
• The prospective of HSDP (its focus) three:
– the community perspective that try to answer the
questions of how to enable the community to
produce its own health;
– Financial prospective that deals with the question of
how to mobilize and utilize more resources
effectively and efficiently; and
– Capacity building prospective to deal with, what
capacities must the health sector to excel in the
processes.
42
Health strategies/plans…
• A strategic map is drawn to illustrate the cause
and effect relationship of strategic objectives
in the health sector.
• The map provides an insight how the Health
sector is planning to establish an added value
to the community and how the outcome and
the customer value proposition intended
results are achieved.
43
Health sector strategy map
44
Health strategies/plans…
• Strategic objectives are used to break strategic
themes into more actionable activities that lead
to strategic results.
• Strategic initiatives are long term or short term
projects or programs that should be
implemented to ensure success of the strategy.
• Selected in terms of their potential to bring
significant impact in the sector’s strategy.
45
Health strategies/plans…
Strategic Directions for HSDP IV:
1. Health Extension Program
2. Quality of Healthcare
3. Scaling up of Civil service Reform
4. Human Resources Development
5. Health Infrastructure (Construction and ICT)
6. Special Support to Emerging Regions
7. Climate Changes and Health
8. Gender Mainstreaming
46
Summarized priorities and targets of HSDP IV (source: HSDP IV)
Priority
Maternal &
New born
Health
Impact
Outcome
MMR 267/100,000 (from CPR= 66%( from 32%)
590/100,000)
Delivery by SBAs = 62%
(18.4%)
Child Health U5MR 68/1000 (101/1000)
IMR 31/1000 (77/1000)
Fully Immunized=
90%(77%)
Pneumonia Rx=81%
HIV/AIDS
TB
HIV incidence 0.14 (0.28)
ART =484,966, PMTCT= 77%
Malaria
Lab confirmed Malaria
incidence <5 per 1000
Nutrition
Stunting prevalence 30%(from 47%), Wasting
Mortality due to all forms TB case detection 75%
of TB= 20/100,000
prevalence 3%(from 11%)
Pregnant mothers who slept
under treated LLN =86%
U5 TLLN =86%
IRS=77% of Targeted HHs
Bloodlines










HEP
HDA
Supply chain
management
Regulatory
system
Harmonization
and Alignment
HCF
HRD
HIS
Continuous QIP
Referral system
Health Extension Program
Health Extension Program:
• Provides integrated preventive, promotive and
basic curative services at community level.
• Furthermore, at all levels, programs are
integrated at the point of service delivery.
48
Health Extension Program…
1. Family health services
o Maternal and New born care
– Antenatal care
– Delivery services
– Post natal care
o Child health services
–
–
–
–
Integrated management of Childhood Illnesses (IMCI)
Growth Monitoring and Promotion
Immunization
Promotion of essential nutritional action (ENA)
o Family planning services
o Adolescent Reproductive Health Services
49
Health Extension Program…
2. Communicable Disease Prevention and Control
Services: Primarily focus on
–
–
–
–
Malaria
Tuberculosis
HIV/AIDS/STI
Epidemic diseases
3. Hygiene and Environmental Health Services:
Control of insects, rodents and other stinging animals
Ensuring water safety and availability
Proper housing
 Food sanitation
 Waste disposal including proper latrine usage
50
Health Extension Program…
4. Basic Curative care and Treatment of major
chronic conditions
First aid for common Injuries and emergency
condition
 Treatment of major Chronic Conditions and Mental
disorders
 Treatment of Common Infections and complications
5. Health Education and Communication Services
Information, education and communication activities
51
Health strategies/plans…
3. Costing and Financing of HSDP-IV
• Evidences so far strongly point out that the
primary obstacles against fast and sustainable
targeted health gains through implementation
of the proven high impact interventions are lack
of resources and weak implementation
capacity.
52
Health strategies/plans…
• low level utilization of existing proven
effective interventions
– require working more on community
education and mobilization aimed at
substantially increasing the demand and the
timely utilization of the available health
care services at each level of the health care
system.
53
Health strategies/plans…
Major Health Related Legislations in Ethiopia
• The history of health and health related
legislation in Ethiopia dates back as far as the
early 19th century.
• The first health decrees were vaccination against
smallpox
– smallpox epidemic in 1886.
– During Emperors Yohannes and Menelik II,
• Modern medical legislation could be traced back
to the coronation of Emperor Haileselassie I in
1930.
54
Health strategies/plans…
• On July 18, 1930 a law was passed to regulate
the practice of doctors, dentists, pharmacists,
midwives and veterinarians.
• The law specified that no one could practice
these professions without a relevant diploma.
• In 1942 (proc. 27), traditional medicine was
given a formal recognition.
•
55
Health strategies/plans…
• Between 1941and present time, some 27 Public
Health enactments were made available:
– Public Health Proclamation (NG 91, 1947, 66-68)
– Medical Practitioners Registration Proclamation (NG
100, 1948, 1-3)
– Establishment of Ethiopian Pharmaceutical
Manufacturing Factory NG 167/1994
56
Health strategies/plans…
• Council of Minister of regulation established
regulation no (NG 174/1994) to provide for
licensing and supervision of Health service
Institution.
• Establishment of the Pharmaceutical and Medical
supplies import and wholesome sale enterprise (NG
176/1994)
• Nutrition Research Institute Established under
council of ministry of regulation( NG 4/1996)
57
Health strategies/plans…
• Establishment of Health Education Center NG
40/1998
• Establishment of Ethiopian Health Professional
Council (NG 76/2002)
• Establishment of FMHACA ( Regulation No
661/2009)
• Currently, there are more health regulation
initiatives on the pipeline under the newly
reorganized FMHACA.
58
Healthcare Regulation System
• Regulation usually intends to ensure that
providers are able to deliver quality care by
ensuring the quality of the physical facility,
medical personnel, equipment, and supplies.
• Customers started to bother not only about
getting treatment but also about their health
outcomes.
59
Healthcare Regulation System…
• Quality is ensured basically by regulating
health practitioners and health service
providers through the following three
approaches:
1. Licensing
2. Certification
3. Accreditation
60
Healthcare Regulation System…
1. Licensing
– It is a mechanism by which an executive organ or
authority gives permission to an individual
practitioner to engage in an occupation or to a
healthcare institutions to operate and deliver health
services.
– Helps governments to ensure public health and safety
by controlling the entry of healthcare practitioners
and service provider facilities into the country’s
healthcare market and by establishing standards of
conduct for maintaining that status.
61
Healthcare Regulation System…
A. Facility Licensing
is the process of judging a health care
facility or practice against a set of standards
that specify the minimum structure that
must be fulfilled in order for the facility to
operate.
Licensing standards specify the equipment,
staff, and physical facilities that are
essential for delivering medical care.
62
Healthcare Regulation System…
• If the facility meets these standards it is granted
a license to open and provide healthcare to
clients.
• Licensing of health care facilities is mandatory.
• The goal of licensing is not to define desirable
quality but to define the minimum acceptable
level of capability to deliver service
63
Healthcare Regulation System…
B. Health practitioners licensing
• Health practitioners’ licensing is the process by
which a regulatory body based on preset
standard requirements issues permission to an
individual to practice his or her respective
profession.
• Licensing is mostly mandatory.
• Usually granted on the basis of examination or
proof of education, or both, rather than on
measurement of actual performance.
64
Healthcare Regulation System…
• The regulatory body by issuing a license certifies
that those licensed have attained the minimal
degree of competency necessary to ensure
reasonable protection of public health, safety,
and welfare.
• Regulatory body can be a Government or
Professional Associations, independent Council
or Board.
65
Healthcare Regulation System…
• The regulatory body is accountable to:
– Set standardized requirements for licensing health
practitioners
– Examine applicants’ credentials to determine whether
their education, experience, and moral fitness meet the
preset legal and administrative requirement
– Administration of examinations to test the academic and
practical qualifications of medical graduates against preset
standards
– Granting of licenses on the basis of reciprocity or
endorsement
– Investigation of charges of violation of standards
established by law and appropriate regulatory measures:
suspension or revocation for violators.
66
Healthcare Regulation System…
2. Certification
– is a process by which a recognized authority evaluates
and recognizes an individual provider or an
organization as having met pre-determined
requirements, usually to demonstrate competence in
a specialty area.
– Unlike licensing certification programs are usually
voluntary, and give certified persons special
recognition or authorization to use a particular title or
official designation.
67
Healthcare Regulation System…
– Certification makes practitioner feel he or she
is the best qualified to do particular work,
which should result in a professional attitude
and motivation to improve competence.
– Certification also enables the public to identify
practitioners who have met a standard of
training and experience set above the level
required for licensure.
68
Healthcare Regulation System…
3. Accreditation
 is the formal process by which a recognized
accrediting body assesses and recognizes that a
healthcare organization meets pre-established
performance standards.
 Accreditation standards are usually regarded as
optimal yet achievable and are designed to encourage
continuous improvement efforts within accredited
organizations.
69
Healthcare Regulation System…
 The standards used to assess performance for
accreditation are commonly developed by
expert committees working with the accrediting
body and revised periodically to reflect
advances in technology or policy changes.
 By focusing on optimal rather than minimum
standards of care, accreditation instills a strong
performance improvement orientation,
stimulating healthcare organizations to pursue
increasingly higher levels of quality.
 Unlike licensing accreditation is voluntary.
70
HIS Policies and Procedures
• Legal, regulatory and planning context of health
information is a key resource for effective HIS.
• It enables the establishment of mechanisms to
ensure data availability, exchange and quality.
• Legal and policy guidance is needed to elaborate
specifications for health information access and
to protect confidentiality, etc.
71
HIS Policies and Procedures…
• Ethiopia has established a functional central HIS unit
under FMoH
• However, it lacks to develop and implement clear
policies and procedures related to capturing, storing
processing, and transmitting and
communicating/disseminating health information in
the country.
• This doesn’t include the HMIS four technical areas
on selected national health indicators and
standardized data, recording and reporting tools
with the procedures that apply to the HMIS only.
72
HIS Policies and Procedures…
Health Information Related Initiatives
 overall objectives of the Health Management
Information System are:
– Develop and implement a comprehensive and standardized
national HMIS and ensure the use of information for evidence
based planning and management of health services.
– To review and strengthen the existing HMIS at federal,
regional, woreda, health facility and community levels and
ensure use of health information for decision making at all
levels.
– To achieve 80% completeness and timely submission of
routine health and administrative reports.
– Achieve 100% of evidence based planning at woreda health
office and hospital level.
73
HIS Policies and Procedures…
The strategy for implementation of HMIS
objectives are:
– Institutionalize HMIS at all levels.
– Build capacity of health workers to analyze,
interpret and use health information for DM.
– Introduce appropriate HMIS technology at all levels
of the health system in collaboration with the
concerned bodies such as the National Information,
and communication technology (ICT) Authority.
74
HIS Policies and Procedures…
– Define the minimum standard of inputs
required for HMIS at different levels of the
health system.
– Initiate and sustain regular program review
and feedback system.
– The breakdown of the plan is detailed
according to what activities are carried out by
the various levels in the healthcare system.
75
HIS Policies and Procedures…
A. Woreda Health Offices level:
– Establishment of HMIS posts and assignment of
appropriate personnel in the organizational structure
as per the national standard.
– Determination of the qualification requirements, job
descriptions, career path, and incentive package
standards for personnel working on HMIS.
76
HIS Policies and Procedures…
– Ensure the proper reporting and feedback mechanism is
laid out beginning from HEWs to the HMIS personnel at
woreda level.
– Provide the necessary health and administrative reports
to the RHBs as per the guideline.
– Allocate funds for HMIS and provide the necessary
facilities for the HMIS units/personnel.
– Implement and monitor HMIS in collaboration with the
RHBs.
– Collaborate on the expansion of the geographic
information system and woreda connectivity.
77
HIS Policies and Procedures…
B. Key Activities at RHB level:
– Adapt and implement qualification requirements, job
descriptions, career path, and incentive packages for
personnel working on HMIS at different levels of the
health system.
– Adapt and implement National HMIS Strategy,
manuals and standards developed at national level.
– Conduct regular on-the-job training to HMIS focal
personnel, program managers and health workers.
78
HIS Policies and Procedures…
– Equip HMIS units at all levels.
– Implement HMIS in collaboration with the FMOH.
– Collaborate on the establishment of electronic network
from federal to woreda level as part of implementation
of HMIS.
– Initiate and sustain the development of Health and
Health Related Indicators in the regions.
– Advocate the allocation of adequate funds for
implementation of National HMIS in woredas.
79
HIS Policies and Procedures…
C. Key Activities at the FMoH level :
–Assign a multidisciplinary team at
Planning and Programming Department
–Provide the necessary facility so that it
will be able to spearhead the
development and implementation of
HMIS at national level.
–Develop and popularize the National
HMIS Strategy and user-friendly manuals.
80
HIS Policies and Procedures…
• Develop and popularize qualification
requirements, job descriptions, and career path
and incentive packages for personnel working on
HMIS at different levels of the health system.
• Standardize HMIS indicators; harmonize the
reporting system and collect gender, age and
facility type disaggregated data.
81
HIS Policies and Procedures…
• Develop, adapt and implement HMIS userfriendly guidelines and revise International
Classification of Disease (ICD) coding system.
• Initiate pre-service training on HMIS in health
professional training institutions.
• Implement HMIS on pilot basis before
nationwide replication.
• Mobilize funds for implementation of National
HMIS.
82
HIS Policies and Procedures…
• Conduct system analysis for the application of
ICT to HMIS, pre test and
• implement the application and expand
geographic information system.
• Monitor the implementation of program review
and research recommendations through HMIS.
• Publish Health and Health Related Indictors
bulletin annually.
83
Assessment-2
1. What are the strategies to be followed to achieve HMIS objectives?
____________________________________________________
____________________________________________________
2. Who is/are responsible for granting college accreditations in
Ethiopia?
____________________________________________________
3. Describe the essential health service package of Ethiopia
____________________________________________________
____________________________________________________
4. What are the major components of HSDP IV
____________________________________________________
____________________________________________________
84
Assessment-2
5. Describe at list two HMIS related activities
performed at different level in the health care
system.
6. Explain the differences and similarities of and
i. Licensing,
ii. Accreditation
iii. Certification
7. Identify the main core elements of Ethiopian Health
policy
85
3. Health Service Planning
Learning objectives
At the end of this topic you should be able to
 Define planning
 Identify types and features of planning
 Distinguish the different approaches of health
service planning
 Assist in Developing, implementing and
monitoring health service planning
86
Basics of Health Service Planning

Planning is defined as a systematic process of
identifying and specifying desirable future
goals and outlining appropriate courses of
action and determining the resources required
achieving them (WHO, district health service
planning)
Basics of Health Service Planning…

Others may define it in a beat different way as
follows.



Deciding in advance what to do, how to do it, when
to do it and who to do it.
It bridges the gap from where we are now to where
we want to go.
Combination of compiling and analyzing,
information dreaming up ideas, using logic and
imagination and judgment in order to come to a
decision about what should be done
Basics of Health Service Planning…

A systematic process of identifying and specifying
desirable future goals and outlining appropriate
courses of action and determining the resources
required to achieve them.
Basics of Health Service Planning…
Why planning?
 Planning health service programs in the health sector
is essential to meet the following purposes.
 Fundamental: reach the objectives of the organization
 Protective: to minimize risk by reducing uncertainties
surrounding the organization and outline management
action.
 Affirmative (confirmatory / positive): to Increase the
degree of organizational success
Basics of Health Service Planning…





Economy in operation: helps us to select the
best alternatives that help us to achieve the best
result at a minimum cost possible.
It helps for effective utilization of resources.
It improves the efficiency of the operation,
better utilization of resources.
To provide a basis for monitoring and
controlling work:
Fundamental purpose is to help organization
reach its objectives).
Basics of Health Service Planning…

Health services planning may be defined as the
process of defining community health
problems, identifying needs and resources,
establishing priority health goals, and setting
out the administrative actions needed to achieve
those goals.
Basics of Health Service Planning…


The primary aim of health planning is to
improve the health status of a given population
while safeguarding equity and fairness of access
as well as responsiveness of the health system
to the needs of the population.
The health plan should achieve this goal
through the provision of efficient and effective
health services, taking into account available
resources and the available means and methods
of health care delivery.
Basics of Health Service Planning…
Depending on the time a plan is prepared for, it
can be:
 Annual /Operational Plan : contain details
for carrying out or implementing, those plans
in day-to-day activities.
 derived from and in harmony with strategic
planning and establish sub-objectives along
with operational programmes, policies and
procedures in major units of the organization
such as departments

Midterm plan: when the health plan go
beyond one year and covers two to three
years.
Basics of Health Service Planning…


Strategic plan:
designed to meet an organization’s broad goals
and focus on environmental assessment and
addresses objective and strategy


It also known as long term plan.
The HSDP ( each phase comprises of 5 years
duration) is a good example.
Basics of Health Service Planning…
Principles of planning
 One Plan, One Budget, One report,
 is the idea that all the major activities
happening at various levels of the health
system are included in one joint plan
 Evidence based and Flexibility.
Basics of Health Service Planning…



“One plan” means that all stakeholders
(government (both federal and regional), donor,
NGOs and the community) agree to be part of a
broader sectoral plan.
The health sector will have one country-wide
shared and agreed strategic plan (HSDP)
developed through extensive consultation.
All other regional, zonal, woreda and facility
plans will be local sub-sets of this strategic plan
and should be consistent with the latter.
Basics of Health Service Planning…



The HSDP at all levels will have annual plans which
are developed in similar consultation process.
One Budget: ideally means all funding for health
activities are pooled and channeled through
government channels.
However, there is also a less radical definition of
“one budget” – all funds for health activities reflected
in one plan and one documented budget, but actually
disbursed through separate channels.
Basics of Health Service Planning…


One Report: A set of indicators has been
identified to monitor progress in achieving
HSDP.
Reports should be based on these indicators
and the agreed one plan without duplicating the
channels of reporting
Basics of Health Service Planning…



Evidence Based: Planning in the health sector should
be conducted with the help of concrete, complete and
reliable evidence.
Based on the evidences root causes of health problems
of the society should be identified and tackled using
proven high impact and low cost interventions.
Furthermore, a logical and systematic approach should
be used to define Strategic Objectives and performance
measures.
Basics of Health Service Planning…


Flexibility: Plans should have some degree of
flexibility in a way that important revision is
possible therefore; plan should be revised as
needed.
The new planning process recognized this fact
and considered flexibility as principle of
planning in the health sector.
Basics of Health Service Planning…
Planning steps
 There are basic steps in the planning process
that make a continuous cycle of planning and
1. Situation analysis
2. Problem analysis and prioritization
3. Setting objectives and targets
4. Developing interventions
5. Determining resource requirements
Basics of Health Service Planning…
6.
7.
8.
Preparing plan of action
Implementation
Monitoring and evaluation
Basics of Health Service Planning…
1.Situation


analysis
involves assessment of the current situation from
various perspectives to establish the actual health
situation in terms of needs and priorities.
Includes critical analysis of the previous plan ,reviewing
the existing policy guidelines in order to familiarize
yourself with the existing directives and regulations to
be followed; and identifying problems with giving
consideration to health and health-related problems
based on available data from: HMIS, community
surveys, census and your own experience.
Basics of Health Service Planning…

The identified problems can be categorized as
primary health problems (illness such as
HIV/AIDS, Tuberculosis, and Malaria) or
secondary health problems (like inadequate
health resources, poor service coverage).
Basics of Health Service Planning…
2.



Problem analysis and prioritization
is the art of critical examination of problems
against existing health related conditions of
your region or zone or woreda.
Once the major problems have been identified,
their causes should be analyzed by asking and
finding out why they exist.
The analysis can be done by using tools such as
route cause analysis.
Basics of Health Service Planning…


After you identified the prevailing problems
and their route causes, you need to rank them
based on their order of importance and this
process is known as problem prioritization.
Prioritization is making decisions on how
limited resources could be best allocated to
priority health problems or needs.
Basics of Health Service Planning…
3.


Setting objectives and targets
An objective is the intended result of a
successful activity or program within given
inputs and process.
Objectives will be formulated to address the
identified priority problems and their
immediate causes
Basics of Health Service Planning…


Objectives should be specific, measurable (or at
least observable), attainable (given resources,
environment and management capacity),
realistic and time-bound (SMART).
After you set objectives, you need to specify
the number and quality of activities that has to
be carried out to realize the objectives. Such
determining amount of activities to be
performed is known as setting targets.
Basics of Health Service Planning…
4.

Developing interventions
answer questions like what do we need to do to
get there and the options( alternate course of
actions) with details of tasks or interventions to
be carried out, by whom, during what period, at
what costs and using what resources in order to
achieve set objectives and targets.
Basics of Health Service Planning…
5.



Determining resource requirements
allows to translate all activities of the intervention(s)
to resources such as money, human resource, time and
information.
Example: resource requirement to distribute 5000 ITN
to a certain rural kebele may need the following
resources to be available.
Human resource: one driver, 5 daily laborer, 1 malaria
expert, 1 cashier
Basics of Health Service Planning…


Money: 20,000 birr for the net, 10,000 for
salary/labor cost and 1,000 fuels
Information; baseline information and
information on the progress and effect of
distributing the ITN in that particular kebele.
Basics of Health Service Planning…
6.

Preparing plan of action
A plan of action is usually prepared in a tabular
format and will normally contain the following
items: the problem, objective(s)/interventions,
activities, inputs, responsible body,
implementer, activity monitoring indicator,
planned output, activity cost and
implementation time frame.
Basics of Health Service Planning…
7.
Implementation

Once the planning and budgeting has been completed
and approved by the appropriate authority, the success
of the plans will depend on how well they have been
implemented.
There are three aspects that should be kept in mind
while implementing the plan of action.

Basics of Health Service Planning…

Effectiveness: Effectiveness refers to what extent the
particular activity outputs have been achieved as compared to
the targets set. In order to achieve the objectives set in the plan
of action, all activities should be fully implemented, reaching
the set targets and covering all the activity components.

Efficiency: It relates the output to the resource inputs
(human resources, financial resources, time, and other
materials) and refers to the measure of output per unit resource
input.
Basics of Health Service Planning…



Timeliness: While preparing the plan of action,
activities are planned to be implemented within a
given period of time. Proper implementation of
activities requires prior preparation in identification
of resources needed, allocation of tasks and setting
deadlines.
These deadlines and allocated tasks should be made
known to all members of the team involved in the
activity.
This will ensure timely completion of activities.
Basics of Health Service Planning…
8.

Monitoring and evaluation
The key question to be addressed at this stage
of the planning cycle is “how will we know
when we get there and what have we
achieved?”
Basics of Health Service Planning…
Planning Approaches
 The common methodologies of planning are:
a.
b.
Top-down and bottom-up
Balanced Score Card framework
Basics of Health Service Planning…
Top-Down and Bottom-Up Approach
 Health sector planning in Ethiopia follows TopDown and Bottom- Up approach.
 A top-down approach means an indicative plan
produced at higher level and cascaded to lower levels
 At federal level national indicative plan with
disaggregated targets by region is developed in
consultation with RHBs and then will be sent to the
lower levels.
Basics of Health Service Planning…


The indicative plan is important to give
direction and align the plans at all levels with
the priorities.
Based on the indicative plan lower level will
prepare comprehensive plan that will be
finalized jointly with higher level and
aggregated to the upper level.
Basics of Health Service Planning…
Bottom-up approach :


issues at grass root level will be reflected at the regional and
national levels, the regional and national level plans will
therefore rely on the actual conditions existing on grass root
levels.
Furthermore the strategic and annual plans at all levels should
be:
1. Linked with resource mapping process
2. Approved by relevant government authority
3. Linked to each other (strategic- Annual)
4. Comprehensive
Basics of Health Service Planning…
Balanced Score Card (BSC)
 is a strategic planning and management
approach that help everyone in an organization
understand and work towards a shared vision
and strategy.
 The logic of BSC strategic planning starts at
high strategic altitude, mission, vision and core
values which are translated in to desired
strategic results.
Basics of Health Service Planning…

Once the strategic thinking and necessary
actions are determined, annual program plans,
projects and service level agreements can be
developed and translated into budget requests.
Basics of Health Service Planning…
Features of planning





Futuristic
anticipate the future what is required and how it will be
accomplished
Decision making
determine what is to be done, when, where, how, and for what
purpose.
choosing among the alternatives.
Resource allocation.
Continuous and dynamic Why?
because planned activities are affected by internal and external
factors.
Basics of Health Service Planning…




Planning involves selection of suitable course of
action.
Planning is undertaken at all levels of the organization
because all levels of management are concerned with
the determination of future course of action.
Planning is flexible as commitment is based on future
conditions, which are always dynamic (changing).
Planning is a continuous managerial function involving
complex processes of perception, analysis, conceptual
thought, communication, decision, and action.
Activity -3
1. What is health service planning?
2. Explain the different features of planning
3. Discuss the different types of planning
4. Describe the steps of planning
5. Explain purposes of health service planning
6. Discuss principles of planning
7. Describe the common health service planning approaches128
5. Ethics and Laws in Medical Record
Handling
Learning objectives
On completion of this topic, you should be able
to:
– Define ethics, code of practice and professional
obligation of Health Information technician(HIT)
– Identify health related laws applicable to HIT
– Identify ethical principles to be followed while
handling medical records
– Recognize the ethical and legislative environment in
relation to HIT in Ethiopia
– Explain the applications of ethics and law to HIT
129
Ethics and Health Related Laws
• Ethics is a branch of philosophy dealing with
moral principles that may be connected to beliefs
about what may be considered wrong or right.
• It is the science of moral value.
• is derived from the Greek word “ethos” meaning
“the set of moral principles” or
• “a system of moral principles” or “rules of
behavior”.
• An ethical behavior is one that is considered to
be morally correct or acceptable.
130
Ethics and Health Related Laws…
• There are different kinds of ethics. Ethics
can be categorized in accordance with the
subject matters it deals with like:
– medical ethics, bioethics, information ethics,
economic ethics, journalistic ethics, and
communication ethics, legal ethics etc.
 The focus of this topic will be information
ethics.
131
Ethics and Health Related Laws…
Professional ethics
• is the application of the concept of ethics to a
person who belongs to a learned profession or
whose occupation requires a level of training and
skill.
• Professionals are capable of making judgments,
applying their skills and reaching informed
decisions in situations that the general public
cannot, because they have not received the
relevant training.
132
Ethics and Health Related Laws…
• Professional people and those working in
acknowledged professions exercise specialist
knowledge and skill.
• How the use of this knowledge should be governed
when providing a service to the public can be
considered a moral issue and is called professional
ethics.
• Health information technicians, who are practicing
their profession, must act and work within the basic
principles and guidelines for morally acceptable
behaviors in relation to their profession.
133
Ethics and Health Related Laws…
Code of Ethics
• A Code of Ethics, in its formal sense, is an
attempt by an organization to codify the values
of the group i.e. a statement of overarching
principle telling members what is right and what
is wrong as a guide to all decision making within
the organization.
134
Ethics and Health Related Laws…
• Codes of ethics set out general principles, often
social or moral, that guide rather than dictate
behavior.
• Codes of professional ethics serve several
purposes such as:
– It provides ethical guidance for the professionals
themselves
– It furnishes a set of principles against which the
conduct of the professionals may be measured, and
135
Ethics and Health Related Laws…
• It provides the public with a clear statement of the
ethical considerations that should shape the
behavior of the professionals themselves.
• Moreover, since the field of health information is in
a state of constant change, it should be flexible so as
to accommodate ongoing changes without
sacrificing the applicability of its basic principles.
• It is therefore inappropriate for a Code of Ethics for
HITs to deal with the specifics of every possible
situation that might arise.
136
Ethics and Health Related Laws…
• Instead, such a Code should focus on the ethical
position of HITs as a professional, and on the
relationships between HITs and the various
parties with whom they interact in a professional
capacity.
• These various parties include (but are not limited
to) patients, health care professionals,
administrative personnel, health care institutions
and governmental agencies.
137
Ethics and Health Related Laws…
Major ethical principles and standards of ethics in
HIM
• Ethical principles are an important tool to
protect the privacy and confidentiality in HIM
• These ethical principles provide a framework for
analyzing and resolving ethical problems.
• Involvement in the protection of individual
health record requires observance of ethical
principles which must not be violated.
138
Fundamental Ethical Principles
1. Principle of Autonomy
– All persons have a fundamental right to selfdetermination.
– Autonomy implies an individual is master of
himself/herself and he/she can act, make free
choices and take decisions without the involvement
of another person.
– However there are pre-conditions for the
application of autonomy principle, which are:
139
Fundamental Ethical Principles…
– Competency of a person i.e. is the capacity to be a
moral agent, for example a person who is 18 years and
above in Ethiopia is competent and Liberty or freedom.
• The principle of autonomy is based on the value of
giving due regard to clients view and respecting
their choices.
• For example, autonomy in health information
management would requires that HIT’s must make
sure that the client, not a spouse or third party, is
making the decision regarding access or disclosure
to a third party about its private health
information.
140
Fundamental Ethical Principles…
2. Principle of Equality and Justice
• All persons are equal as persons and have a right
to be treated accordingly.
• Justice means “fairness” which implies giving
each person/ client what he or she deserves.
• Justice requires you that “equals be treated
equally and un-equals unequally”.
141
Fundamental Ethical Principles…
• As a matter of principle all clients are equal as they
all come for health service and therefore need to be
treated equally.
• However, in some circumstance this principle may
not work.
– For example when there is an emergency a physician
may need immediate access of the clients’ health record,
which must be pulled out ahead of other patients’ who
are already waiting in line.
– In this circumstance, client may be treated differently
than those who may be waiting to access their own
health information.
142
Fundamental Ethical Principles…
3. Beneficence and Non-Maleficence
• The principles of beneficence and non- maleficence
are best considered together, as they are
complementary principles.
• In simple terms, beneficence means doing good and
non-maleficence means avoiding evil or harm.
• The first one states that “All persons have a duty to
advance the good of others where the nature of this
good is in keeping with the fundamental and ethically
defensible values of the affected party”.
143
Fundamental Ethical Principles…
• The second principle is “All persons have a duty
to prevent harm to other persons in so far as it
lies within their power to do so without undue
harm to them”.
• The principles of beneficence and nonmaleficence translate into the duties to
maximize benefits while minimizing harms.
144
Fundamental Ethical Principles…
• Beneficence would require HIT’s to ensure proper
information disclosure.
– the information is released to individual who need it for
something that will benefit the client; including
continuation of care, or for health insurance payment
purposes.
• On the other hand the principle of non- maleficence
would require that a patient’s information is not
released to someone who does not have the
legitimate authorization to access it, and who might
harm the client in some way if access were
permitted.
145
Fundamental Ethical Principles…
• This may happen for example, when an
employer seeks to use health information for
discriminatory purposes in employment.
146
Professional Obligations
• Ethical and professional obligations in HIT can be
categorized into six categories.
• Each category demarcates the different domains of the
ethical relationships that exist between HITs and specific
stakeholders.
These categories are:
1. Obligations to client
2. Obligations to colleagues in the health care team
3. Obligations to the employer
4. Obligations to the public
5. Obligations to self
6. Obligations to professional association
147
Professional Obligations…
1. Professional obligation to client and the health care
team
• In the course of performing ones professional duty, the
following major obligations towards clients and colleagues
must be observed:
– With regard to the patient and the health care team, HIT
personnel is obliged to provide the necessary services to those
who seek access to client information in accordance with the
applicable rule.
– Individuals who may request access to client information
include health care professionals or even the client himself or
herself.
– Here you must ensure the honor of the profession and the
health and well-being of client before all personal and
financial interest.
148
Professional Obligations…
– HIT personnel are expected to protect both the
medical and social information of the client.
– Clinical information, like diagnoses, procedures, or
genetic data must be protected as well as
behavioral information like the use of drug or
alcohols, and sexual habits.
– Particularly it is increasingly important to protect
social information like drug abuse to avoid
discrimination.
149
Professional Obligations…
• HIT personnel are expected to protect confidential
information of the client.
• This involves ensuring the information collected and
documented in the patient information system is
protected by all members of the health care team and by
any other person with legal access to the information.
• HIT personnel should preserve and secure the health
information in their control.
• This includes obligation to maintain and protect the place
where you stored the record (hard copy, electronic or
imaged) and to secure the information in both manual and
computerized information systems.
150
Professional Obligations…
• HIT personnel have to promote the quality and
advancement of health care in the institution
they are serving.
• As an important member of the health care
team HIT personnel must provide their valuable
expertise in the collection of health information
that will help other healthcare providers to
improve the quality of care they are delivering.
151
Professional Obligations…
• HIT personnel need to observe their scope of
responsibility to which they are assigned.
• They must not make or pass clinical judgments.
• Sometimes health care data may indicate a
problem with a provider of care, the treatment
of diagnosis or some other problems; in such
cases the obligation of the HIT personnel is to
provide data not to pass judgment.
152
Professional Obligations…
• The obligation rest with the health care team
that reviews the data.
• The obligation of the HIT personnel is to
report accurate result.
153
Professional Obligations…
2. Professional obligation to the employer
• Demonstrate loyalty to employer.
• This can be done by respecting and following the rules, policies
and regulations of employment.
– giving the employer adequate notice when the decision to
change employment or resign is reached.
– Observe all laws, regulations, and policies that govern
health information management.
– Keep up to date with regional and federal laws; employer
policies and procedures affecting HIT.
– Accept payment only in relation to work responsibilities.
– HIT personnel must never accept money illegally by
disclosing patient information and trading in patient
secrecy.
154
Professional Obligations…
3. Professional obligation to the public
• Advocate change when patterns or system
problem are not in the best interest of the
patient.
• Protect clients, the health care team, the
professional association and colleagues.
• Refuse to participate in or hide unethical
practices.
155
Professional Obligations…
• Become accountable for noticing trends and
potential problems with regard to providers of care,
diagnosis and procedure.
• Furthermore refuse to conceal illegal, incompetent,
or unethical behaviors.
• Report violation of practice standards to the proper
authorities.
• Avoid sharing information learned at work with
family or friend, and avoid discussing such
information in public places.
156
Professional Obligations…
4. Professional Obligation to self and professional
association
• Being honest about one’s education, credentials
and work experience when applying for a job,
• being careful to report only academic
qualification attained, and submitting only
document which are successfully earned.
• In the HIT profession, personal competency and
professional behavior is very important.
157
Professional Obligations…
• HIT personnel must try to ensure that peers and
colleagues are proud to have them in the health
information team.
• HIT personnel should set goal/ aim at advancing
his/her career.
– This can be done by not stopping his/her education
when one has earned the professional qualification
one is currently studying.
– Rather try to continue to attend educational sessions
to keep up to date with changing circumstances.
158
Professional Obligations…
• Strengthen the health information professional
association.
• This obligation includes
– becoming a member of a professional association,
actively participating in different activities of the
association, and encouraging others to seek a career in
the health information field.
• Promote and participate in health information
research. When problems are discovered within a
health information system, studies must be
conducted to clarify their source and potential
solutions.
159
Professional Obligations…
• Despite the fact that HIT professional
association not yet established in Ethiopia,
professionals should contribute their faire
share to the establishment of their
professional association and obey the
abovementioned professional obligations.
160
Law and Health Related Laws
What is Law?
• Law is defined as a set of rules or principles dealing with
human activities and formally recognized as binding or
enforceable by a controlling authority.
• Laws are passed by government to keep society operating
smoothly and to control behaviors that could threaten the
public safety.
• Enforcement of these laws is possible by penalties for
violation which are decided by courts of law. Penalties
vary with the severity of the violation.
• Those persons who violate the law may be fined,
imprisoned or both and professionals who violate laws
may also lose their registration or license to practice their
profession.
161
Law and Health Related Laws…
Basis for a law
• The Constitution of the Federal Democratic Republic of
Ethiopia divides the power and responsibilities of the
Federal government among:
– The legislature - which is the law maker,
– The executive - which is the law enforcer, and
– The judiciary - which is the interpreter of the law.
• The House of Peoples Representatives is the legislative
branch which originates proclamation that becomes
federal law.
• The executive branch of the government (the Council of
Ministers) through delegation from the House of Peoples
Representatives can issue regulation.
162
Law and Health Related Laws…
• In addition, administrative offices with
delegation from the House of Peoples
Representatives or the Ministers of Council can
issue directives.
• Directives are the lowest form of laws in the
hierarchy of legislation.
• In a country having a federal set up like Ethiopia,
regions have also their own legislative, executive
and judiciary organs exercising their powers and
duties in the region.
163
Law and Health Related Laws…
Health related laws
• Health related laws are laws which set rules and principles
relating to the health sector operation and includes a vast range
of laws dealing with issues affecting the health and welfare of
the people.
• There are many categories of laws having direct or indirect
application to the health sector in general and HIT in particular.
• While this legislation varies from country to country, health
related laws in general cover legislations related to:
164
Law and Health Related Laws…
–
–
–
–
–
–
–
–
–
–
–
–
–
Disease control and medical care,
Health professional regulation
Ethics and patients rights
Health information and statistics
Pharmaceuticals and medical devices
Health institution and services
Nutrition and food safety
Occupational health and accident prevention
Mental health
Health insurance
Smoking, alcoholism and drug abuse
Environmental protection
Criminal sanctions and human rights.
165
Law and Health Related Laws…
• Among the above mentioned health related laws:
– health information and statistics;
– ethics and patients rights;
– Health professional regulation and
– human rights document are the major legislative
documents which have direct or indirect application
to the HIT profession and privacy and confidentiality
of personal health information in particular.
166
Law and Health Related Laws…
• Though HIT involves other professionals and
support staffs, the HIT personnel are the primary
custodian of the medical record and bear the
primary responsibility in respect to this record.
• This is because they are in charge of privacy and
confidentiality protection in the course of
handling, security and disclosure of the medical
record.
167
Law and Health Related Laws…
• In the Ethiopian context, some of the above
mentioned legislative text can be generally
found under the Constitution of the Federal
Democratic Republic of Ethiopia and
international human rights documents which
Ethiopia endorsed such as the Universal
Declaration of Human Rights and International
Covenant on Civil and Political Rights.
168
Law and Health Related Laws…
Difference between Ethics and Law
• Both professional ethics and law share two
fundamental goals: the regulation of behavior and
the protection of society at large. Ethics and Law,
therefore, share the goal of creating and maintaining
societal good.
• In respect to the HIT profession, the ethical and legal
requirements aim at primarily the protection of
privacy and confidentiality of personal health
information of client/patient.
169
Law and Health Related Laws…
• Though both ethical and legislative requirements
strive to this end, ethics and law differ in a range
of issues.
• Professional ethics is a set of principles and in
general require professionals to behave in a
certain manner just because doing something is
right or wrong.
170
Law and Health Related Laws…
• An illegal act by a professional is always
unethical but unethical act is not necessarily
illegal.
• This follows the issue of whether ethical
standards are enforceable or not.
• Though moral values are a beginning to the
development of legal rules for social order, an
ethics statement which is not adopted into law is
generally unenforceable.
171
Law and Health Related Laws…
• However, courts of law may see the ethics
statements or principles of professional
associations or regulatory bodies when they
interpret laws affecting that profession.
• Therefore, ethical standards influence legal
standards by creating professional ethics
standards
172
Law and Health Related Laws…
• In contrast, law sets a general standard of conduct
which must be adhered to or civil or criminal
consequences may follow a breach of the standard.
• These laws are written, approved and then enforced
by the government body which approved of them.
• In other words laws go through a process to get
approved, then are written into laws, and then are
enforced.
173
Law and Health Related Laws…
• Enforcement of these laws is through
penalties decided by courts of law.
• This may include fines, civil or criminal
penalties, depending on the gravity of the
violation.
174
Law and Health Related Laws…
Legal Framework and enforcement in HIM
• Individual health record is known to be an important
legal document.
• This record has to do with the protection of clients’
legal right of privacy and confidentiality of the
information and
• it may be used in medical malpractice suit and
settlement of health insurance payment.
• There are various relevant issues that must be
known by HIM personnel in order to fully grasp the
legal implications when managing patients’ health
record.
175
Law and Health Related Laws…
• HIT professionals need to meet various legislative requirements in
respect to collection, security, right of access, use and disclosure of the
individual health information and ownership and control of the health
record.
• Therefore, it is very important to become familiar with all the
requirements and standards set collection, security and rights of access
to personal health information.
•
In addition, know and apply requirements on how the information can
be used, and under what circumstances it may be disclosed.
• have an important implication in the protection of the right to privacy
and confidentiality of personal health information.
•
In addition, it is important to understand what the HIM personnel’s
role and functions is in the life cycle of specific individual health
information.
176
Law and Health Related Laws…
• Legal responsibility of professional conduct may be
civil liability or criminal liability.
• Under civil liability of professional misconduct the
person may be required to pay compensation to the
person who suffers any damage by the act or
omission which is done by the professional.
• In the case of HIT professionals, anyone who
discloses the personal health information of the
client/patient in violation of any applicable law may
be required by courts of law to pay compensation to
a person whose privacy is unjustly disclosed.
177
Law and Health Related Laws…
• In addition, within the legal procedure anyone who
discloses personal health information may be held
accountable for criminal sanction.
• Where the HIT professional violates the privacy and
confidentiality of personal health information in
violation of legal requirements he/she may be
required to suffer court process of criminal liability.
• Depending on the severity of the breach, the
professionals may be required to be fined or
imprisonment.
178
Law and Health Related Laws…
Medical Record as a Legal Document
• Good medical records are essential not only for the
present and future care of the patient but also as a
legal document to protect the patient and the health
institution.
• For both purposes, they must be complete,
accurate, and available when needed.
• They must be used and stored according to all
governing laws and also to the policies of the health
facility.
179
Law and Health Related Laws…
• Legally, medical records are used to support the
patient’s claim in case of injury, for the
protection of the attending doctor against claims
of malpractice, and for the protection of the
health institution against criticism and claims for
injuries and damages.
• Medical records are considered the property of
the health institution and are compiled and kept
primarily for the benefit of the patient.
180
Law and Health Related Laws…
• The personal data contained in the medical
record is considered confidential and the
property of the patient.
• That is, the information contained in a medical
record belongs to the patient and is a
confidential communication between the
doctor or other health professional and the
patient.
181
Law and Health Related Laws…
• Although the physical medical record is considered to be
the property of the health institution and the
information in the medical record is the property of the
patient, information cannot be released without the
consent of the patient.
• Exceptions to this rule include the use of the
information:
– By doctors and other health professionals for the continuing
care of the patient.
– For medical research where the patient is NOT identified,
and
– For the collection of health care statistics when the
individual patient is NOT identified.
182
Law and Health Related Laws…
• Situations in which Medical Records are used as Legal
document
• Medical records are generally used in court for
the following:
1.
2.
3.
4.
5.
6.
Worker's Compensation
Personal Injury Claims
Malpractice Claims
Will case
Criminal case
Insurance cases
183
Law and Health Related Laws…
1. Worker's Compensation
• A person injured in the course of his or her
duties and while acting in the scope of his or
her employment is entitled to compensation
for bodily injury and disability.
• The medical record is used as evidence to
show the date of injury, the type and severity
of injury, and the patient’s expected recovery.
184
Law and Health Related Laws…
2. Personal Injury Claims
• A person may claim to have been injured through
the fault or neglect of another and sues to recover
damages for injuries sustained.
• The medical record would be used to show how the
injury happened as recorded in the patient’s words
on admission to the hospital.
• The medical record would also be used to show the
extent of the injuries, treatment given, duration of
care and expected recovery or disability.
• It is the most frequent situations by which Medical
records are used as evidence.
185
Law and Health Related Laws…
3. Malpractice Claims
• In this type of case the Plaintiff (person suing)
claims damages from a doctor, a hospital, nurse
or other health professional for negligence in
rendering care or giving improper treatment.
• The medical record would be used to show that
there was no negligence and that treatments
rendered were adequate and proper.
186
Law and Health Related Laws…
4. Will Case
• A patient may have made a will during his or her
health institution stay.
• After the death of the patient, an attempt may
be made to set aside the will by seeking to prove
that the patient was not mentally incompetent.
• The medical record would be used to show the
mental state of the patient at the time of making
the will.
187
Law and Health Related Laws…
5. Criminal Cases
• Medical records have been used in many criminal cases
and the most frequent use includes:
• Assault cases: to prove the assault and extent of injuries.
• Violent or unexplained death: to prove death resulted
from natural causes, accident, misadventure or murder.
• Sexual assault cases: to prove the condition of a patient
on admission or attendance at a hospital and the history
of the assault related by the patient.
• Mental competency: hospital medical records may also be
used as evidence in proving the mental condition of a
patient.
188
Law and Health Related Laws…
6. Insurance Cases
• Used by the patient for proof of injury and/or
disability in personal accident cases or by the
insurance company to disclaim responsibility.
• In order to treat medical records as legal documents,
the following points should be considered in your
daily practice of handling them:
– Use blue or black ink unless you are using a computer.
– Do not use pencil or ink that can be erased.
– Write so that it can be read clearly, sloppy writing causes
errors.
– Date all of your notes.
189
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–
–
–
–
–
–
–
Write the time that you took your notes.
Sign your full name and title.
Do not use white or any other cover up for mistakes.
Write only the facts. Never add personal comments or
feelings.
Do not use abbreviation unless they are accepted for use by
your health institution.
Do not allow anyone to touch or look at your medical records
unless they are a healthcare worker assigned to take care of
the patient.
Keep all medical records in a safe and secure place.
Medical records are confidential. Do not disclose or discuss
any facts of the patient or their care with anyone other than
the assigned healthcare staff or the patient themselves.
190
Application of Ethics and The law in HIT
• The laws and ethics governing the provision and
maintenance patients’ privacy protection and
confidentiality have a broad application in the HIT
profession.
• The following is expected of HIT personnel:
– To bring about honor in the course of professional service to
the HIT profession;
– To advance HIT knowledge and practice through continuing
education, research and dissemination;
– To state truthfully and accurately your credentials,
professional education and experiences;
– To facilitate interdisciplinary collaboration in situations
supporting health information practice;
– To respect the inherent dignity and worth of every person and
refuse to participate in all unethical practices or procedures.
191
Application of Ethics and The law in HIT…
• Furthermore, in the course of collection and use
of patient’s personal information, ethical
requirements demand the utmost security must
be maintained during disclosure of personal
health information in order to ensure privacy and
confidentiality of personal health information.
192
Application of Ethics and The law in HIT…
• To keep personal health record secure patients’
information must not be disclosed unless it is
relevant or necessary for service provision for the
patient/client, for public use, and where there is
valid consent and other justifiable grounds in
accordance with the relevant laws and
regulation.
193
Application of Ethics and The law in HIT…
• In addition to ethical standards, Legislation require
the collection, use, security and disclosure of
personal health information in a certain manner and
all health professionals are expected to work in line
with these legislative standards where applicable.
• The principles applicable to the collection, use,
security and disclosure of this information will be
useful for standard service delivery to the
patient/client and protection of confidentiality,
research purpose and management of the health
system, including:
– planning, resource allocation, policy development,
monitoring and evaluation and reporting.
194
Application of Ethics and The law in HIT…
• However, in one way or another, all these rules
regarding the collection, use, security and disclosure of
this information have to do with the protection of the
right to privacy and confidentiality of personal health
information.
• Though we do not currently have separate law
governing HIT, the Constitution of the Federal
Democratic Republic of Ethiopia (FDRE) and other
international human rights documents to which Ethiopia
is a member and party like the Universal Declaration of
Human Rights (UDHR) of 1948 and the International
Covenant of Civil and Political Right (ICCPR) of 1966
provides the right to privacy protection.
195
Application of Ethics and The law in HIT…
• Since the right of privacy may be violated in
relation to collection, safeguarding and security,
disclosure, right of access and transfer of health
record and other related subjects, the rules
related to these items can be taken as an
explanation on how you should protect
patients/clients privacy in the course of your
professional activities.
196
Application of Ethics and The law in HIT…
• Therefore it’s very important to see the positive
application of both ethics and the law as vital in
particular for the protection of privacy and
confidentiality of personal health information
which is one of the basic rights of
patients/clients in our case and recognized
under international human rights documents
which Ethiopia guarantees to observe and
protect.
197
Activity-5
1. Discuss about four fundamental principles of
ethics (Define each term) and give examples
for each.
i. Autonomy__________________________
ii. Beneficence_________________________
iii. Non-Malfeasance_____________________
iv. Justice______________________________
2. How can justice as a principle be applied in
health information Technician?
198
3. Mention at least two major differences
between ethics and law.
4. The application of ethics and law in the HIT is
only for the protection of privacy of personal
health information? Yes / No, give reason for
your answer.
5. What will happen if professionals ignore
applicable ethical standards?
199
6. Mention the different kinds of ethical and legal
measures against persons who violate applicable
rules of a profession?
7. Discuss various administrative (disciplinary)
measures an employer can take against HIT
professionals who violate his/her ethical and legal
duty.
8. Explain the importance to use Codes of ethics?
200
Case-1:
• Ato Solomon is working in Harar General Hospital as
head of the medical record unit. He has read medical
record documents of patient and learnt that the patient is
drug/substance addicted. While chatting somewhere else
with friends, a friend has raised an issue about the
personality of that patient. During expressing his opinion
about the person, Ato Solomon disclosed to his friends
about patient’s drug addiction. Which professional
obligation(s) is violated by Ato Solomon?
Case-2:
• When you have learned that your best friend has disclosed
the patient’s social information illegally to an
unauthorized person. What should you do? What dictates
you to decide so? Is it not unethical to expose your best
friend’s sin to others?
201
6. Patient Privacy and confidentiality of
Health Information
Learning Objectives
At the end of this section the learner should be able
to:
– Explain concepts of patient confidentiality of
information.
– Apply patient’s privacy and confidentiality of patient
information.
– Identify patient/client right to access of care.
– State ethical standards related to patient privacy right
and confidentiality.
– Describe general Medico-Legal principles in relation to
patient Medical records
202
Privacy and Confidentiality
• As health information technician, one should have
clear understanding of these interrelated concepts.
• Privacy is the right of every person to be left alone
and no one can interfere in the personal life of the
individual.
• No matter that health record is in the possession of
the medical record keeper physically, the
information is still the property of the client.
• Therefore, it is the client who has a say in his
individual health information.
203
Privacy and Confidentiality…
• Confidentiality means the responsibility of a health
record keeper to limit disclosure of individual health
information unless authorized by the client or specifically
under law.
• Includes the responsibility of professionals to use, disclose
or release such information only with the knowledge and
consent of the client.
• Security includes physical or electronic protection of the
integrity, availability and confidentiality of personal health
information.
• In addition, this responsibility extends to make sure that
the mediums used to enter, store and communicate this
individual health record are safe and secured.
204
Privacy and Confidentiality…
• Accordingly the basic responsibilities in HIT are to provide
privacy and confidentiality.
• Ensure patient’s privacy, maintain confidentiality of
information, and ensure data security measures are used
to prevent unauthorized access to the patient’s
information.
• In addition, HIT personnel are expected to ensure that
release policies and procedures of health institutions are
followed properly, and all violations of privacy or
confidentiality of individual health information are
reported to the appropriate authority.
205
Privacy and Confidentiality…
Release of Individual Health Information
• Unlike in the past when only few people wanted
access to the information contained in a patient’s
medical chart, there are many more stakeholders
who want to access this information.
• Some of these are:
– Insurance companies who want to determine the
extent of the damage caused to the person eligible
for insurance payment, and
– Someone in a law suit who wants to challenge the
health status of his accuser.
206
Privacy and Confidentiality…
• The healthcare facility should develop a policy for
the release of patient information.
• It is important to ensure that all staff, not only in
the Medical Record Unit, but also in all other
sections of the health care facility, are aware of the
policy and that it is followed.
• There are four methods of releasing information:
1. Direct access to the medical record;
2. Supply abstract
3. Verbal release
4. Photocopying
207
Privacy and Confidentiality…
• Unauthorized person cannot take any or part of a medical
record out of file, or read, copy, or otherwise tamper with
them.
• If a request is made for the release of information, the
request should contain the following:
–
–
–
–
Full name of patient, address and date of birth;
Name of person/persons or institution requesting information;
Purpose and need of the information;
Extent and nature of information to be released, including
dates; and
– A recently dated authorization, signed by the patient or
authorized representative
– E.g. parent or guardian of a child
208
Privacy and Confidentiality…
Patient Consent for Release of Records
– No information concerning a patient should be released to another
person without the written consent to release information from his
or her medical record, the information contained in it can only be
released to a court by subpoena or a court order.
– If a patient is under the age of 18 years or otherwise subject to a
guardianship order, any consent for access to information should be
given in writing by the patient's parents or legal guardian.
– If the patient lacks the capacity to provide genuine consent then
the written consent must be obtained from the person's legal
guardian. In the case of a patient who has died, the written consent
to access
– information from the patient's medical record should be provided
by the next of kin shown on the medical records.
209
Ethical standards related to Patient Privacy Right
• Among other things health information privacy is
vital for the following major reasons:
1. information privacy is a fundamental human
right (with Constitutional protection which is the
supreme law in Ethiopia).
• It is a right that is essential to the dignity and
integrity of an individual.
• It should also be noted that the information is
the patient’s property; it does not belong to
anybody else.
210
Ethical standards related to Patient Privacy Right
2. Second, if appropriate health information privacy is not
guaranteed, the client caregiver relationship will suffer
negative impacts.
• This means clients will not tell the necessary
information or will avoid seeking care.
• Therefore, the necessity for protection of individual
health information is very important.
• This right to privacy is understood as an individual right
protected under the Constitution, international human
rights documents like the UDHR and ICCPR and other
laws.
211
Ethical standards related to Patient Privacy Right
• The UDHR provides that no one shall be subjected
to arbitrary or unlawful interference with his
privacy, family, home or correspondence, or to
unlawful attack on his honor and reputation.
• The right to privacy is found to be very important in
examining the protection of individual health
information.
• One aspect of the right to privacy is defined as: The
right to be free from unlawful intervention of one’s
personality, the publicizing of one’s private affair
with which the public has no legitimate concern; or
the wrongful intrusion in to one’s private activities.
212
Ethical standards related to Patient Privacy Right
• Everyone has the right to the protection of the
law against such interferences.
• Therefore, HIT personnel are duty bound to
protect individual health information from any
kind of unlawful interference.
213
General Medico legal principles
• The HIT must be familiar with the legal requirements
regarding medical records as per the national policy
to be able to cope with medico-legal problems.
• The term Medico-legal is defined as something of or
pertaining to the intersection between medicine and
law.
• The HIT must also be able to identify legitimate and
illegitimate requests for information.
• Remember that being used for patient care a medical
record is also a legal document and should be
treated accordingly.
214
General Medico legal principles…
• No information concerning a patient should be
released to another person without the written
consent of the patient or the patient's legal
guardian.
• If the patient lacks the capacity to provide genuine
consent, then the written consent must be obtained
from the person's legal guardian.
• Medical records should be kept under adequate
security and only removed from the hospital or
health care center upon receipt of a subpoena,
statutory authority, search warrant, or court order.
215
General Medico legal principles…
• When an original medical record leaves the
hospital for legal purposes, a photocopy of the
medical record is made beforehand and kept in
the hospital until the original is returned.
• The copy is subsequently destroyed.
• The health care facility is NOT legally bound,
however, to release information if it affects the
health care facility or the attending health care
workers.
216
General Medico legal principles…
• The information requested is identified and the
attending health care worker asked to write a
report.
• In many health care facilities a pre-designed form
may be used if a discharge summary is already in the
medical record, it is checked and if it includes all the
requested information, a copy is made.
• This will save the doctor having to write a new
report. If the original medical record is needed, the
lawyer must produce a court order or subpoena to
enable the release of the medical record.
217
Example of format for a summary of medical
record information for medico-legal case:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Date:______________
To: (name of lawyer or law firm requesting information)____________________________
Dear ___________________
The following is a summary of the medical record of (patient’s name) __________________
Age: _____ living at (address)______________________________________________
________________________________________________________________________
who was admitted to this hospital on (date of admission)_____________________________
and who was discharged (or died) on (date of discharge or death) ___________________
History: _____________________________________________________________
Physical Examination: ______________________________________________
Laboratory Reports: ___________________________________________________
X-Ray Reports: _________________________________________________________
Operation/Procedure: __________________________Findings: ____________
_________________________Pathological Report: ____________________________
______________________________________________________________________
Final Diagnosis: ____________________________________________________
Result On Discharge: ______________________________________________
Signed: ___________________________(Attending doctor)
218
Activity: 6
1.
2.
3.
4.
5.
Write the definition of privacy and confidentiality of patient
information with your own words.
Discuss Ethical standards related to patient/client privacy right and
confidentiality of patient/clients information.
Sister Askale is a Nurse who works as head of Medical wards in a
nearby Hospital. She wanted the Health Information Technician to tell
the diagnosis of Ato Feyissa Hailu who is the cousin of her husband
and treated a month before in the medical outpatient department of
the hospital. How do you respond to her request?
Who do you think is the owner of the medical record and the
information within the medical record?
It is always prohibited to disclose personal health information without
the consent of your client. True or False? Explain the reasons for your
answer.
219
7. Security and Access to Health
Information
Learning Objectives
At the end of this topic, you should be able to:
• Identify issues related to the use and disclosure of
individual health information
• Identify common information security measures
• Identify the legislative requirements for the
collection and security of individual health
information
• Define the right of access to individual health
information
220
• Security Measures to Patient/Client Medical Record
• Medical records may be maintained as paper-based or computer
records. Regardless of the
• systems, health facility and individual staffs must take reasonable
steps to protect the
• personal information contained in the medical records from loss,
unauthorized access,
• modification or disclosure. Staffs, particularly the medical record
unit staffs need to protect
• medical records against such unauthorized access where those
medical records are stored or
• transmitted. A breach of the security measures in place should
result in disciplinary action
• with a range of penalties including dismissals.
221
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Handling Confidential Information
Confidential health information must be stored, transported, transmitted, handled, used, and
disposed of in ways that protect the information from unauthorized access, alteration,
destruction, disclosure, copying, theft, or physical damage. However, such ways of handling
medical records shouldn’t be obstacle to use the medical record for provision of care when
needed. You must have security measures in place to protect work areas and patientidentifiable
information. Some of the security measures for paper-based or electronic medical
records are:
• System access management
• Personnel clearance procedures
• Password protection of computer applications
• Secure disposal of confidential waste
• Sanctions for misuse of systems and data
• Signed confidentiality agreements
• Data backup and disaster recovery procedures
• Assigned responsibility for confidentiality and security of information
• Confidentiality and security awareness training
222
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Some good practices to meet security requirements are:
• Policies, Physical and administrative safeguards: The medical record unit,
computers and portable devices that contain patient health information should be
physically protected from unauthorized access by means of a security measure such as
having alarm systems or locking with key. Written policies and administrative
measures like designating security officers, training the work force, controlling
information access and periodic security reassessment through staff training and
monthly review of user activities can minimize unauthorized access to patient
information in the health facility.
• Prevent Unauthorized or Inappropriate Access: Issue unique user names and
passwords to everyone who will use the EHR (if accessed this way) to prevent
unauthorized or inappropriate access to patient information and system controls.
• Use Encryption Technology: Whether an EHR is locally installed or accessed over
the Internet, encryption technology can protect patient health information from being
read by unauthorized parties when it is transmitted, or stored on any device, including
mobile devices. Encrypting personal health information puts information in a coded
form that can only be read by an authorized user who has a “key.”
223
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•
•
• Backup: To keep information available when and where it is needed, plan for backing
up your EHR system.
Policies and Procedures to Health Information Access and Disclosure
Medical record policy will endeavor to protect the confidentiality and security of its patient
health information against inappropriate access, inappropriate use, tampering,
loss/destruction and inappropriate disclosure through the use of reasonable safeguards. The
purpose of this policy is to set forth the general principles and procedures for maintaining the
confidentiality and security of patient health information.
The medical record service shall be properly equipped to enable its personnel to function in
an effective manner and to maintain medical records so that they are readily accessible and
secure from un-authorized use. The organization policy should address the following areas.
224
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•
The medical record unit shall have written policies and procedures that are
reviewed
at least once every three years, revised more frequently as needed, and
implemented.
They shall include at least:
1. Procedures for record completion, including chart analysis.
2. Conditions, procedures, and fees for releasing medical information.
3. Procedures for the protection of medical record information against the loss,
alteration, destruction, or unauthorized use.
• All entries in the patient's medical record shall be written legibly in ink, dated,
and
signed by the recording person. If computer generated orders with a physician's
electronic signature are used (in case of EMR), the Health care facility shall
develop a
procedure to assure the confidentiality of each electronic signature and to prohibit
the
improper or unauthorized use of any computer generated signature.
225
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•
Access and disclosure are usually associated with the concept of ownership and control of
health information or the health record. Access of health information means using the
personal health data internally within a health institution like a hospital or health center,
however, disclosure relates with the manner how health information should be disseminated
externally. In principle, medical records, x-rays, laboratory reports or other physical
documents relating to the delivery of health care service are owned by the specific health
institution. However, this doesn’t mean that the client have no right over the health record.
Rather, the information within the record is the property of the client. It’s out of this concept
that the client is granted the right to take a copy or view or otherwise access his/her health
information or amends the information when it’s found to be proper.
In order to give access to personal health information, it should be understood that all the
rules and regulations applicable to access and disclosure of health information must be
applied. It is part of the obligation of health information technicians to keep clients’ health
information confidential, whether the information is transmitted verbally, on paper, or
electronically. Therefore, you have to obey applicable laws and policies of the health
institutions to which you are working for as HIT.
226
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All health information is to be kept confidential unless the client authorizes the use and
disclosure of personal information or it is specifically allowed by law. If the client is
considered unable to give authorization, such as in the case of minors, a legal guardian should
give the consent for release of information. When all requirements are fulfilled disclosure of
health information will be limited to the minimum necessary to achieve the purpose of the
disclosure.
Use and disclosure of personal health information other than for the primary purposes can be
possible in two cases. Firstly, personal health information can be disclosed or used when
consent is acquired or collected from the client/patient. The second case or condition where
personal health information disclosed is for his/her legal representative. In the former case,
you may disclose or use individual health record by the consent of the client or to a person
represented by the individual. In the latter case, there must be clear authorization from the
law that you can use or disclose personal health information without the consent of the client.
In addition, use and disclosure may be subject to notice and approval by the client, to a health
professional regulatory body for the purpose of conducting investigations, discipline
proceedings, practice reviews or inspections relating to the members of a health profession or
health discipline. For example a health professional council or other regulatory body may see
the record that is prepared by a doctor to examine its correctness or there may be mal practice
or ethics complaint against this doctor. In this case the professional regulatory body may wish
to examine the record documented by the doctor.
Since the information on the record belongs to the client, in the case of disclosure the
individual has a right to know to whom his/her information is given and for what purpose.
The information recorded shall be retained by the custodian for a period of 10 years
following the date of the disclosure.
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Patient access to their health information
Clients have right of access to their own health information for different purposes. They may
need to inspect copy or amend the information on the medical record when they believe they
have wrongly provided inaccurate information.
Under the draft regulation of HMIS, clients have the right to access their own health
information. The client may access their records at any time they want in accordance with the
policy of a specific health institution. This right may be exercised through a receipt of a copy
or by viewing the health information in the medical record.
In this case, the client is required to submit their requests in writing. If there is a form
prepared for this purpose, ensure that the person is really the one who is the subject of the
information. Because of the privacy and confidentiality implication of giving access, it should
be done very carefully. This can be ensured by requiring the client to present an identification
card and checking the information that belongs to the client.
In the case of representation (where the client authorize another person to be given access to
health information), if the client has signed a written authority for access to be granted to a
person named in the instrument of agency, the person so named shall be given access to the
health information requested.
On the other hand a client who believes there is an error or omission in his individual health
record may in writing or orally request, depending on the case, the custodian or health
professional to correct or amend the record. Where the error concerns the client’s
demographic data the health information technician may be of help. On the other hand, if the
appropriate custodian or health professional agrees or refuse to make the correction or
amendment in accordance with the relevant guideline, he shall make the correction or
amendment or refuse the same and give notice to the client that the correction or amendment
has been made or refused.
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Record Keeping during Refusal of treatment by Patients
Patients have the right to refuse treatment and need to be made aware that they may refuse all
or part of any care and treatment proposed and may withdraw previously given consent at any
time.
• Refusal may be written, verbal or by any form of communication possible.
• It is also revocable at any time.
• If there is any concern about the capacity of the patient to give valid consent, it
should be discussed preoperatively with senior staff. Any remaining concerns
should then be discussed with the Director of Medical Services or equivalent.
Before complying with a direction to refuse or withdraw treatment, the health professional is
required to take all steps to ensure that the patient has been provided with all relevant
information; the patient has understood the information; and s/he has made an informed
decision.
Relevant information includes:
• The nature of the illness
• Any alternative forms of treatment that may be available
• The consequences of those forms of treatment
• The consequences of remaining untreated
Medical records that clearly reflect the decision-making process can be pivotal in the success
or failure of legal claims. In addition to the discussion with the patient, the medical record
should describe any involvement of family or other third parties. If imminently or potentially
serious consequences are likely to happen because of patient refusal, health care providers
should make the refusal signed, witnessed and documented.
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Self-check Assessment
Activity: 1
Write down the common security measures
Activity: 2
Elaborate the following concepts.
a. Information Access
b. Unauthorized Access
_________________________________________________________________
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c. Information Disclosure
d. Information security
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Activity: 3
As part of the security measures, a health organization should develop and use policies
and procedures related to health information handling of patients. What are the key
points that the developed policies and procedures should address? Write the points
using your own words.
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• Activity: 4
• W/o Askale Taye is 50 years old patient, from Shashemane town,
Admitted to Hawassa
• Referral hospital for severe injury she sustained on her left leg. The
surgeon decided to
• perform amputation of the leg below the knee as the lower part of
the left leg become
• gangrenous (dead tissue). However, she refused the surgery and
requested for discharge
• from the hospital. As HIT of the hospital, what information
elements (that has to be
• recorded by the health care provider on here treatment refusal)
should be checked for
• completeness before her discharge is completed?
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Hospital Admission and Discharge
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Learning Objectives
Upon completion of this topic, you should be able to:
• Identify the content of admission\discharge recording tools
• Demonstrate patient admission and discharging procedure
• Describe patient information’s that should be recorded while
admitting a
patient
• Monitor and update admitted patient medical record
• Identify basic hospital statistics for inpatient services
• Identify the content of discharge summaries
• Explain patient discharge and clearance procedures
• Verify patient’s medical records for completeness before filing
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Hospital Admission
Before we discuss the admission and discharge procedures, let us try to define terms related to
admission and discharge process in a hospital.
Outpatient (or out-patient): is a patient who is not hospitalized for 24 hours or more but
who visits a hospital, clinic, or associated facility for diagnosis or treatment. Treatment
provided in this fashion is called ambulatory care.
Inpatient (or in-patient): is a patient "admitted" to the hospital and stays overnight or for an
indeterminate time, usually several days or weeks. Treatment provided in this fashion is
called inpatient care. Inpatients usually occupy a bed in a health care facility for at least four
hours or overnight. The time needed before a person is declared an inpatient varies from
country to country. In this regard, there is no written document in Ethiopia that specifies the
time that should be spent in hospital before it is declared as inpatient. . The admission to a
hospital involves the writing an admission note and it documents the patient's status, reasons
why the patient is admitted for inpatient care, and the initial instructions for that patient's
care. Patient’s leaving of the hospital is commonly termed as patient discharge, and involves
a corresponding discharge note or summary.
Where a patient is admitted on the expectation that he or she will remain overnight, but the
patient dies or is discharged before the midnight census, the patient should still be regarded as
inpatient, whether or not a hospital bed is occupied or treatment is provided. Such admission
is commonly known as ‘admission for 24 hours observation’ in Ethiopia.
Admission: Is a formal process whereby a person is accepted by a hospital for the purpose of
hospital treatment as an inpatient.
Bed management: is the allocation and provision of beds, especially in a hospital where beds
in specialist department (wards) are a scarce resource. The "bed" in this context represents
not simply a place for the patient to sleep, but the services that go with being cared for by the
medical facility: Admission processing, physician time/visit, nursing care, necessary
diagnostic work, appropriate treatment, and so forth.
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Admission procedure
The admission of a patient to hospital is ordered by a doctor and carried out by an admission
clerk. At the time of admission, a patient already has a medical record number and medical
record. Thus, a new number is not issued. The hospital, however, needs to keep a daily list of
all admissions. All patients admitted, whether admitted for the first time or not and other
admission related information on the appropriate recording tool.
8.4 Admission /Discharge recording tools
With the reformed HMIS, there are three basic recording tools for inpatient services: The
Admission/discharge card, Register and Tally. However, there are many clinical forms by
which healthcare providers document the entire patient’s information captured during the
inpatient stay of the individual. Our focus in this module will be introducing those card,
register and tally sheets mentioned earlier. Other inpatient forms, on which most of the
clinical events related to a patient are documented, will be summarized in the subsequent
subtopic.
Admission/discharge Card
Admission / Discharge card is very useful recording tool of the patient’s information related
to personal identification, ward admitted, admission diagnosis, discharge diagnosis, condition
at discharge, admission and discharge dates and other financial information related to the
inpatient services offered.
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Admission/Discharge Register
The purpose of completing this register for each inpatient service is to gather information that
enables the facility to identify top causes of morbidity and mortality of inpatient department.
In addition, the data contained by the register helps to identify specific diseases or clinical
conditions of priority that are targeted for eradication or control. The register is case register
(not longitudinal register) where each row is used to record information of one patient
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admission and the same row will be completed at the time of discharge of that patient. It is
located at all the wards (rooms where admitted patients receive inpatient services).
The data to be filled in the admission/discharge registered is available in the medical records
of each inpatient cases and it will be collected and entered at the time of admission and
discharge each case.
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• Content of Admission/ Discharge Register
• The admission/discharge register has five basic groups of columns. These
groups of related
• columns are for identification, admission, provider initiated HIV testing
and counseling
• (PIHTC), discharge and finance information.
• Identification includes: Medical Record Number (MRN), Age, and Sex,
woreda / sub-city.
• Admission includes: Date of Admission, Admission diseases classification
(HMIS diagnosis)
• PIHTC includes: HIV test offered, HIV test performed and HIV test result
• Discharge includes: date of discharge, length of stay, condition at
discharge and discharge
• diagnosis (Based on HMIS disease classification)
• Finance includes: Cost of service, Amount paid, and Voucher Number.
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IPD Tally sheet:
This tally sheet is important to summarize the inpatient services and diseases disaggregated
by age group, sex and New/repeat status. It is filled by the care provider at the end of each
day. Counts should be summed and state at the bottom the tally sheet at the end of each
month.
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8.5 Information Recorded while Admitting a patient
Most of the documents in the health record are clinical services and some of these clinical
forms are discussed in the previous learner module 2 (Managing Medical Records). However,
here we will try to describe and summarize the most important one as follows.
I. History and physical examination recording form/patient form
Function: To record patient history and physical examination findings.
Location: Inside the Medical record folder
Work process: When a patient is admitted as an in-patient a full history and physical
examination should be conducted by the attending physician.
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II. Progress note
Function: To record clinical findings and progress of the patient during the hospital stay.
Location: Medical record folder
Work process: When patient is seen by a clinician, the information obtained will be recorded
with date, clinical details, and signature of the attending clinician.
III. Nursing Process Forms
• Nursing admission assessment form
• Nursing problem statement list
• Nursing care plan
• Nursing patient progress report
Function: To describe the nursing assessment, care plan and outcome of nursing care of an
admitted patient.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record.
IV. Medication Administration Record
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Function: To record all medications ordered and administered to a patient.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s MR as part of the permanent record.
V. Fluid Balance Chart
Function: To record all fluid inputs and outputs for patients at risk of fluid overload or
dehydration.
Location: Bed-side clip board during the patient’s stay, but must ultimately be included in the
patient’s Medical record folder as part of the permanent record.
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VI. Consent forms
Function: The consent form outlines the risks associated with a particular procedure. A
signed consent form indicates that the patient (or designated proxy) has been informed of the
risks and has authorized the procedure.
Location: Medical record folder
VII. Referral and Feedback Form (if relevant)
Function: To document patient history at the hospital and to provide reason for referral
Location: One copy in the Medical record folder and one copy to patient.
8.6 Monitoring and Updating Patient Information during patients
hospital stay
This part of managing medical record is entirely done during the inpatient stay of the patient.
Main responsibility lay on the care providers involved in the treatment process of the patient.
As described earlier, most of the clinical documents that constitute the medical records of
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inpatient cases are the clinical forms. The HIT has to check for the accuracy, completeness
and on-time recording of these clinical forms on regular bases. The methods and the tools
used to monitor and update these forms are similar to those medical records produced during
the outpatient services as it is covered in the learner module of ‘Managing medical records’.
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• Basic hospital statistics for inpatient services
• Even though healthcare statistics is well covered in other learner
module, it is important to
• highlight the most important hospitals statistics required to monitor
its performance. Each
• relevant statistics are described by its name, definition and formula.
• 1. Inpatient Death/mortality rate
• Definition: A patient who expires/died while he/she is inpatient of a
hospital. The term
• ‘mortality’ is referred as death. It is a ratio of all inpatient deaths for
a given period to the
• total number of discharges and deaths in the same period.
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• Inpatient death rate:
• Total number of deaths of inpatient in a given period x 100
• Total number of discharges and deaths in the same period
N.B Inpatient death rate should be calculated
based on discharge data not admission data.
• This is because a patient who is hospitalized has
a chance of being discharged as died.
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
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Number of IPD deaths cause meningitis
case fatality rate  Total number of admissions (dx : meningitis ) x100
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Health System contd.
D1.4. Admission rate.
Number of inpatient admissions
Admission rate 
x1000
Population in the catchment area
Interpretation:
• Admission rate reflects the interaction between demand and supply of inpatient care.
• Like outpatient service utilization, admission rate is inversely related to certain barriers that
may be physical (distance), economic (cost to patient), cultural (low awareness and health
care seeking behavior) or technical (poor quality of health care).
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D1.5. Bed occupancy rate (BOR).
Definition:
• The bed occupancy rate is the average percentage of occupied beds during
the period under review (usually one year).
Bed occupancy rate 
Number of patient bed - days
Number of beds avaialable x Number of days in period
Interpretation:
• BOR reflects the level of utilization of inpatient services.
• Inpatient services incur a high overhead. In Ethiopia hospitals consume
more than 40% of public sector health funds.
• Inpatient capacity that is greater than demand wastes resources.
• A low BOR requires investigation.
• A low BOR may also reflect low quality of service.
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Health System contd.
D1.6. Average length of stay (ALOS).
Definition:
• The average length of stay of patients in an inpatient facility during a given
period of time.
Average length of stay 
number of bed days
Number of inpatient admissions
Interpretation:
• ALOS reflects the appropriate utilization of inpatient services.
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• Average length of stay
• Definition: a length of stay for one patient is
the number of calendar days from admission
to discharge. The average length of stay is the
average of the sum of length of stay of any
group of inpatients discharged during a
specified period of time.
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• Ave. Length of stay=
Total inpatient service days of discharged (including deaths) Patients for a given period
Total number of discharges and deaths in the same period
Example: In June, a hospital has discharged 2,086 patients (including deaths, but excluding
• newborns).
• Their combined inpatient service days were 13 654 days. Using the above formula, the
• average length of stay of these patients was:
• = 13654
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2086
• = 6.54 or 6.5 days
• That is, the average stay as inpatient during June was 6.5 days.
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• Bed occupancy rate
• Definition: the percentage of inpatient beds
occupied over a given period. To calculate the
• bed occupancy rate for certain period, you need
to know the number of patient days (also known
as inpatient service day) which is a unit of
measure of denoting the services received by one
inpatient during one 24 hour period. A total
patient day is the sum of all inpatient
• service days for each of the days during a given
period.
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• Bed occupancy rate=
Total number of patient days for a given period X 100
Available beds X the number of days in the period
Example: Black lion hospital has 500 available beds and
provided 13,250 patient days in
• Hidar (November). Hidar has 30 days. The bed
occupancy rate of the black lion hospital was:
13,250 x 100
88.3%
500x30
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Case fatality rate
• Definition: The case fatality rate is defined as the
number of deaths assigned to a given cause
(disease) in a certain period, divided by the
number of cases of the disease reported during
the same period.
Case fatality rate of disease x =
Number of deaths for a given disease y x100
Number of cases of the same disease reported y
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• The number of days of care rendered to an
inpatient is from admission to discharge.
• The duration of an inpatient's hospitalization
is considered to be one day if he is admitted
and discharged on the same day and also if he
is admitted on one day and discharged the
next day. The day of admission should be
counted but not the day of discharge.
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Discharge and clearance procedures
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The hospital discharge process is initiated on the recommendation of a physician. The process
may vary from hospital to hospital as hospitals have their own policies regarding discharge.
Patients should make sure they understand any follow-up instructions before leaving the
hospital and, if not, they should ask for clarification. Possible questions they might need
clarification on include:
• Does the patient need a follow-up visit? Who should he/she see? Should the
patient call to make the appointment or is it already arranged?
• What medications have been prescribed? Are there any side effects? If there
are, should the patient stop taking the medication?
Medical record staff responsible for this procedure should be trained to ensure that the
medical records are completed promptly and correctly.
Completing Discharge Summaries
A discharge summary is a summary of the patient’s stay in hospital written by the attending
doctor. The minimum detail provided in a discharge summary is:
• Patient identification
• Reason for admission
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• Examinations and findings
• Treatments while in hospital and
• Proposed follow up/ Death summary
Upon the discharge a patient, the following information should be recorded on
admission/discharge register entry that corresponds to the particular patient admission related
information.
• Date of discharge of the patient
• Length of stay (the difference of data of discharge and date of admission)
• Condition at discharge: the possible value can be improved or referred or dead left
against medical advice or absconded (runaway from the hospital suddenly).
• HMIS Diagnosis: Based on the HMIS disease classification.
• Cost of the service: exact cost in terms of Birr.
• Amount Paid: the amount of money paid for the service during stays and discharge
(see figure 8.4).
• Voucher number: from the payment receipt.
Organizing Documentation of Discharged Patients
While in hospital, the patient’s medical record develops with the recording of clinical
information by doctors and other health professionals. Results of pathology tests etc. are
added as they are received. Nurses record daily progress notes and special observations. If a
patient has any special tests and/or surgical procedures, relevant information is included. On
discharge/death of the patient the medical record, including all forms relating to the
admission plus any previous records, should be sent to the Medical record unit as soon as
possible or within 24 hours.
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Admission/discharge service payment form.
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The discharge procedure begins with the receipt of the medical records of discharged
patients/deceased.
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• The medical records of discharged client/deceases should be sent to the Medical
Record Department by the ward staff on the same day of discharge/death or the
next morning. In some countries, a staff member from the Medical record unit
collects the medical records of discharged/deceased from the wards at a specific
time every day.
• The Medical record unit staffs are responsible for the daily bed census, which they
receive from each ward at the beginning of the day.
• From the bed census forms staff are able to record details of discharges and deaths
and prepare a daily discharge list. This list is extremely important and should be
duplicated and sent to a number of sections in the health care facility.
8.9 Verifying Medical Records for Completeness for discharged
patient
The Medical record unit staffs are responsible for managing the medical records of
discharged patients and should check to see if they have all the medical records of discharged
patients from the previous day. If any are missing they should contact the ward to find them.
Once a patient has been discharged, the medical record should be returned promptly to the
Medical Record Unit. Failure to do so may result in a missing medical record. Once the
patient is no longer in the ward, their medical record can easily be misplaced.
Medical record completion procedure begins with the receipt of the medical records of
completed services, discharges and deaths. Those medical records should be sent to the
medical record department by the health care staff by the end of the day and before that all
the processes should be completed from each unit. In some cases, a staff member from the
medical record unit collects the medical records from the health care facility wards every day.
It is a good practice to list and send the summary of discharged and dead patient to the
medical record unit.
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• The clerk in the medical record unit checks each medical record to ensure that all
the forms are in the record. For example, if the patient has had an operation an
operation report should be in the record. In addition all progress notes, pathology
and x-ray forms, nursing notes etc. should be included. There should also be a
final discharge note made by the attending doctor including to where the patient
has been discharged and arrangements for follow-up.
• The clerk then sorts the forms into the correct order (if they are not already sorted).
In the case of new patient the forms are attached to a medical record folder with a
clip or fastener. If the patient has been in health care facility before the old records
are retrieved and the latest admission forms are added by placing them behind the
appropriate divider or in a chronological order.
• The clerk also needs to check if the doctor has completed the lower part of the front
sheet. That is, the HMIS diagnosis has been recorded along with any other
condition treatment while in the facility.
• The signature of the health care provider is important as it shows that the doctor has
completed the medical record and takes responsibility for the content.
Returning Patient Document to MRU
The Medical Record of discharged patients or the deceased should be returned to the Medical
Record unit within 24 hours of discharge. The Medical Record unit should review the
Medical Record to see if all forms have been properly signed, particularly the discharge
summary. If they are not signed, the Medical Record Department should alert the physician
on record or case team leader to complete and sign the discharge summary
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• Self Check Assessment
• Activity: 1
• Describe the following concepts and hospital
statistics
• a. Admission
• b. Inpatient
• c. Wards
• d. Discharge Summary
• e. Average length of stay
• f. Bed occupancy rate
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Activity: 2
In May, 2012, the total number of discharged client at Zewditu referral Hospital have added
up to 2,086 patients (including deaths, but excluding newborns).Their combined inpatient
service days were 13, 654 days. What is the average length of stay of these patients?
_________________________________________________________________
___________________________________________________________________
Activity: 3
Write down relevant information included in patient discharge summary.
_____________________________________________________________________
Activity: 4
Who decide to discharge patient from a hospital?
_____________________________________________________________
_____________________________________________________________
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Activity: 5
W/o Selamawit is a 45 years old female who sustained injury to her left shoulder and
admitted at Dessie referral Hospital. Her physician performed physical examination and
requested for x-ray of the shoulder joint area. Her physical assessment and radiological
examination reveals a fracture and dislocation of the shoulder joint. After six weeks of
inpatient treatment, her condition was improved and was discharged from the hospital, then
after; a discharge summary was prepared and signed. Finally, the health information
technician checked her medical record while returning to the medical record unit for filing.
Unfortunately her radiology report sheet and physical examination sheet were missed from
the chart.
a. How do you handle the missing document? Explain the steps involved with your own
words.
_____________________________________________________________
b. Who will be responsible for the missed document? How do you correct this
documentation problem?
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