Annex 2: Baseline Health Facility Assessment Checklist

Data will be collected through observation, interview of informants and review of records
including minutes, reports, cards, registers, tally sheets and other documents based on the
type of question. For each questions there will be options such as “Yes”,” Partial”,” No” and
“Not Applicable(NA)”. Hence, a mentors will choose one of the option for each question and
describe if any issues/observations under the remark and description column.

Mentee Facility identification

Name of health facility:_________________ Type of Facility ________

Woreda:______________ Zone/sub city:_____________

Region_______________

Contact person:

Name: _______________________________

Telephone: _____________________

Email: ______________________________

Date: ___________________

Mentor’s profile

Level of Certified
Mentor’s Name Profession Organization Telephone Email Signature
Education (Y/N)

330 HIS MENTORSHIP TRAINING MODULES

 Yes/
partial/
Description/
SN Checklist Questions No / Remark
Reason if No
NA or
Number

Part I: Facility level questions

1 HMIS Unit/Structure

1.1 Staffing, Office and equipment

Does the HMIS unit have dedicated office/Desk?

Is HMIS focal person assigned?

Is his/her qualification HIT?(if not indicate the qualification
under description)
Is the HMIS unit fully staffed as per the standard?
Does the health facility has a functional computer dedicated
to DHIS2?

1.2 HMIS Training

1.2.1 Total Number of HMIS unit staff in the facility

Number of HIT/HMIS unit staff trained on the following training
1.2.2
topics in the last 2 years
HMIS training (TOT/End user)
IR Implementation Guideline
ESV_ICD-11 training
Data quality & Information use
DHIS2 training
CHIS training
eCHIS training
Other (specify)
Does the Health Facility conduct HIS capacity need
1.2.3
assessment?

Percent of health providers and MRU staff took end user

1.2.4 Observe evidence
training (In last 2 years period)(Basic/onsite)

HMIS training (TOT/End user)

IR Implementation Guideline
ESV_ICD-11 training
Data quality and Information use
DHIS2 training

1.3 Availability of guidelines and SOPs

HMIS procedure manual

Indicators reference guideline
Data quality manual
Information use manual
ESV_ICD-11 implementation guide
ESV_ICD-11 SOP
ESV_ICD-11 job aid
DHIS-2 end user manual

PARTICIPANT MANUAL 331

1.4 Availability of revised HMIS tools (2021 version)
Does health facility have all types of individual medical
records including tracer cards in adequate quantity? (stock
level of at least 3 months)
Does health facility have all the required registers?
Does health facility have all the required Tally sheets?
1.5 Digitization
1.5.1 Infrastructure
Does the health facility has a functional Health Net?
Does the health facility have functional Local Area Network
(LAN) to all departments?
1.5.2 DHIS 2
Does the facility implemented DHIS-2? Observation
If yes, does it offline or online?
Do end users understand all the functionalities/ features of
DHIS2? Demonstration &
observe
Do end users use DHIS-2 for data analysis and use?

What are the existing challenges in implementation and use

of DHIS-2?

11.5.3 eHRIS
Does the health facility implemented e-HRIS? Observation

Do end users understand all the functionalities/ features of Demonstration &

e-HRIS? observe

What are the existing challenges in implementation and use

of e-HRIS?
11.5.4 EMR
Does the facility implement EMR-MRU? Observation
Does the facility implement full EMR?
Do end users understand all the functionalities/ features of Ask for demonstration &
MRU-EMR? observe
What are the existing challenges in implementation and use
of EMR?
11.5.5 EMR-ART Software

Does the health facility implemented ART software?

Do end users understand all the functionalities/ features of Ask for demonstration &
ART software? observe

What are the existing challenges in implementation and use of

ART software?

332 HIS MENTORSHIP TRAINING MODULES

2 Data Quality
2.1 LQAS
Does the facility conduct and document LQAS on HMIS
service record monthly?
Does the facility conduct and document LQAS on HMIS
disease record monthly?
Does the HMIS focal person understand the purpose,
procedure and interpretation of LQAS?
Do all PMT members participated on LQAS and sign on LQAS
check sheet?
Is LQAS conducted at department level?
Proportion of departments conducted LQAS
2.2. Other data quality dimensions
Does the facility use timeliness and completeness monitoring
Observe
form/Data Quality Logbook?
Does the facility submit report timely in the last three months? Observe
Does the facility submit complete report in the last three
Observe
months?
Does the facility conduct crosscheck of data on registers
Observe
against individual medical records?
Does the facility conduct content completeness of data on
Observe
registers?
Does the facility conduct content completeness of individual
medical records (summary sheet, ESV-ICD11 records on patient Observe
cards etc..)?
3 Information Use
3.1 Performance Monitoring Team (PMT)
Does the facility establish Performance management team
Observation
(PMT)?
Observe minute and
Is the PMT established according to national standard?
letter of assignment
Is the PMT chaired by the head of the health facility as per the Observe minute and
national standard? letter of assignment
Is PMT conduct meeting on regular basis? Observe minute
Does the PMT use PMT minute logbook during meeting? Observe minute

Does PMT track key quality and equity indicators? Observe minute

Does the team compared performance with the plan for Key
Observe minute
indicators?
Are performance gaps identified and prioritized? Observation

Does the team did root cause analysis for priority problems/
Observation
gaps using appropriate method?

Does the team developed Plan of action (POA) using the Observe minute or
appropriate plan template? proceeding

Does the team monitor the implementation of the Plan of

action (POA)?

Are minutes shared with relevant units/case teams for action?

Is written feedback given to lower level supervisory unit or

case teams on strengths and weaknesses based on the
analysis?

PARTICIPANT MANUAL 333

3.2 Department/case team level PMT
Does the facility established department/case team level
PMT?

Does these teams practiced reviewing the performance of the

respective department/case team level at least monthly basis?

Does this team check the data quality status (content

completeness, consistency among registers, tallies, individual
medical records etc.)? Of the respective department/case
team level at least monthly basis?

3.3 Clinical audit and Data use

Does the facility assign team of professionals for clinical audit?
Does the facility-identified indicators and develop audit tools
for clinical audit?
Does the facility conduct clinical audit?
Does the facility use audit finding for service improvement?
(explain with example)
Does the facility involve clinicians in clinical audit and use of
its finding? (explain with example)
3.4 Data Visualization and Display

Does the facility prepare minimum data visuals (graphs, tables,

maps, etc.) showing achievements toward targets (indicators, Observation
geographic and/or temporal trends)?

Does the facility display data visualization in departments,

Observation
HMIS unit or any other place?
3.5 Dissemination
Does the facility produce any newsletter/ brochure/ bulletin
(annual, quarterly, etc.) that shows the performance of the Observation
facility based on an analysis of HIS data?
Does the health facility conduct assessment(s), audits and
disseminate findings?
Part II :Department level questions
4 Medical Record Unit
4.1 MRU working procedures
Are all cards (IMR) in one central card room
Do all the IMRs shelved in order of MRN?
Is it easy to retrieve IMR from MRU?(Take sample)
Do MRU staffs know the procedures on how to give and
retrieve IMR? (ask three staffs on the steps)
Is MRN provided to each client/patient? (except VCT)

Does the facility use MPI system (Either manual or electronic)

Does the IMR collected and returned back to MRU daily?

Does the facility use tracer card system?

Does the facility identified active and inactive IMRs and
shelved separately?
Is there any mechanism to handover IMR between porters and
nurses at service delivery points?
What do MRU staffs do when they got multiple MRN for a
single patient/clients?

Take random sample of 10 IMRs and check the order

334 HIS MENTORSHIP TRAINING MODULES

4.2 Central –Patient register (MRU)
Do MRU staffs register all new cards in the central register?
Do MRU staffs register all repeat cards retrieved in the central
register?
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
each page?

Do they properly complete Patient Client attendance tally

See the guide
sheet?
4.3 Availability and use of Individual Medical Records(take a sample )
Answer Key: (A) Yes, Partial, No, NA (B) Yes, Partial, No, NA (C) Yes, Partial, No, NA
Available
Legibility Completeness
Cards and Use
A B C
Integrated individual Folder
Patient Card/History Sheet
Service ID Card
Master Patient Index card
Tracer card
Integrated RH card
Woman’s Card
Admission/ discharge card
Appointment card
5 Outpatient department
5.1 Recording practice on Registers and tallies and other recording formats
5.1.1 Emergency Registration (Emergency Room)
Do they understand each data element on the Emergency
See the guide
register?

Do they record all required data on Register completely and

See the guide
correctly?

Do they sum up the required data elements at the end of

See the guide
each page?

Do they record diagnosis based on the ESV_ICD 11 in the

See the guide
register?
Do the documented data on the register legible?
Do they complete ESV_ICD 11 customized tally sheet? See the guide
5.1.2 OPD Register

PARTICIPANT MANUAL 335

 Do they understand each data element on the OPD register?
Deep dive & ask if they understand the definition of ‘New’ and See the guide
‘Repeat’ visits?
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do they use the ESV_ICD 11 in the OPD register? See the guide
Do the documented data on the register legible?
Do they complete the PITC tally from the OPD abstract
See the guide
Register?
Do they complete ESV_ICD 11 customized tally sheet? See the guide

5.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements monthly against Medical records
table

Do they check the data completeness on the register and

Check the minute
report regularly(Content completeness)/ monthly

5.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
period?

Does the case team/department prepare minimum data

visuals (graphs, tables, maps, etc.) showing achievements Observe
toward targets?

336 HIS MENTORSHIP TRAINING MODULES

6 Maternal and child health department
6.1 Recording practice on Registers and tallies and other recording formats
6.1.1 Family planning Registers
Do they understand each data element on the FP register? See the guide
Do they understand ‘new’ and ‘repeat’ definitions? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they record the right abbreviation for contraceptives they
Register review
have provided?
How do they manage recording on the register if a client
Interview: ask gently
comes more than 5 times in a year?
Do the documented data on the register legible?
Do they complete PITC tally from FP register? See the guide
Do they properly fill FP service and method dispensing tallies? See the guide

Select five MRNs of FP

clients from FP register
(one MRN from each
Do they fill FP service summary sheet?
of the last five days) &
check if summary sheet
is completed

6.1.2 Long acting Family Planning removal Registers

Do they understand each data element on the LAFP register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?

Do the documented data on the register legible?

Do they complete PITC tally from LAFP register? See the guide
6.1.3 ANC Register
Do they understand each data element on the ANC register? See the guide

Do they record all required data on Register completely and

See the guide
correctly?

Do they sum up the required data elements at the end of

See the guide
each page?

Do the documented data on the register legible?

Do they complete ANC tally sheet correctly and daily? See the guide

Do they complete PITC tally from ANC register? See the guide

6.1.4. Delivery Register

Do they understand each data element on the Delivery
See the guide
register?
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?

Do the documented data on the register legible?

Do they complete PITC tally from delivery register? See the guide

PARTICIPANT MANUAL 337

6.1.5 PNC register
Do they understand each data element on the PNC register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible?
Do they complete PITC tally from PNC register? See the guide
6.1.6 PMTCT Register

Do they understand each data element on the PMTCT

See the guide
register?

Do they record all required data on Register completely and

correctly? Follow up questions will be if they record all HIV
See the guide
positive pregnant, lactating mothers (both new and on ART
follow up) & exposed infants on the register properly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible? See the guide
Do they complete PMTCT tally from PMTCT register? See the guide
6.1.7 Abortion Register
Do they understand each data element on the Abortion
See the guide
register?
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible? See the guide
Do they complete abortion tally sheet? See the guide
Do they complete PITC tally from abortion register? See the guide
6.1.8 Routine Immunization register
Do they understand each data element on the register? See the guide

Do they record all required data on Register completely and

See the guide
correctly?

Do they complete EPI tally sheet daily? See the guide

Do the documented data on the register legible?
6.1.9 TT immunization registration

Do they understand each data element on the TT register? See the guide

Do they record all required data on Register completely and

See the guide
correctly?
Do the documented data on the register legible?
Do they complete immunization tally sheet daily? See the guide
6.1.10 Pregnant and lactating women nutrition screening Register
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?

Do they sum up the required data elements at the end of

See the guide
each page?

Do the documented data on the register legible?

338 HIS MENTORSHIP TRAINING MODULES

6.1.11 Compressive & integrated nutrition service register (CINS)
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible?
Do they complete Compressive & integrated nutrition service
See the guide
tally sheet
6.1.12 Therapeutic Food program register
Do they understand each data element on the register? See the guide

Do they record all required data on Register completely and

See the guide
correctly?

Do the documented data on the register legible?

Do they sum up the required data elements at the end of
See the guide
each page?
3.1.13 NICU (neonatal intensive care unit ) register
Do they understand each data element on the NICU register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible?
Do they complete ESV_ICD 11 customized tally sheet daily? See the guide
6.1.14 Cervical cancer screening
Do they understand all the required data item See the guide
Do they record all required data on Register completely and
See the guide
correctly?

Do they sum up the required data elements at the end of

See the guide
each page?

Do the documented data on the register legible?

Do they complete PICT Tally sheet? See the guide

6.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table

PARTICIPANT MANUAL 339

 Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)

6.3 Data use

Is there practice of monitoring performance/data use in the Observe documented
unit regularly on monthly basis? minute
Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently
Was performance versus plan compared for Key indicators
Ask and observe
and identify areas of improvement?
Were root causes of problems identified & action plan
prepared with responsible implementer assigned along with Review the action plan
time frame?
Does the facility prepare minimum data visuals (graphs, tables,
Observe
maps, etc.) showing achievements toward targets?
7 TB/Leprosy/HIV Units
7.1 TB/Leprosy Unit
7.1.1 Recording practice on Registers and tallies and other recording formats
7.1.1.1 Unit TB Register
Do they understand each data element on the register? Deep
dive and also ask if they understand the different treatment See the guide
outcome categories?
Do they record all required data on Register completely and
See the guide
correctly?
Do they understand and correctly complete cohort report? Interview
Do the documented data on the register legible?
Do they complete PICT Tally sheet? See the guide
7.1.1.2 TB contact Screening & LTBI treatment Follow up register
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do the documented data on the register legible?
7.1.1.3 Leprosy Register
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do the documented data on the register legible?
7.1.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table
Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)

340 HIS MENTORSHIP TRAINING MODULES

7.1.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently
Was performance versus plan compared for Key indicators
Ask and observe
and identify areas of improvement?
Were root causes of problems identified & action plan
prepared with responsible implementer assigned along with Review the action plan
time frame?

Does the facility prepare minimum data visuals (graphs, tables,

Observe
maps, etc.) showing achievements toward targets?

7.2 HIV unit

7.2.1 Recording practice on Registers and tallies and other recording formats
7.2.1.1 HTS Register
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do the documented data on the register legible?
Do they complete HTS tally sheet See the guide
7.2.1.2 ART Register
Do they understand each data element on the register? Deep
dive and ask if they understand the definition of survival See the guide
analysis and how to report?

Do they record all required data on Register completely and

See the guide
correctly?
Do they use all the tallies that are required for ART service
(Clinical care, currently on ART and ART by regimen tally See the guide
sheets)?
Do the documented data on the register legible?
Check by taking 3
Check for completeness of the intake form, and follow up form randomly selected ART
charts.

Do they understand all the required data item on the forms Interview
7.2.1.3 PEP Register
Do they understand each data element on the register? See the guide
Do they record all required data on Register completely and
- See the guide
correctly?
Do the documented data on the register legible?
Do they follow client for duration of treatment and outcome? See the guide
7.2.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table
Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)

PARTICIPANT MANUAL 341

7.2.3 Data use
Is there practice of monitoring performance/data use in the Observe documented
unit regularly on monthly basis? minute
Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently
Was performance versus plan compared for Key indicators
Ask and observe
and identify areas of improvement?
Were root causes of problems identified & action plan
prepared with responsible implementer assigned along with Review the action plan
time frame?
Does the facility prepare minimum data visuals (graphs, tables,
Observe
maps, etc.) showing achievements toward targets?
8 Inpatient department
8.1 Recording practice on Registers and tallies and other recording formats
8.1.1 IPD Register
Do they understand each data element on the IPD register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do they use the ESV_ICD 11 in the IPD register? See the guide
Are the data on the register consistent with the individual
See the guide
patient cards?
Do the documented data on the register legible?
Do they complete the IPD service tally sheet? See the guide
Do they prepare and complete ESV_ICD 11 tally sheet daily? See the guide
Do they complete PITC tally from IPD register? See the guide

Randomly Select five

MRNs of discharged pts
Do they complete Admission/Discharge card. from IPD register and
review the admission/
discharge card

8.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table

Do they check the data completeness on the register and

Check the minute
report regularly(Content completeness)

342 HIS MENTORSHIP TRAINING MODULES

8.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
time frame?

Does the facility prepare minimum data visuals (graphs, tables,

Observe
maps, etc.) showing achievements toward targets?

9 Intensive Care Unit

9.1 Recording practice on Registers and tallies and other recording formats
9.1.1 ICU register
Do they understand each data element on the ICU register? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?

Do they record diagnosis based on the ESV_ICD 11 in the

See the guide
register?

Do they complete the ESV_ICD 11 tally sheet? See the guide

Do they complete the IPD service tally sheet? See the guide

9.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table

Do they check the data completeness on the register and

Check the minute
report regularly(Content completeness)
9.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently
Was performance versus plan compared for Key indicators
Ask and observe
and identify areas of improvement?
Were root causes of problems identified & action plan
prepared with responsible implementer assigned along with Review the action plan
time frame?
Does the facility prepare minimum data visuals (graphs, tables,
Observe
maps, etc.) showing achievements toward targets?

PARTICIPANT MANUAL 343

10 Referral and Liaison Department
10.1 Recording practice on Registers and tallies and other recording formats
Referral register
Do they understand each data element on the referral
register? Deep dive and also ask if they record both referral See the guide
ins and outs
Do they record all required data on Register completely and
See the guide
correctly?
Do the documented data on the register legible?
Do they sum up the required data elements at the end of
See the guide
each page?
10.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level
Check the minute/
Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table
Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)
10.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
time frame?
Does the facility prepare minimum data visuals (graphs, tables,
Observe
maps, etc.) showing achievements toward targets?
11 Pharmacy services
11.1 Recording practice on Registers and tallies and other recording formats
Dispensing Register
Do they understand all the required data item? See the guide
Do they record all required data on Register completely and
See the guide
correctly?
Do they sum up the required data elements at the end of
See the guide
each page?
Do the documented data on the register legible?
Do they complete tracer drug availability Tally sheet? See the guide
Do they use fill supplier fill rate form?
11.2 Data quality practices
Check the minute/
Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

344 HIS MENTORSHIP TRAINING MODULES

 Check the minute/
Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table
Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)
8.3 Data use
Is there practice of monitoring performance/data use in the Observe documented
unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
time frame?

Does the facility prepare minimum data visuals (graphs, tables,

Observe
maps, etc.) showing achievements toward targets?

12 Laboratory Services
12.1 Recording practice on Registers and tallies and other recording formats
Laboratory register

Do they understand all required data item? See the guide

Do they record all required data on Register completely and

See the guide
correctly?

Do the documented data on the register legible?

Do they complete pregnancy test tally sheet daily? See the guide

12.2 Data quality practices

Check the minute/

Do they check the number on register, and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level
Do they check the data completeness on the register and
Check the minute
report regularly(Content completeness)
12.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
time frame?

Does the facility prepare minimum data visuals (graphs, tables,

Observe
maps, etc.) showing achievements toward targets?

PARTICIPANT MANUAL 345

13 Operation theater
13.1 Recording practice on Registers and tallies and other recording format
OR Register

Do they understand each data element on the OR registry? See the guide

Do the documented data on the register legible?

Do they record all required data on Register completely and

See the guide
correctly?
13.2 Data quality practices

Check the minute/

Do they check the number on register, tally and report to be
accuracy check table at
submitted prior to submission to HMIS Unit monthly
case team level

Check the minute/

Do they crosscheck Register against Medical records for crosscheck Register
selected indicators/data elements against Medical records
table

Do they check the data completeness on the register and

report regularly(Content completeness)

13.3 Data use

Is there practice of monitoring performance/data use in the Observe documented

unit regularly on monthly basis? minute

Do they understand the definitions and interpretations of their Select few indicators
program indicators and ask gently

Was performance versus plan compared for Key indicators

Ask and observe
and identify areas of improvement?

Were root causes of problems identified & action plan

prepared with responsible implementer assigned along with Review the action plan
time frame?

Does the facility prepare minimum data visuals (graphs, tables,

Observe
maps, etc.) showing achievements toward targets?

346 HIS MENTORSHIP TRAINING MODULES

Annex 3: Follow-up Health Facility Checklist
HIS Mentorship follow-up Checklist

I. Background Information

Background Info

Date of Visit # of mentoring visits Onsite ____ Remote: ____

Mentoring Facility Type Mentoring Facility Name

Mentee facility Type Mentee facility Name

Region Zone/Woreda

Mentor’s Level of Certified

Profession Organization Telephone Email Signature
Name Education (Y/N)

II. Review of previous visit action plan

Review previous /last visit action plan including priority problems, interventions, responsible
person and schedule.

Then, review what has been done so far, activities, what changes they realize and barriers they
faced in the process for each problem.

1.1. Priority problem one: ______________________________________________

 Suggested interventions: __________________________________________

Review tested changes Description

What did you try? (Review the plan)

• Describe details of what the mentee/team tried

What happened?
• Did everything (process) go as planned? Why or why not?
• What did or did not work?
• Is the process documented? (Observe)

Barriers
• What barriers or challenges did you encounter? How did you overcome
them? (observe if documented)

Measurement and Data Collection

• What was your measure?
• How did you collect data and report the change?

PARTICIPANT MANUAL 347

 Results (Study)
• What did you achieve this period/month? (describe the achievement)
(observe if documented)
• Observe whether the related indicator is displayed in run chart and
assist them on interpretation
• Did you appreciate any change on the program? (describe)
• What do you think of these results? How do you rate the result
(satisfactory, need improvement, need more work …)?

Act
• Should you keep this change? Stop it? Revise it?
• What would you recommend for next steps?
• Would you like to introduce other interventions?

Plan
• Discuss the process with the service delivery unit head/focal person.
• What is your plan for next month, until next visit? (mentor should assist
the mentee/team)

Documentation
• Check whether all the process is documented and give feedback

1.2. Priority problem two: ________________________________________

 Suggested interventions: _________________________________________

Review tested changes Description

What did you try? (Review the plan)

• Describe details of what the mentee/team tried

What happened?
• Did everything (process) go as planned? Why or why not?
• What did or did not work?
• Is the process documented? (Observe)

Barriers
• What barriers or challenges did you encounter? How did you
overcome them? (observe if documented)

Measurement and Data Collection

• What was your measure?
• How did you collect data and report the change?

Results (Study)
• What did you achieve this period/month? (describe the
achievement) (observe if documented)
• Did you appreciate any change on the program? (describe)
• Observe whether the related indicator is displayed in run chart
and assist them on interpretation
• What do you think of these results? How do you rate the result
(satisfactory, need improvement, need more work …)?

348 HIS MENTORSHIP TRAINING MODULES

 Act
• Should you keep this change? Stop it? Revise it?
• What would you recommend for next steps?
• Would you like to introduce other interventions?

Plan
• Discuss the process with the service delivery unit head/focal
person.
• What is your plan for next month, until next visit? (mentor
should assist the mentee/team)

Documentation
• Check whether all the process is documented and give
feedback

II. Other prioritized problems from Internal Mentoring

Ask the mentee whether s/he conducted internal mentoring since the last visit. Review the
prioritization step and review the problems. Support the mentee to identify interventions and
develop action plan.

Service Plan
Prioritized
S.N delivery What Means of
Problems When Where Who
unit (Intervention) verification
1
2
3

III. Mentee Competency Assessment

During each visit, the mentor should identify gaps on technical, behavioral or other competency
skill components of the mentee and should mentor on that specific area.

Provide Provide self-learning

Gaps identified
mentoring materials
1
2
3

IV. Closing

• Ask the team if they have any question that they would like to ask you. Is there anything
we can help them with on the next visit? Support/facilitation requested from QI team:

• Discuss a timeframe for your next visit. Date for next visit:_______________________

• Thank and praise the team for their work. Give words of encouragement.

Note: What you observed as a mentor should be documented properly.

PARTICIPANT MANUAL 349

Annex 4: Baseline Health Administration Units Checklist
Name of mentee institution:_______________________

Type of institution:_______________________

Name of Mentor(s):

1.________________________

2. ________________________

3. ______________________

4. __________________________

Date of Mentoring: ____________________

Yes/ Describe
1. The woreda health office has put in place the inputs needed to strengthen HIS Remark
No Why if No
The woreda health office has a well-organized monitoring and evaluation/
planning unit or sub-unit
A. The woreda health office have adequate staff for planning, HMIS or M &
E Unit as per the structure?
1.1
B. Dedicated office/Desk for planning/HMIS unit?

C. Presence of dedicated computer for HMIS/M&E unit?

At least six currently updated manuals which facilitate the implementation

of HIS are in place within the Woreda Health Office (accessibility should be
indicated, either hard or soft copy)

A. HMIS procedure/data recording and reporting?

1.2 B. HMIS Indicator Reference Guide?
C. All HMIS disease classification booklets (NCoD)?
D. Data quality Manual?
E. Data use Manual?
F. CHIS manual ?
2. Does the woreda health office has budget for any of the below activities
A Supportive Supervision?
B Review meeting ?

3. The Woreda Health Office has a system for timely supportive supervision with fixed
schedule

350 HIS MENTORSHIP TRAINING MODULES

 Previous action plan reviewed before conducting next
supportive supervision
3.1
A. YES
B. NO
The Woreda Health Office conducted supportive
3.2
supervision in the last quarter
Was the Supportive supervision done using checklist that
address HIS components?
A.Yes the check list addressed major components of HIS
3.3
B.Yes the check list addressed partially HIS
C.Checklist was used but it does not address HIS at all
D.Checklist was not used at all
Written supportive supervision report/feedback provided
3.4 to the health facilities (observing written document is
required)
Action plan with responsible person and time table
prepared to facilitate follow-up?
3.5
A. YES
B. NO
4. Capacity building and mentoring to strengthen the HIS in the past three months

Woredal health office capacity for mentoriship for HIS

4.1 A. There is trained mentors in the woreda
B. There is no trained mentors in the woreda
The Woreda Health Office conducted mentoring at least
once in the past three months-
4.2
A. YES
B. NO
Action plan with responsible person and time table
prepared to facilitate follow-up of gaps identified?
4.3
A. YES
B. NO
Does the woreda conducted HIS capacity need
assessment in the past six months?
4.4
A. YES, Observed
B. NOT Conducted
Does the WorHO addressed the HIS capacity gap based
on the findings?
4.5 A. YES, all are addressed
B. YES, Partially addressed
C. NOT addressed
5.Digitization of HIS

PARTICIPANT MANUAL 351

 DHIS2 functionality during the past three months?
A. YES functional, online
B. YES functional, offline
C. DHIS2 not functional at all

5.1 WorHO practice backup storage of data monthly from

DHIS2?
WorHO staff have access to DHIS2?
WorHO ensured the entry of denominator, baseline and
target in DHIS2?

Access to eCHIS dashboard by WorHO office head and

woreda HMIS focal person
5.2
A. YES
B. NO
The WoHO has a functional internet connectivity during
the past three months?
5.3
A. YES
B. NO
The WorHO regularly update master facility list
5.4 A. YES
B. NO
The woreda health office is currently using mBrana for
LLITN and vaccine supplies management
5.5
A. YES
B. NO
6. Governance and leadership
Does WorHO establish stakeholder or partner forum?
6.1 A. YES
B. NO
Does WorHO level established stakeholder or partner
forum meet regularly and monitor overall HIS performance
6.2
A. YES
B. NO
Section B: Data Quality
1 The woreda health office conducted RDQA
The woreda health office had conducted verification
1.1
component of RDQA in the last three months?
In the last three months, to what extent the woreda has
met the data accuracy target?
1.2 Calculate as total number of indicators whose data
verification is b/n 0.9 and 1.1 / Total number of indicators
for which data verifiction was done
Data quality gaps improvement action plan was prepared
based on data verification findings?
1.3
A. YES

B. NO

352 HIS MENTORSHIP TRAINING MODULES

 2 Report Completeness
The woreda Health Office keeps a log book that helps to
track reporting completeness?
2.1
A. YES
B. NO
2.2 Completeness of woreda adminstrative reports
Completeness of reports (representative) from the Primary
2.3 health care unit (Reports sent from the health center &
health post)
3 Report timeliness
3.1 Timeliness of woreda adminstrative reports
Health facilities in the woreda has submitted report
3.2
according to the national schedule

WorHO conducted report completeness, timeliness and consistency

analysis on monthly bases
4
A. YES
B. NO

WorHO provide written feedback on report completeness, timeliness and

5
consistency analysis monthly to health facilities.

Section C: Data Use

The Woreda based health sector (WBHS) plan:

A. The woreda has annual WBHS plan which is cascaded to health facilities
and WorHO case team

B. The woreda has annual WBHS plan and cascaded the plan to either
1
health facilities or WorHO case team

C. The woreda has WBHS plan but not cascaded to health facilities and
WorHO case team

D The woreda doesn’t have a WBHS plan at all

Performance management team(PMT) is in place and established according

to national standard

A. PMT is in place and the members are put together based on the national
standard
2
B. PMT is in place but the members are not put together based on the
national standard

C. PMT is not established at all

3 PMT is convening on a monthly basis with (50%+) members

PMT is chaired by the head of the Woreda Health Office or deligates as per
4
the national standard

PARTICIPANT MANUAL 353

 5 PMT is reviewing key performance indicators

The WorHO is tracking key coverage, quality and equity

5.1
indicators
5.1.1 The WorHO tracked key HMIS indicators (Plan versus
Performance for key indicators)
Calculate as total number of months where plan versus
performance for key indicators is done/total number of
months in the period

5.1.2 Evidence of analysis by any form of disaggregation

(Age, sex, urban/rural etc)?

A. YES
B. NO
Performance gaps are identified by comparing
achievement against target (At least once in the quarter)?
5.2
A. Yes
B. No
Root cause analysis is done for low performing key
indicators, at least once in the review period for priority
indicator
A. Root cause is identified for all low performing key
5.3 priority indicators

B. Root cause is identified for only some low performing

indicators

C. Root cause is not identified for all the low performing

indicators

Action plan is prepared for the identified priority

problems/challenges with roles and responsibilities,
resources and timeline

5.4 A. Action plan is prepared for all the identified priority

problems/challenges
B. Action plan is prepared for some of the identified
priority problems
C. Action plan is not prepared at all
The action plan is being implemented (previous action
plan reviewed before convening the subsequent PMT
meeting and what has been done and not done is
5.5
reviewed)
A. There is documented evidence for actions taken
B. No action is taken

PMT action plan/meeting minutes/feedback were

circulated to case teams: ( written minutes with formal
5.6
letter, can be made using social media platform or in
person by hardcopy)

Updated DHIS2 dashboard for the woreda’s selected key indicators

A. The woreda has an updated DHIS-2 dashboard for selected key
indicators
6
B. The woreda has a DHIS-2 dashboard for selected key indicators but it is
not updated
C. The woreda has never created a DHIS-2 dashboard for its key indicators

354 HIS MENTORSHIP TRAINING MODULES

 Written feedback was given to lower level supervisory unit on the
7
performance of Key indicators in the past three month
The Woreda Health Office has presented or disseminated analytic report
A. Every Quarter
8 B. bi-annually
C. Annually
D. None
The Woreda Health Office has displayed information in the form of table,
chart, etc. based on selected indicators in the office compound using local
language
A. Updated Information is displayed in the WoHO compound in local
10
language
B. Updated Information is displayed in the Woreda Health Office compound
in English
C. No information was displayed in the Woreda Health Office compound
The Woreda Health Office held performance review meeting with
community in the last quarter?
11
A. YES
B. NO
The Woreda Health Office held performance review meeting with health
facilities in the last quarter?
12
A. YES
B. NO
Presence of any change in performance, quality, equity as a result of use of
data for action
13
A. Yes
B. No
Section D: Data quality and performance review practices at department/case team
level

Does case team/Department level case team established

officially?(Observe the documents,any evidences)

Does each has plan(at least monthly,quarterly and annual plan)(Observe the
documets)

Does each started to practice performance review(Plan Vs achievement)

Woreda health office case team practiced team level data quality
review(From DHIS2 for their respective program)

PARTICIPANT MANUAL 355

Annex 5: Follow-up Health Administration Units Checklist
I. Background Information

Background Info

Date of Visit # of mentoring visits Onsite ____ Remote: ____

Mentoring HI Type Mentoring HI Name

Mentee HI Mentee HI Name

Region Zone/Woreda

Work place Certified

Name of Mentors Signature
& Title (Y/N)
1

I. Review of previous visit action plan

Review previous /last visit action plan including priority problems, interventions, responsible
person and schedule.

Then, review what has been done so far, activities, what changes they realize and barriers they
faced in the process for each problem.

2.1. Priority problem one: ______________________________________________

______________________________

• Suggested interventions: ___________________________________________

Review tested changes Description

What did you try? (Review the plan)

• Describe details of what the mentee/team tried

What happened?
• Did everything (process) go as planned? Why or
why not?
• What did or did not work?
• Is the process documented? (Observe)

Barriers
• What barriers or challenges did you encounter?
How did you overcome them? (observe if
documented)

356 HIS MENTORSHIP TRAINING MODULES

Measurement and Data Collection
• What was your measure?
• How did you collect data and report the
change?

Results (Study)
• What did you achieve this period/month?
(describe the achievement) (observe if
documented)
• Observe whether the related indicator is
displayed in run chart and assist them on
interpretation
• Did you appreciate any change on the
program? (describe)
• What do you think of these results? How do you
rate the result (satisfactory, need improvement,
need more work …)?

Act
• Should you keep this change? Stop it? Revise
it?
• What would you recommend for next steps?
• Would you like to introduce other interventions?

Plan
• Discuss the process with the service delivery
unit head/focal person.
• What is your plan for next month, until next visit?
(mentor should assist the mentee/team)

Documentation
• Check whether all the process is documented
and give feedback

2.2. Priority problem two: ________________________ _____________

_____________________________________

 Suggested interventions: ___________________________________________

Review tested changes Description

What did you try? (Review the plan)

• Describe details of what the mentee/team tried

What happened?
• Did everything (process) go as planned? Why or why not?
• What did or did not work?
• Is the process documented? (Observe)

PARTICIPANT MANUAL 357

 Barriers
• What barriers or challenges did you encounter? How did you
overcome them? (observe if documented)

Measurement and Data Collection

• What was your measure?
• How did you collect data and report the change?

Results (Study)
• What did you achieve this period/month? (describe the
achievement) (observe if documented)
• Did you appreciate any change on the program? (describe)
• Observe whether the related indicator is displayed in run
chart and assist them on interpretation
• What do you think of these results? How do you rate the
result (satisfactory, need improvement, need more work …)?

Act
• Should you keep this change? Stop it? Revise it?
• What would you recommend for next steps?
• Would you like to introduce other interventions?

Plan
• Discuss the process with the service delivery unit head/focal
person.
• What is your plan for next month, until next visit? (mentor
should assist the mentee/team)

Documentation
• Check whether all the process is documented and give
feedback

II. Other prioritized problems from Internal Mentoring

Ask the mentee whether s/he conducted internal mentoring since the last visit. Review the
prioritization step and review the problems. Support the mentee to identify interventions and
develop action plan.

Service Plan
Prioritized
S.N delivery What Means of
Problems When Where Who
unit (Intervention) verification
1

358 HIS MENTORSHIP TRAINING MODULES

 III. Case identification and Discussion (if any)

If the mentee identified any case during implementation, the mentor is expected to review the
case and solve the problem using different problem solving skills.

IV. Mentee Competency Assessment

During each visit, the mentor should identify gaps on technical, behavioral or other competency
skill components of the mentee and should mentor on that specific area.

Provide Provide self-learning

Competency gaps
mentoring materials
1
2
3

V. Closing

• Ask the team if they have any question that they would like to ask you. Is there anything
we can help them with on the next visit? Support/facilitation requested from QI team:
• Discuss a timeframe for your next visit. Date for next visit:_______________________
• Thank and praise the team for their work. Give words of encouragement.

Note: What you observed as a mentor should be documented properly.

Annex 6: Mentoring Log book

This logbook is used to document the major findings, solutions and recommendations provided
by mentors during mentoring. Once the baseline is conducted, every mentor should document/
update this log book at the end of each mentoring session.

Mentoring date (s)________________

Mentor’s name (s)________________

1.________________________ Signature: _____________Telephone: ______________

2.________________________ Signature: _____________Telephone: ______________
3.________________________ Signature: _____________Telephone: ______________

Recommendations
Solutions
Major HMIS related Gaps/challenges identified provided to the
provided on site
facility/institution
Problems identified in the MRU (For health facilities only)

Problems related to recording on registers and tally sheets (For

health facilities only)

Problems related to reporting

Problems related to data quality

Problems related to performance monitoring (Data Use)

Other issues identified during the mentoring session

PARTICIPANT MANUAL 359