Doh Assessment Tool

TECHNICAL REQUIREMENTS

Department of Health

Bureau Of Health Facilities And Services (BHFS)

ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS

OUTLINE OF CONTENTS

(110Page 2 of 2)

Assessment Tool for Licensure of Hospitals Revision: 00 Effectivity date: 10/01/12Page 1 of 4

I. GENERAL INFORMATION(page 2)

II. HOSPITAL ADMINISTRATION

A. Services

1. Administrative Service(pages 3-9)

1.1. Human resource

1.2. Accounting

1.3. Budget and Finance

1.4. Billing and claims

1.5. Medical Records

1.6. Procurement

1.7. Property and Supply Management

1.8 Linen and Laundry

1.9 Housekeeping

1.8. Nutrition and Dietary

1.9. Security Services

1.10. Ambulance Services

1.11. Central Information Management

1.12. Medical Records

1.13. Medical Social Services

1.14. Nutrition and Dietetics

1.15. Pharmacy

2. Patients Rights and Organizational Ethics (pages 13-15)

2.

3. Patient care (pages15-22)

4. Leadership and Management (pages 23-24)

5. Human Resource Management (page 25)

6. Information Management (page26)

7. Safe Practice and Environment (pages 27-37)

8. Patient and Staff Safety

11.Waste Management (page 49-52)

12.Improving Performance (page 52)

13. Leadership and Management

A. Clinical Services(page 53)

1.Level 1

2.Level 2

3.Level 3

III. PERSONNEL

POSITION STAFFING REQUIREMENT(pages 54-57)

1. Top Management Personnel Qualification Standard

2. Administrative

3. Clinical

4. Nursing

5. Ancillary

III.

A.

B.

C.

IV. EQUIPMENT AND INSTRUMENTS ()

A. List of Equipment and Instrument Requirement

1. Administrative

2. Clinical

Emergency Room

Outpatient Care

Operating Room

Recovery Room

High Risk Pregnancy Unit

Delivery Room

Pathologic/ Premature Nursery

Intensive Care Unit

3. Nursing Unit/Ward

4. Isolation Room

5. Physical Medicine and Rehabilitation Unit

6. Central Sterilizing and Supply Room

7. Dialysis Clinic

8. Ambulatory Surgical Clinic

9. Dental Clinic

7. Dietary

V. PHYSICAL PLANT REQUIREMENT(67-71)

Required rooms/areas/offices

VI.HOSPITAL PROGRAMS(72-74)

1. Blood Services ( 72)

2. Newborn Screening(72)

3. Mother-Baby Friendly Hospital Initiative(73)

4. Health Promotion and Disease Prevention (73)

5. Generics Act (74)

6. Health Emergency Management Services74()

B.

C.

D.

VII.HOSPITAL COMMITTEES (page 75)

VII. HOSPITAL OPERATIONS CRITERIA(page 76)

I.

II.

VIII. SIGNATURE PAGE (page 77)

7 . Maintenance of Environment of Care (pages 37-40)

8. Patient Safety (page 41-49)

I. GENERAL INSTRUCTIONS:

1. Check to make sure that you have the complete tool with a total ofseven-eight(78) pages and copies of the SOE,SOM and NOV Forms.

2. Assign sections of the tool to corresponding team members.

3. To properly fill-out this tool, the Regulatory Officer shall make use of: INTERVIEWS, REVIEW OF DOCUMENTS, OBSERVATION and VALIDATION of findings.

4. If the corresponding items are present or available, place a on each of the appropriate boxes alongside each corresponding item. If not, put an Xinstead.

5. The REMARKS column shall document relevant observations both positive and negative, including innovations and initiatives undertaken by those responsible in the facility.

6. Make sure to fill-in the blanks with the needed information. Do not leave any items blank; writeN.A.if not applicable.

7. (Sh shaded cell means that specific items are not applicable to the hospital level.

8. means the service can be outsourced but must be inside hospital premises.

9. The Team Leader shall at the end of the inspection or monitoring visit, make sure that the team members complete their respective tool section and proceed to accomplish the Summary of Evaluation (SOE) or Summary of Monitoring (SOM) Form and if warranted, the Notice of Violation (NOV) Form.

10. The Team Leader shall ensure that all team members write down their printed names, designation and affix their signatures and indicate the

date of inspection or monitoring,all at the last page of the Assessment Tool, on the SOE and SOM Forms and if warranted, also on the NOV Form.

11. The Team Leader shall make sure that the Head of the facility or, when not available, the next most senior or responsible officer affix his/her signature on the same aforementioned pages and indicate the position, to signify that inspection or monitoring results were discussed during the exitconference and a copy of the SOE or SOM and, only if warranted, that of the NOV, were received.

12. This shall also serve as self-assessment tool for facility owners and monitoring tool.

GENERAL INFORMATION:

Name of Hospital:

Address:

(Number &Street)(Barangay/District)

(110Page 2 of 2)

(Municipality/City) (Province &Region)

Telephone No./ Fax No.

E-mail Address:

License No (for renewal):

Date IssuedExpiry Date:

Hospital Category: Level 1 Level 2 Level 3

Philhealth Accreditation:Center of: Safety QualityExcellence

Classification According to Ownership: Government Private

No. of: Authorized Bed Capacity Implementing Beds

Name of Owner or Governing Body (if corporation):

Name of Hospital Administrator, Medical Director or Chief of Hospital

CODE

STANDARDS

CRITERIA

INDICATOR

SELF-ASSESSMENT

DOH INSPECTION

DOH MONITORING

EVIDENCE

AREA

REMARKS

HOSPITAL ADMINISTRATION:

Goal- To be responsiveto the requirements of quality health service delivery, health regulation, health financing andgood governance.

1.1.1

1.1.1.a

1.1.1.a.1

ADMINISTRATIVE AND FINANCE SERVICE: The AFS shall ensure adequate and timely financial and direct support services to all hospital units.

Administrative Group:

Human Resource Management

There shall be a comprehensive human resource management plan which includes recruitment, selection, promotion, separation, welfare and benefits in accordance with applicable laws.

Documented and implementable policies and procedures

Approved documented policies, guidelines and procedures on:

a) Staffing plan

b) Recruitment and

Selection

c) Hiring/Appointment

d) Orientation & Staff

Development

e) continuing education, and

training

Approved documented policies, guidelines and procedures on

a) Staffing plan

b) Recruitment and Selection

c) Hiring/Appointment

d) Orientation & Staff

Development

e) continuing education, and training

Complete, updated and

easily retrievable

individual personnel file

Evidence of continuous

improvement

Verifier:

Documents review, Observe

Interview staff, Validate

List of personnel check if

Current

:

f) Performance Evaluation

g) Rotation/Transfer

h) Succession Plan

i) Merit, Promotion, Awards

& Incentives

j) Resignation, Termination

and Retirement

k) Physical Examination

record of schedule of duties

appointment/employment

contract, if valid

updated health certificate (as required)

orientation plan/program of new employees implemented

record of schedule of duties

appointment/employment contract, if valid

updated health certificate (as required)

orientation plan/program of new employees implemented

Verifier:


Interview staff, Validate

List of personnel check if

Current

1.1.1.b

1.1.1.b.1

1.1.1.b.2

1.1.1.b.3

1.1.1.b.4

Financial ManagementGroup

Accounting

There shall be a systematic

recording of all financial

transactions, preparation of

financial statements and

relevant reports, and

maintenance and safekeeping of Books of Accounts.

Budget

There shall be a consolidation and preparation of the Budget Proposal, Work and Financial/ Operational Plans including its implementation and monitoring by the hospital staff concerned

Billing And Claims

There shall be a system of billing patients and processing of claims.

Procurement:

There shall be a comprehensive plan of systematic management of procurement and acquisition of supplies, materials,

healthcare equipment, vehicles, services, infrastructure work and other required logistics for the effective and efficient delivery of quality services

documented and implementable policies and procedures



Policies, guidelines and procedures on requisition, purchase, issuance and inventory; disposal of non-functional equipment, instruments, supplies, expired drugs and medicines and reagents are in place.

Documents are readily

available

Look for approved Work and Financial Plan and its implementation

Proof of transactions

Verifier:

Documents review, Interview staff,

Validate

Verifier:


Validate

Verifier:


Validate

Verifier:


Interview staffValidate

Verifier:


Validate

1.1.1.b.5.

1.1.1.b.6.

1.1.1.b.7

1.1.1.b.8

1.1.1.b.9

Property and Supply Management:

There shall be a systematic way of receipt, storage, issuance and conduct of inventory .

Linen and Laundry

There shall be adequate supply of clean linens for patients and other hospital units.

Housekeeping

There shall be provision and maintenance of clean, safe and sanitary facilities and environment for hospital personnel, patients and clients

.Security

There shall be order within the hospital premises and protection of lives, properties and critical infrastructure from threats, harm and losses

AmbulanceServices

(Compliance to A.O. 2010-0003- National Policy on Ambulance Use and Services)


Sorting of soiled and contaminatedlinens in designatedareas

Systematic washing of laundry with safeguard against spread of infection

Disinfection of laundry

Adequate

housekeeping

supplies.

Security check for internal and external customers including use of visitors pass

Documented and approved policies and procedures on patient transport to and from the facility

Documents are readily

available

Policies, procedures and guidelines in cleaning and washing of soiled linens

evidence of continuous review of policies and procedures

evidence of continuous review of policies and procedures

Verifier:


Validate

Verifier:


Validate

Verifier:


Validate

Verifier:


Validate

1.1.1.c.

Central Information Management

There shall be a comprehensive plan of systematic management of data and research for the improvement of acquisition, utilization of finances, assets and development of human resources, operating systems and procedures.

24 hour availability of ambulance for ready use

Available contract/ MOA, if contracted out

Logbook on transport of patients/clients by ambulance to and from the facility


With appropriate manpower, equipment and supplies during patient transport

If contracted out; note specifications in contract or MOA

Verifier:

Documents review, Observe,

Interview staff&Validate

1.1.1.d

1.1.1.e

Medical Records

There shall be an organized system of recording, processing, analyzing, maintaining and safekeeping of all patients' records through the written data in sequence of events covering the diagnosis, treatment and discharge of patients

Medical Social Services

There shall be policies and procedures in place pertaining to social case work, multisectoralnetworking and linkages in understanding the socio- behavioral and economic plight of patients and their families for the holisticapproach in theirmanagement and treatment

Documented and implementable policies and procedures

ICD-10 reference books and with additional ICD-10 modification

Logbooks on:

Admission

OR

DR

ER

OPD

Approved documented policies and procedures and records on:

a)Patient classification according to their capacity to pay

b) Continuity of care

c) Counselling of patients/clients and their families

d) Records of pre-admission and pre- discharge assessment, and discharge plan

Available contract or MOA with DSWD or the LGU whenever applicable

(for private hospitals) Allocation of not less than 10% of its Authorized bed capacity as charity beds.

Compliance to RA 9439, An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses, (IRR, AO No. 2008-0001)

Verifier:


Validate

Verifier:

Observe, Interview staff, Validate

1.1.1.c.

1.1.1.c.

1.1,1.f

1.1.1.b.

Nutrition And Dietetics

There shall be maintenance and provision of safe, high quality and nutritious food to patients and personnel.

Actual implementation and evidence of continuous review of policies and procedures

If contracted out; note specifications in contract or MOA


Verifier:


1.1.1.b.1.1.1.g

Pharmacy

There shall be 24 hours, 7 days a week provision of safe, affordable and efficacious drugs and medicines in accordance with the Generics Act, PNDF and DOH policies, rules and regulations.


Verifier:


CODE

STANDARDS

CRITERIA

INDICATOR

SELF-ASSESSMENT

DOH MONITORING

EVIDENCE

AREA

REMARKS

REMARKS

DOH INSPECTION

2.1

PATIENTS RIGHTS AND ORGANIZATIONAL ETHICS

Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations

2.1.1

1.Organizational policies and procedures respect and support patients' right to

to quality care and their responsibilities in that care.

quality care and their responsibilities in that care.

Informed consent is obtained from patients prior to initiation of care.

All patient charts have signed consent.

DOCUMENT

Patient charts sample charts of patients currently admitted. If hospital is department-alized, get samples during tour of the differentdepartments.

Note: *Informed consent - includes a patient-doctor discussion of the following issues: the nature of the decision or procedure; reasonable alternatives to the proposed intervention; the relative risks, benefits, and uncertainties related to each alternative; assessment to patient understanding; and patient's acceptance or refusal of the intervention.

Wards

(sample size-10 charts, if department-alized, get two from each depart-ment; when a chart is found to have no consent before you reach 10, you do not have to go further.)

2.1.2

2.The organization informs the community about the services it provides and the hours of their availability.

Clinical services are appropriate to patients' needs and the former's availability is consistent with the organization's service capability and role in the community.

Presence of facilities consistent with clinical service capability based on DOH license in accordance with the hospitals level (e.g. level 1 surgical capability, level 2 ICU, level 3 teaching and training hospital).

DOCUMENT REVIEW

List of services available

OBSERVATION:

Look at the facilities, structure, manpower, equipment and supply. Check if the service capability of the hospital is in accordance with thehospital level.

ER

OPD

ICU

OR

RR

PACU

2.2

PATIENT CARE

2.2.1

ACCESS - Goal: The organization is accessible to the community that it aims to serve.

2.2.1.a

3.Physical Access to the organization and its services is facilitated and is appropriate to patients' needs.

Entrances and exits are clearly and prominently marked, free of any obstruction and readily accessible.

Presence of entrances and exits that are readily accessible and free from obstruction.

OBSERVATION

Entrances and exits are accessible and free from any obstruction.

Note: Exit signs should be luminous or illuminated and prominently marked. There should be exit signs in major areas of the hospital and all doors leading to the outside.(Reference: RA 6541 Building Code of the Philippines)

ER

OPD

Wards

ICU

OR/RR/

DR/PACU

Imaging

Laboratory

2.2.1.b

4.Physical access to the organization and its services is facilitated and is appropriate to patients' needs.

Directional signs are prominently posted to help locate service areas within the organization.

Presence of directional signages to locate service areas.

ER

OPD

Wards

Directional signs are prominently posted. Check ER, OPD, wards and lobby.

Other Areas Lobby

2.2x1.c

5.Physical access to the organization and its services is facilitated and is appropriate to patients' needs.

Alternative passageways for patients with special needs (e.g. ramps) are available, clearly and prominently marked and free of any obstruction.

Presence of alternative passageways (ramps, elevators) that are prominently marked and free from obstruction for patients with special needs

ER

OPD

.

OBSERVATION 1.There are alternative passageways for patients with special needs. Check ER, OPD, wards and other areas

Wards

2. They are prominently marked and

Other

areas

.

3. They are free from obstruction

2.2.2

ENTRY

Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment

2.2.2.a

6.The organization uniquely identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel.

All patients are correctly identified by their patient charts.

All patients are correctly identified by their charts.

DOCUMENT and INTERVIEW

Patient chart from ER, ward, OPD and ICU and verify with patient if he/she really is the person indicated in the chart.

ER

OPD

Wards

ICU

2.2.3

ASSESSMENT

Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.

2.2.3.a

7.Each patient's physical, psychological and social status is assessed.

An appropriately comprehensive history and physical examination is performed on very patient within 24 hours from admission. The history includes present illness, past medical, family, social and personal history.

All patients have comprehensive history and PE within 24 hours from admission.

CHART REVIEW

Wards

ER

DOCUMENT

Patient chart from wards or ER.

NOTE: comprehensive history includes present illness, review of systems, past medical, family and personal history.

2..2.3.b

8.Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.

Previously obtained information is reviewed at every stage of the assessment to guide future assessments.

All patient charts have progress notes by doctors.

CHART REVIEW

Medical Records Office

Patient chart from medical records

Note: The progress notes should be done regularly and documented in the patient chart either as separate progress notes sheet or side notes in the doctors order sheet.

2.2.3.c

9.Assessments are performed regularly and are determined by patient's evolving response to care.

Qualified personnel give patients for surgery pre-operative physical and pre-anesthetic assessment.

All patients for surgery have undergone pre-operative anesthetic assessment.

CHART REVIEW

Note: Look for pre-operative anesthetic evaluation in the patient chart. Pre-operative assessment should be done for patients requiring more than local anesthesia.

2.3

IMPLEMENTATION OF CARE

Goal: Care is delivered to ensure the best possible outcomes for the patients

DOCUMENT REVIEW

Monitoring reports, e.g..utilization review of diagnostics exams done, audit reports, manual of procedures, or DOH monitoring reports e.g.. Quality control diagnostic reports (QC reports on softwares, calibration of diagnostic equipment, film reject analysis, etc.)

2.3.1

10.Diagnosticexaminations appropriate to the provider organization's service capability and usual case mix are available andare performed by qualified personnel.

Policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations are documented and monitored.

Proof of monitoring of the implementation of the policies and procedures on quality control of diagnostic examinations

X-ray

Laboratory

2.3.2.a

11.Drugs are administered in a standardized and systematic manner in the provider organization.

12.Drugs are administered in a standardized and systematic manner in the provider organization.

Drugs are administered in a timely, safe, appropriate and controlled manner.

Only qualified personnel order, prescribe, prepare, dispense and administer drugs.

All drugs are administered in a timely, safe, appropriate and controlled manner to the right patient

All doctors, dentists,nurses and pharmacists have updated licenses

.For the timeliness of drug administration, check the hospital policy. If hospital does not have policy, frequency of drug administration in the chart should be checked and validate it thru patient interview

Note: Surveyor may also check for administration of any of the following: antibiotics, anticonvulsants, MgSO4, KCl drip and other drips, calcium gluconate, sodium bicarbonate, etc. For oral medications, do direct observation

Randomly check the licenses of doctors,dentists, nurses and pharmacists.

Chart Review

Wards

Pharmacy

OPD

ER

2.3.2.b

2.3.2.c

2.3.2.d

13.Drugs are administered in a standardized and systematic manner in the provider organization



Prescriptions or orders are verified and patients are identified before medications are administered.

Prescriptions or orders are verified and patients are identified before medications are administered.

Drug administration is properly documented in the patient chart.

Proof that the prescriptions or orders are verified before medications are administered.

All charts have proper documentation of drug administration

.

DOCUMENT

Procedures on verification of orders. INTERVIEW

Observe if staff verifies the prescriptions or orders for drugs with the doctor and the drug against the doctor's orderNote: This is on a case to case basis; includes the route of administration (slow IV) and other precautionary measures/instruction e.g.. ANST

INTERVIEW

Verify from patients if they were correctly identified prior to drug administration.

OBSERVATION

Observe if the staff verifies the identity of patient prior to administration of medications.

CHART REVIEW

Medication sheet in patient chart from the medical records.

Medical Records Room

2.4EVALUATION OF CARE

Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the

needs of the patient are continuously met.

2.4.1

16. The discharge plan

is part of the patient's

careplan and is

documented in the

patient chart.

All charts have discharge plans.

CHART REVIEW

Patient chart from medical records, look at the discharge

orders. It should contain all of the following:

1. May go home order

2.Home medications (if applicable)

3. Follow up visits/schedule

4. Home care/advise

Note: Discharge plan is not synonymous with dischargesummary.

2.5LEADERSHIP AND MANAGEMENT

2.5.1Management team

Goal: The organization effectively and efficiently governed and managed according to its values and goals to

ensure that care produces the desired health outcomes, and is responsive to patient's and community needs.

17.

2.5.1.a

2.5.1.b

17.The organization regularly reviews and updates its policies, guidelines and procedures

18.Terms of reference, membership and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved.

Strategically Posted Vision and Mission of all the Services

Approved Manual of Operations and/ or Written Policies, Guidelines and Procedures on Clinical Services Offered

Strategically Posted Functional and Organizational Chart with Photos Showing Names andRelationship by Positions

Proof of the creation of all committees within the organization which includes the terms of reference for membership

OBSERVATION

DOCUMENT REVIEW

2.5.1.c

19.The organization's management team regularly assesses its own performance and the performance of the organization.

Presence of evaluation and monitoring activities to assess management and organizational performance

INTERVIEW

1. Ask the management team about priorities for performance improvement that relate to hospital wide activities and patient outcomes

2. Ask management team how targets are set.

2.6External Services

Goal: The organization ensures that services provided by external contractors meet appropriate standards

2.6.1

20.Documented

agreements and contracts cover external service

providers and specify that the quality of services provided must be consistent with appropriate set

standards.

Presence of MOA/contract for all outsourced services (e.g. dialysis unit, dietary, laboratory, radiology).

(Outsourced are services/ facilities provided by third party but are inside the hospital)

DOCUMENT REVIEW

1.Contracts/MOA for outsourced services.

2.Valid licenses of all providers of the outsourced services.

Document review

OBSERVATION Actual presence of the outsourced services within the hospital if applicable

Imaging

Laboratory

Other areas

Note: The contracts/MOA should be updated. MOA is sufficient for some hospitals where the outsourced services are not within the facility.

3.1

3.1.1

Human Resource Management

Human Resource Planning

Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and

external customers and to achieve its goals.

3.1.1.a

3.1.1.b

21.Planning ensures

that appropriately

trained and qualified

(and where relevant,

credentialed) staff are

available to

undertake the type

and level of activity

22.performed by the

organization. This

includes those who

are consulted when

suitable expertise is

not available within

the organization.

23.Workload is monitored and

appropriate guidelines consulted to

ensure that appropriate staff

numbers

and skill mix are available to achieve

desired patient and organizational

outcomes.

24.Relevant, accurate , quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.

The organization documents and follows policies and procedures for hiring, credentialing, and privileging of its staff

Staff numbers and skill mix are based on actual clinical needs.

Policies and procedures on records storage, retention and disposal are documented and monitored.

Presence of policies and procedures for credentialing and privileging of staff.

DOCUMENT REVIEW

Policies and procedures for credentialing and privileging of staff

.

Staff to bed ratio for licensed doctors, nurses and midwives/Nursing Aides follow the DOH prescribe ratio.

Policy on records storage, retention and disposal.

DOCUMENT REVIEW

1. List of total number of licensed doctors and dentists, registered nurses and midwives/ nursing aides based on HR records and

2. The schedule of duties for the previous and current month

3. Number of beds applied for and the actual being used.

OBSERVATION

Number of beds

DOCUMENT REVIEW

Policies and procedures on record storage, safekeeping and maintenance, retention and disposal.

Wards

document review

4.1 DATA COLLECTION, AGGREGATION AND USE

Goal: Collection and aggregation of data are done for patient care, management of services, education and research.

4.2

RECORDS MANAGEMENT

Goal: Integrity, safety, access and security of records are maintained and statutory requirements aremet.

4.2.1

Medical Records

4.2.1.a

25.There shall be an organized

system of processing,

analyzing, maintaining and safekeeping of all patients' records through the written

data in sequence of events

covering the diagnosis,

treatment and discharge of patients.

When patients are admitted or are seen for ambulatory or emergency care, patient charts documenting any previous care can be quickly retrieved for review, updating and concurrent use.

Presence of policies and procedures on systematic filing, retrieval, disposal and management of medical charts, contents include the following:

-Doctors Progress Notes

-Informed Consent

-Problem List

Clinical and Graphic Record of Vital Signs (TPR sheet)

-Personal History and Physical Examination records

-Newborn Record and Physical Maturity Rating, if warranted

Doctors Progress Notes

-Medication and Treatment Record

-Laboratory and X-ray Reports

-Dietary Assessment

-Nurses Progress Notes

-Records of Transfer/Referral to Another Physician or Health Facility

-Inpatient Referral/Consultation Notes of Other Physicians

-Final Diagnosis

Advance Directive, if any

DOCUMENT REVIEW

(Note also the following:

1. ICD-10Coding is being used.

2. Medical Records Officer is trained on ICD-10 Coding.

4.2.1.b.1

26.Clinical records

are readily accessible to facilitate patient care, are kept confidential and safe, and comply with all

relevant statutory

requirements and codes of practice.

The organization has policies and procedures and devotes resources including infrastructure to protect records and patients charts against loss, destruction, tampering and unauthorized access or use. Only authorized individuals make entries in the patient chart.

Presence of procedures to protect records and patients charts against loss, destruction, tampering and unauthorizedaccess or use.

DOCUMENT REVIEW

Polices and procedures on records management for the entire hospital to maintain privacy, accuracy and prevent loss and destruction.

OBSERVATION

Observe 20 nurses in the wards and records personnel on how they protect patient chart against loss, tampering and unauthorized use.

Document review

6x1

6x1.1

SAFE PRACTICE AND ENVIRONMENT

PATIENT AND STAFF SAFETY

Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective

environment of care.

6x1.1.a

6x1.1.b

27.The organization plans a safe and effective environment of care consistent with its mission, services, and

with laws and regulations.

28.The organization plans a safe and effective environment of care consistent with its mission, services, and with laws and regulations.

The organizational environment complies with structural standards and safety codes as prescribed by law.

There are management plans which address safety, security, disposal and control of hazardous materials and biological wastes

Emergency and disaster preparedness, fire safety, radiation safety and utility systems.

Presence of a management plan addressing safety, security, disposal and control of hazardous materials and biologic wastes, emergency and disaster preparedness, fire safety, radiation safety and utility systems.

If facility has nuclear medicine, ask for the certificate issued by the Philippine Nuclear Research Institute (PNRI).

DOCUMENT REVIEW

Management plan which includes polices, procedures and programs, risk assessment, hazards surveillance among others that address the following:

1. Safety

2. Security

3. Disposal and control of hazardous materials/biologic wastes

4. Emergency and disaster preparedness

5. Fire safety

6. Radiation safety

7. Utility systems

Note: The hospital must have plans for all the elements enumerated in the criteria. Plans should have guiding policies and specificprocedures.

6x1.1.c

29.The organization plans a safe and effective environment of care consistent with its mission, services, and with laws and regulations.

There are management plans for the safe and efficient use of medical equipment according to specifications.

Presence of operating manuals of the medical equipment.

Document review

ER

OPD

WardsICUOR/DR/RRFacilities and maintenanceImaging

Laboratory

Others

DOCUMENT

.

Operating manuals for the medical equipment

6x1.1.d

30.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.

Policies and procedures that address safety, security, control of hazardous materials and biological wastes, emergency and disaster preparedness, fire safety, radiation safety and utility systems are documented and implemented.

Proof of implementation of the policies, procedures and safety programs on

Document review

1. Water safety - water analysis results for the past 6 months.

1. electrical safety

2. Fire and emergency preparedness - check for exit plans, plans for earthquake and other disasters.

3. Control of hazardous materials - MOA/Contract of outsourced services for waste management

INTERVIEW

1. Ask staff from ER, Wards, OPD, Laboratory, Pharmacy, and facilities and maintenance on the manner of waste segregation and disposal (general waste, liquid & solid waste, infectious waste; non-infectious, hazardous and non-hazardous

2. Hospital safety program

3. Mechanical safety program of the hospital

2. medical device safety

ER

3. chemical safety

OPD

4. radiation safety

Wards

5. mechanical safety

Imaging

6. water safety

Laboratory

7. combustible material safety

Pharmacy

8. waste management

Facilities and

maintenance

9. hospital safety program (fire, emergency and disaster preparedness)

Other areas

OBSERVATION

1. Electrical safety - check for exposed wires and sockets, octopus connections"

2. Emergency preparedness - check for evacuation plans, presence of fire extinguishers

3. Control of hazardous waste - waste disposal system, segregation of waste, proper labeling of waste receptacles

4. Chemical safety - check safe storage and disposal of reagents

DOCUMENT

1. Quality control programs and corrective and preventive maintenance programs

2. Record of disposal of radiologic wastes

3. Preventive and corrective maintenance logbook

4. Film reject analysis test results

INTERVIEW

Ask staff about their role in the hospital waste management program particularly manner of radiologic waste disposal.

OBSERVATION

6x1.1.e

.

.

DOCUMENT REVIEW

Presence of policies and procedures for the safe and efficient use of medical equipment

Document review

(including the implementation of DOH AO# 2008-0021on the gradual phase-out of mercury)

6x1.1.f


Policies and procedures for the safe and efficient use of medical equipment according to specifications are documented and implemented

Proof of the implementation of the policies and procedures for the safe and efficient use of medical equipment.

ER

DOCUMENT

Wards

1. Operating manual

OR/RR/DR

2. Preventive and corrective maintenance logbook

Facilities and maintenance

3. Qualifications of staff handling medical equipment

Imaging

Laboratory

INTERVIEW

1. Ask staff in the ER, ICU, wards, OR/RR/DR, facilities and maintenance, imaging and laboratory about the policies and procedures for use of medical equipment and their role in the implementation of such policies and procedures.

Other areas

2. Ask staff in the ER, wards, ICU and OR/RR/DR for the hospital's program on the gradual phase-out of mercury.

6x1.1.g


The design of patient areas provides sufficient space for safety, comfort and privacy of the patient and for emergency care.

Presence of adequate space, lighting and ventilation in compliance with structural requirements (for patient safety and privacy).

ER

OBSERVATION

OPD

1. Adequate space

Wards

2. Adequate lighting (lights are working, lighting is adequate enough for conduct of

general activities)

3. Adequate ventilation

ICU

OR/RR/DR

Imaging

Laboratory

Pharmacy

6x1.1.h


Risks are identified, assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used.

Presence of policies and procedures on risk identification, assessment and control.

Document review

DOCUMENT REVIEW

Policies and procedures on risk identification, assessment and control, security risks, use of personal protective equipment, etc.

6x1.1.i


A coordinated security arrangements in the organization assures protection of patients, staff and visitors

Presence of an appointed personnel in charge of security.

Hospital order or memo DOCUMENT REVIEW

Contract of security agency or appointment of in-house security

Document review

or Appointment of person in charge of security

Other areas

INTERVIEW

Ask the personnel in charge of security what the policies on security of the hospital are OBSERVATION

Presence of security guard/s or personnel in charge of security

7x1 MAINTENANCE OF THE ENVIRONMENT OF CARE

Goal: A comprehensive maintenance program ensures a clean and safe environment.

7x1.1

35.The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care

An incident reporting system identifies potential harms, evaluates causal and contributing factors for the necessary corrective and preventive action.

Presence of incident reporting system/sentinel event monitoring system (which may include nosocomial infections, unexpected deaths, adverse drug reactions, flood transfusion reactions, falls, etc).

DOCUMENT REVIEW

Minutes of Leadership meeting

Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events

"Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge.

INTERVIEW

Ask readers and staff from wards and ER how the incident reporting system works.

Wards

ER

ICU

OR

7x1.2

36. Emergency light and / or power supply, water and ventilation systems are provided for, in keeping with relevant statutory requirements and codes of practice.

Presence of generator/emergency light, water system, adequate ventilation or air conditioning.


DOCUMENT

Other areas

Preventive and corrective maintenance logbooks for generator/ emergency light/ water tanks/ aircons

OBSERVATION

1. Presence of generator/emergency light, water tanks, adequate ventilation or air conditioning

2. Test if faucets and water closets are working

7x1.3

37.Equipment is serviced only by people trained in the maintenance of that equipment. Registers and records of equipment and related maintenance are kept.

Proof of training of the staff who is in charge of the maintenance of the equipment.

DOCUMENT REVIEW

Proof of training of service personnel if in-house or Certificate of Training, attendance sheet, Certificate of Attendance, diploma, citation or MOA/Contract for outsourced services (verify qualification of technicians).

Facilities and

maintenance

INTERVIEW

Ask about how equipment (generator, airconditioner, medical devices and other equipment etc.) are maintained.

7x1.4

38.Current information and scientific data from manufacturers concerning their products are available for reference and guidance in the operation and maintenance of plant and equipment.

.

Presence of operating manuals equipment

Facilities and

maintenance

DOCUMENT

Imaging

Operating manual of generators, air conditioners and other non-medical equipment.

Laboratory

Other areas

8x1

INFECTION CONTROL

Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel,

visitors and trainees are identified and

8x1.1.a

39.An interdisciplinary infection control program ensures the prevention and control of infection in all services.

Presence of an Infection Control

Committee (ICC) with defined goals, objectives, strategies and priorities or for a primary hospital - a designated doctor and nurse in-charge of infection control.

DOCUMENT

REVIEW

DOCUMENT REVIEW

1. ICC composition (for a primary hospital - proof of designation of a doctor and nurse in-charge of = in2. ICC functions and activities fection control)

3. Minutes of meeting, at least quarterlyactivities

4. Statistics on nosocomial infections

INTERVIEW

Ask a member of the ICC regarding infection control program of the hospital.

8x1.1.b

40.An interdisciplinary infection control program ensures the prevention and control of infection in all services.

Presence of an infection control program ensuring prevention and control of infections on all services.

DOCUMENT REVIEW

1. Policies and procedures on prevention and control of nosocomial infection or Infection control manual

2. Policies on rational anti-microbial use based on the hospital antibiogram in coordination with Microbiology laboratory and Pharmacy Therapeutics Committee

3.Reports of infection control activities e.g.

training,outbreakinvestigation, preventive programs

8x1.2.a

41.The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections.

The organization takes steps to prevent and control outbreaks of nosocomial infections.

Presence of coordinated system-wide procedure for isolation of nosocomial infections.

Document review

DOCUMENT REVIEW

Procedures on isolation of nosocomial infections

ER

INTERVIEW

Wards

Ask= staff in ER, wards and ICU the procedures on isolation

ICU

isolation - physical isolation of a patient with infection

8x1.2.b



Presence of coordinated system-wide procedure for case containment of nosocomial infections.

DOCUMENT REVIEWProcedures on case containment of nosocomial infections

Document

review

ER

Note: case containment - means prevention of spread of infection

Wards

examples: reverse isolation, prophylaxis for exposed personnel, vaccination, immunization

ICU

INTERVIEW

.

Validate from staff in ER, wards and ICU the procedures on case containment

8x1.2.c



Presence of coordinated system-wide procedure for asepsis.

DOCUMENT REVIEW

Procedures on asepsis

INTERVIEW

Ask staff from ER, wards, laboratory and ICU about the approaches for asepsis during diagnostic and treatment procedures.

ER

Wards

ICU

Laboratory

8x1.3.a

44.The organization uses a coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties.

There are programs for prevention and treatment of needle stick injuries, and policies and procedures for the safe disposal of used needles are documented and monitored.

Presence of policies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles.

DOCUMENT REVIEW

1. Policies and procedures for prevention and treatment of needle stick injuries

2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks

ER

Wards

INTERVIEW

ICU

.

Interview hospital staff on how they handle and dispose needles

Laboratory

OBSERVATION

Presence of receptacles for proper disposal of sharps.

8x1.3.b

45.The organization uses a coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties.

There are programs for the prevention of transmission of airborne infections, and risks from patients with signs and symptoms suggestive of tuberculosis or other communicable diseases are managed according to established protocols.

Presence of program on prevention of transmission of airborne infections and risks from patients with signs and symptoms suggestive of tuberculosis or other communicable diseases.

DOCUMENT REVIEW

1. Infection control procedures on isolation and universal precaution

ER

2. Program for the protection of healthcare workers e.g. personal protective equipment (PPEs)

Wards

3. Policies on all patient admission/referral, isolation and timely case reporting of highly transmissible and notifiable infectious disease e.g. meningococcemia, SARS, avian flu, etc.

ICU

4. Hand hygiene procedures

Laboratory

5. Environmental care and healthcare waste management

6. Procedures on recycling & reuse of equipment i.e. personal protective equipment

INTERVIEW

Validate hospital policies on infection control such as use of PPEs, isolation precautions and hand washing.

OBSERVATION

1. Observe for use of gloves, surgical masks.

OR/DR

3. Look for separate holding area/room for highly infectious cases.

4. Ask a hospital staff to demonstrate hand washing technique.

Ward

ER

OR/DR

8x1.4

46.Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and maintenance of associated environment, conform to relevant statutory requirements and codes of practice.

Presence of policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies.(Refer to Annex__ Sterilization Guidelines in Hospital Setting)

DOCUMENT REVIEW

1. Policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments andsupplies.

2. Policies on decontamination, disinfection, sterilization, disinfectants for specific medical equipment/items and area.

3. Housekeeping procedures in specific patient areas.

8x1.5

47.When needed, the organization reports information about infections to personnel and public health agencies.

Presence of policies and procedures on reporting of infections to personnel and public health agencies.

DOCUMENT REVIEW

Presence of policies, procedures and guidelines for safe reuse of items which comply with relevant statutory requirements.

DOCUMENT REVIEW

INTERVIEW

Ask heads and staff about the following:

1. Policy on reuse of items

2. SOPs on reuse

3. Reporting

4. Personnel in charge

9x1

ENERGY AND WASTE MANAGEMENT

Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies

to achieve environmental sustainability

9x1.1

48.The handling, collection, and disposal of waste conform to relevant statutory requirements and codes of practice.

Presence of licenses/permits/ clearances from pertinent regulatory agencies implementing among others the following: RA 9003, RA 6969, RA 275, PD 1586 DOH Hospital Waste Management Manual, RA 8749 (Clean Air Act

DOCUMENT REVIEW

Pertinent licenses/permits from regulatory agencies (LGU, DENR, etc.)

9x1.2

49.The organization implements a waste disposal program which involves reuse, reduction and recycling.

Proof of implementation of policies and procedures on waste disposal.

DOCUMENT REVIEW

1. Issuances - memos, guidelines on waste disposal

ER

2. Contracts with waste handlers or disposal contractors, (if applicable)

Wards

3. Hospital policy that conforms to the joint DOH-DENR circular on waste management for LGUs

ICU

INTERVIEW

Ask staff regarding SOPs on actual procedure waste disposal.

OBSERVATION

1.Waste Segregation of waste

2.Proper labeling of waste receptacles

3.Recyclable waste staging areas

4. Proper management of temporary storage areas prior to hauling for disposal.

Imaging

Laboratory


9x1 IMPROVING PERFORMANCE

Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of internal and external clients.

9x1.1

50.The organization has a planned systematic organization- wide approach to process design and performance measurement, assessment and improvement

51.The organization provides better care service as a result of continuous quality improvement activities.

Presence of Quality Improvement Program

Presence of patient satisfaction survey

DOCUMENT REVIEW

1. Policy creating the QI program

2. Proof of meetings or similar documents of QA Committee activities

3. Policies and procedures on a performance measurement and improvement

INTERVIEW

Validation of alI activities thru interview of pertinent staff including frontliners and Committee members. DOCUMENT REVIEW

1.Patient satisfaction survey results

2.Patient satisfaction survey questionnaire(may check on the domains and items)

CODE

POSITION STAFFING

REQUIREMENT I:

(Top Management Positions)

CRITERIA

INDICATOR

SELF-ASSESSMENT

DOH INSPECTION

DOH MONITORING

EVIDENCE

AREA

REMARKS

10x1

10x2

Hospital Administrator

Medical Director/ Chief of Hospital or Medical

CenterChief

For level 1, must have completed at least 20 units towards a Masters Degree in Hospital Administration or Related CourseANDat least 3 years experience in a supervisory/ managerial position

For levels 2 and 3,must have completed a Masters Degree in Hospital Administration or Related Course or at least 5 years experience in a supervisory managerial position

Verifier:

Documents review, Interview staff, Validate:

Diploma/ Certificate of units earned

Proof of

employment/appoint-ment

10x4

10x4

Chief of Clinics/Chief

Medical Professional

Services

Department Head

For levels 2 and 3,must be a Diplomate/ Fellow in a Specialty area AND at least 5 years experience in a supervisory/managerial position

For levels 2 and 3, must be a Diplomate/ Fellow in a Specialty Society of the Specialty Department he/she heads

Verifier:


Diploma

Proof of

employment/appointment

Verifier:


Diploma

Proof of


10x5

10x6

Chief Nurse/Director

of Nursing/Deputy

Director for Nursing

3.5 Administrative

Officer

For level 1, must

have completed at

least 9 units towards a

Masters Degree in

Nursing AND at least 2

years experience in

nursing supervisory/managerial position

For levels 2 and 3, must have a Masters Degree in Nursing AND at least 5 years experience in a nursing supervisory position

For level I, must have completed at least 20 units towards a Masters Degree in Hospital Administration or Related Course AND at least 3 years experience in a supervisory /managerial position.

For levels 2 and 3, must have completed a Masters Degree in Hospital Administration or Related Course AND at least 5 years experience in a supervisory managerial position.

Verifier:


Diploma/ Certificate of

units earned

Proof of


Verifier:


Diploma/ Certificate of

units earned

Proof of


SELF ASSESSMENT

DOH INSPECTION

DOH MONITORING

REMARKS

CODE

POSITION STAFFING REQUIREMENT II

LEVEL 1

LEVEL 2

LEVEL 3

11x1

ADMINISTRATIVE

1.1 Chief of Hospital /Medical

Director/Medical Center Chief

1

1

1

1.2 Administrative Officer

1

1

1

1.3 Clerk:

- Pool

1:50 beds

1:50 beds

1:50 beds

- Accounting

1

1

1

- Medical Records

1:50 beds

1:50 beds

1:50 beds

- Cash Clerk

0

1

1.4 Accountant

1

1

1

1.5 Budget /Finance Officer

1

1

1.6 Bookkeeper

1

1

1

1.7 Billing Officer

1

1

1

1.8 Cashier

1

1

1

1.9 Human Resource Mgt. Officer

1(designate)

1

1

1.10 Training Officer

1(designate)

1

1

1.11 Medical Records Officer (ICD

trained)

1

1

1

1.12 Supply Officer

1

1

1

1.13 Storekeeper/ Linen Custodian

1

1

1

1.14 Laundry Worker

1

1:50 beds

1:50 beds

1.15 Utility Worker

1/Shift

1:50 beds/shift

1:50 beds/shift

1.16 Security Guard

1/shift

1/entrance/exit per shift

1/entrance/exit per shift

1.17 Engineer

1

1

1.18 Medical Equipment/Biomedical Technician

1

1

1.19 Maintenance Personnel

1

1/shift

1/shift

1.20 Mechanic

0

0

1

1.21 Nutritionist-Dietitian (for level 2 and in case of sharing, must be residing within the locality)

1(sharing is allowed e.g. hospital and municipal/city government)

1:100 beds

1:100 beds

1.22 Cook

1

1:100 beds

1:100 beds

1.23 Food Service Worker

0

1:50 beds

1:50 beds

1.24 Food Service Supervisor

0

1

1

1.25 Medical Social Worker (For level 1, If there is MOA with DSWD-LGU, the Medical Social Worker should be physically present in the hospital)

.1

1

1

11x2

Clinical:

2.1 Chief of Clinics/Chief Medical

Professional Services

1

1

2.2 Department Head

1/

department

1/

department

2.3 Consultant Physician (Diplomate/

Fellow of a Specialty/ Sub-Specialty Society after a formal residency training program)

((number not prescribed))

2.4 Physician (must not go on duty more than forty-eight (48) hours continuous duty)

1:20 beds at any time plus 1 reliever

50 beds = 6

Every additional 50 beds = additional 2

100 beds = 8

Every additional 50 beds = additional 3

( For Departments with accredited residency training program, number will depend on the requirement of specialty board concerned).

11x3

Nursing:

3.1 Chief Nurse/Director of Nursing

1

1

1

3.2 Asst. Chief Nurse (maybe

designated as

Training Officer)

0

100 beds and above=1

100 beds and above=1

3.3 Supervising Nurse

1:50 beds

50 beds and below = 1,

51-100 beds = 2,

101-150 beds = 3,

151 beds and above = 4

1 per department /special area

3.4 Supervising Nurse (Critical Care

Units)

-CCUs include all types of ICUs,

including Post-Anesthesia Care Unit

(PACU) and RR

1 per critical care unit

1 per critical care unit

3.5 Head Nurse

1:15 RNs

1:15 RNs

1:15 RNs

3.6 Staff Nurse

-For every three (3) RNs, there

must be one (1) reliever)

1:12 beds at any time



3.7 Staff Nurse (CCUs)

-Base the ratio on the actual number

of occupied CCU beds at the time of

inspection



3.8 Nursing Attendant/ Midwife

-Optional if the Authorized Bed

Capacity (ABC) is less than twenty-

four (24) beds. If the ABC is 24

beds and above, the ratio will apply.




3.9 Nursing Attendant/ Midwife (CCUs)

-For every three (3) Nursing

Attendants/Midwives, there must be

one (1) reliever



3.10Operating Room Nurse

1/shift

1/shift( may increase depending on the average number of OR cases per day)

1/OR/shift( may increase depending on the average number of OR cases per day)

3.1 Delivery Room Nurse

1 per/shift

1/shift( may increase depending on the average number of deliveries per day)

1/DR/shift( may increase depending on the average number of deliveries per day)

3.12 Emergency Room Nurse

1/ shift

1 shift

1/Dept/shift

3.13 Out-Patient Department Nurse

1

1

1/Dept.

11x4

.ALLIED MEDICAL PERSONNEL

4.1Pharmacist (full-time,registered);

must be physically present while

the retail outlet is open for

business)

Adequate

Adequate

Adequate

4.2. Pathologist

1

1

1

4.3 Med. Technologist (full-time,

registered)

Adequate

Adequate

Adequate

4.4 Other Lab. Personnel (specify)

Adequate

Adequate

Adequate

4 5Dentist

1

1

2

4.6Dental Aide

1

1

2

4.7Radiologist

1

1

2

4.8Radiology Technologist

Adequate

Adequate

Adequate

4.9 Radiation Safety officer

1(designate)

1(designate)

1

4.10 Physical Therapist

1

4.11 Respiratory Therapist( may be on call for level 2)

REQUIRED NUMBER

CODE

STANDARD REQUIREMENT

Level 1

Level 2

Level 3

SELF ASSESSMENT

DOH INSPECTION

DOH MONITORING

FINDINGS

(Indicateactual

no. equipment

& instruments)

REMARKS

REMARKS

12x1

EQUIPMENT/INSTRUMENT REQUIREMENT

1.ADMINISTRATIVE

1. Computer/Typewriter

1

1( may depend on the need)

1 ( may depend on the need)

2. Ambulance (Available 24 hours, 7 days

a week and physically present)

(Refer to A.O. 2010-0003- National Policy on

Ambulance Use and Services)

1

1

1

3. Standby Generator with Automatic Transfer

Switch (ATS) (KVA may depend on the load)

1

1

1

4. Emergency Light

1/station/

lobby/

stairways

1/station/lobby/stairways

1/station

/lobby/ stairways

5. Fire Extinguisher

1/room/unit

1/room/unit

1/room/unit

6. Overhead Projector/ LCD

1

1

1

13x1

CLINICAL

EMERGENCY ROOM

1. Ambu Bag

Adult

1

1

1

Pediatric

2. Clinical Weighing Scale

1

1

1

3.Defibrillator

1

1

1

4. ECG Machine

1

1

1

5. EENT Diagnostic Set

1

1

1

6. Emergency Cart (complete with ER

Medicines.) See ann3ex for the list and

quantity.

1

1

9. Examining Table

1

1

1

10. Examining Table with stirrup

1

1

1

11. Gooseneck Lamp/Examining Light

1

1

1

12. Instrument Table

1

1

1

13. Laryngoscope with Different sizes of Blades

1

1

14. Medicine Cabinet

1

1

1

15. Minor Surgery Instrument Set

1

1

1

16. Nebulizer

1

1

1

17. Neurological Hammer

1

1

1

18. Oxygen Unit (anchored)

19. Pulse oximeter

1

1

1

20. Sphygmomanometer (non-mercurial)

1

1

1

Adult Cuff

1

1

1

Pediatric Cuff

1

1

1

21. Stethoscope

1

1

1

22. Suction Apparatus

1

1

1

23. Suturing Set

1

1

1

24. Thermometer (non-mercurial)

25. Tracheostomy Set

1

1

1

26. Vaginal Speculum Set

1

1

1

27. Wheelchair

1

1

1

28. Wheeled Stretchers with guard and wheel lock

or anchor

1

1

1

14x1OUTPATIENT CARE

1. Clinical Weighing Scale

1

1

1

2. ECG Machine

1

1

1

3. EENT Diagnostic Set

1

1

1

4. Gooseneck Lamp/Examining Light

1

1

1

5. Examining Table with wheel lock or anchor

1

1

1

6. Instrument Table

1

1

1

7. Minor Surgery Instrument Set

1

1

1

8. Neurological Hammer

1

1

1

9. Oxygen Unit

1

1

1

10.Sphygmomanometer (non-mercurial)

1

1

1

Adult Cuff

1

1

1

Pediatric Cuff

1

1

1

11. Stethoscope

1

1

1

12. Suture Removal Set

13. Thermometer, non-mercurial

1

1

1

13. Vaginal Speculum Set

1

1

1

14. Wheelchair

1

1

1

2.3OPERATING ROOM

1. Air-conditioning Unit

1

1/OR

1/OR

2. Anesthesia Machine

1

1/OR

1/OR

3. Cardiac Monitor with pulse oximeter

PulseOximeter

1/OR

1/OR

4. C/S Set

1

1

1

5. Instrument Table

1

1/OR

1/OR

6. Laparotomy Set

1

1/OR

1/OR

7. Laryngoscope with Blades

1 set

1 set/OR

1 set/OR

8. Major Surgical Instrument Set

1

1/OR

1OR

9. OR Light

1

1/OR

1/OR

10.OR Table

1

1/OR

1/OR

11. Ortho Instrument Set

1

1

1


1

1/OR

1/OR


1

1/OR

1/OR

Adult Cuff

1

1/OR

1/OR

Pediatric Cuff

1

1/OR

1/OR

14. Spinal Set

1

1/OR

1/OR

15. Stethoscope

1

1/OR

1/OR


1

1/OR

1/OR

17. Thermometer, non-mercurial

1

1

1

17. Wheeled Stretcher

1

1

1

15x1

RECOVERY ROOM


1

1

1

2. Bed with Guard Rail and wheel lock or anchor

1

1

1


1

1

1


1

1

1

Adult Cuff

1

1

1

Pediatric Cuff

1

1

1

5. Pulse Oximeter

1

1

1

6. Stethoscope

1

1

1


1

1

1

LABOR ROOM

1.CTG Machine

2. Amniotome


4. Stethoscope

16x1DELIVERY ROOM ( IF APPLICABLE)


1

1/DR

1/DR

3. D/C Set

1

1/DR

1/DR

4. Delivery Set

1

1/DR

1/DR

5. DR Light

1

1/DR

1/DR

6. DR Table with Stirrup

1

1/DR

1/DR

7. Foetoscope (Doppler)

1

1

1/DR

8. Instrument Table

1

1/DR

1/DR

9. Kelly Pad

1

1/DR

1/DR

10.Oxygen Unit, Anchored

1

1/DR

1/DR

11.Sphygmomanometer (non-mercurial)

1

1/DR

1/DR

12.Stethoscope

1

1/DR

1/DR

13.Suction Apparatus

1

1/DR

1/DR

14.Wheeled Stretcher

1

1

1

15.Bassinet

1

1

1

16.Infant Weighing Scale

1

1

1

17X1

HIGH RISK PREGNANCY UNIT

xxxxxxxxxxx

(NOT REQUIRED IN LEVEL 1)

xxxxxxxxxxx

1. Cardiac Monitor

2. Fetal Monitor (CTG Machine)

xxxxxxxxxxx

1

1


xxxxxxxxxx

1

1

4. Oxygen Unit, Anchored

xxxxxxxxxx

1

1

18X1 NEONATAL INTENSIVE CARE UNIT

1. Bassinet

1

1

2. Bili Light

1

1

3. Cardiac Monitor

1

1

4. Emergency Cart

1

1

5. Umbilical Cannulation Set

1

1

6. Laryngoscope with Neonatal Blades

1

1

7. Examining Light

1

1

8. Incubator

1

1

9. Infant Ambu Bag

1

1

10.Infant Weighing Scale

11.Oxygen Unit

1

1

12.Respirator/Mechanical Ventilator

1

1

13.Radiant Warmer

1

1

14. Infusion Pump/Syringe Pump

1

1

15. Glucometer

1

1

16. Nebulizer

1

1

17. Pulse Oximeter

1

1

18. Neonatal Stethoscope

1

1


1

1

2.7 19X1 INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1


1

1

2. Ambu Bag

Adult (in adult units)

1

1

Pediatric (in pediatric units)

1

1

3. Bed with Guard Rail

1

1

4. Cardiac Monitor

1

1

5. Defibrillator

1

1

6. ECG Machine

1

1

7. Emergency Cart with emergency

Medicines(Refer to annex for medicines and supplies)

1

1

8. Endotracheal Tube

1

1

9. Laryngoscope with Blades

1

1

10. Oxygen Unit

1

1


1

1

Adult Cuff (in adult units

1

1

Pediatric Cuff Set (in pediatric units)

1

1

12. Stethoscope

1

1


1

1

14. Tracheostomy Set

1

1


1

1

16. Pulse Oximeter

1

1

1

17. Mechanical Ventilator

1

18. Infusion Pump

1

1

2.8 20x1 NURSING UNIT OR WARD

1. Ambu Bag

Adult (if Adult ward)

1

1

1

Pediatric ( if Pediatric ward)

1

1

1

2. Clinical Weighing Scale (per nursing unit)

1

1

1

3. ECG Machine

1

1

1

4. Emergency Cart or its equivalent(per

nursing unit)

1

1

1

5. Mechanical Bed/Patient Bed with Side Rails

(According to Authorized Bed Capacity)

Actual count

Actual count

Actual count

6. Bedside Table corresponds to total beds

_

_

_

2.Laryngoscope with different Sizes of Blades

7. Nebulizer

1

1/Medical/

Pediaward

1/Medical/

Pedia ward

Neurological Hammer

1

1

1

8. Oxygen Unit, Anchored

(may increase depending on the need)

1

1

1


Adult Cuff

1

1

1

Pediatric Cuff

1

1

1

10.Stethoscope

1

1

1

13.Suction Apparatus

1

1

1

11.Thermometer (non- mercurial)

CE 21X1 CENTRAL STERILIZING & SUPPLY ROOM

1. Autoclave ( may increase depending on

the need)

1

1

1

2.Steam Sterilizer ( may increase depending

on the need)

0

1

1

22X1

DENTAL CLINIC

1. Dental Chair

1

1

1

2. Operating Stool per Dental Chair

1

1

1

3. Autoclave

1

1

1

4. Air Compressor

1

1

1

5. Dental X-ray

1

1

1

6. Mouth Mirror Explorer

1

1

1

7. Explorer, double end

1

1

1

8. Scalerjacquettes set No. 1,2,3

1

1

1

9. Low speed hand piece (angled head)

1

1

1

10. Cotton pliers

1

1

1

11. High speed hand piece with

bur remover

1

1

1

12. No.150 forceps (maxillary universal

1

1

1

forceps)

13. No.151 forceps (lower universal

forceps)

1

1

1

14 .No.150 s forceps (primary teeth)

1

1

1

15. No. 8L and No18R forceps(upper molar)

1

1

1

16. No.151A forceps (mandibular premolar)

1

1

1

17. No.17 forceps

1

1

1

18. No.15 S forceps (lower primary teeth)

1

1

1

Rongeur forceps

1

1

1

19. Surgical chisel and mallet

1

1

1

20.. Bone file

1

1

1

21. Surgical Scissor

1

1

1

22. Root elevator

1

1

1

23. Periostal elevator No. 9 double end

1

1

1

24. Gum Separator double end

1

1

1

25.Cowhorn forceps

1

1

1

26. Bonefile Stainless end

1

1

1

A 2

DIALYSIS CLINIC- Not required for Levels 1 and 2.

(Refer to AO 2012-0001 New Rules and RegulationsGoverning the Licensure and Regulation of Dialysis Facilities in the Philippines

Use checklist for Dialysis facility

24 2 UNI

AMBULATORY SURGICAL CLINIC

Use checklist for Ambulatory Surgical Clinic

PHYSICAL MEDICINE and REHABILITATION UNIT

Bicycle Ergonometer

Electric Stimulator

1

1

1

Exercise plinth/bed

1

1

1

Overhead pulley

1

1

1

Exercise stair with rails

1

1

1

Paraffin wax

1

1

1

Parallel bars with postural mirrors

1

1

1

TENS

1

1

1

Ultrasound

1

1

1

Ultrasound

1

1

1

DIETARY

Exhaust Fan

1

1

1

Food Scale

1

1

1

Garbage Receptacle with Cover

Osterizer/ Blender

1

1

1

1

1

1

Oven

1

1

1

Push Cart

1

1

1

Refrigerator/Freezer

1

1

1

Stove

1

1

1

Utility Cart

1

1

1

Cx1 27x1

PHYSICAL PLANT-

REQUIRED ROOMS AND AREAS:

Level 1

Level 2

Level 3

Lobby

Waiting Area

Information and Reception

Communication Booth (Area for level 1)

Toilet

Admitting Office ( Area for level 1)

(May be comined)

Med. Records Office/Room

Business Office(may be combined with

Admin Office for level 1)

Billing

Cashier

Budget and Finance

Personnel Office (may be combined with Administrative Office for level 1)

Office of the Admin. Officer

Office of Chief of Hospital

Office of the Chief of Clinics/Chief

Medical Professional Services

Conference and Training Room

Library

Staff Toilet

Property/ Supply Office /Room for level

Laundry and Linen Room or Area

Receiving and

Releasing Area

Sorting and Washing

Area

Pressing and Ironing

Area

Storage Area

Not required if contracted out

Engineering /Maintenance Office for Level 2

Maintenance Area

Motor Pool Area


Housekeeping

Area

WASTE HOLDING /STORAGE AREA (color coded)

28x1

DIETARY

29 29

NUTRITIONIST-DIETITIAN OFFICE OR AREA FOR LEVEL 2

Supply Receiving Area


Cold and Dry Storage Area

Food Preparation Area

Toilet

Cooking and Baking Area

Washing Area

Serving and Food Assembly

Dining Area

Garbage and Disposal Area

30

SOCIAL SERVICE OFFICE

31

MORGUE for Level 3, Cadaver Holding Area

for Level 1 and 2

Pathologist Office

Autopsy Area

Shower Area

Toilet

32

Clinical Service

33

29x1

EMERGENCY ROOM (MAY BE COMBINED WITH OPD FOR LEVEL 1)

Waiting Area

Toilet (adjacent or w/in ER)

Nurse Station

Examination& Treatment Area with

Lavatory

Observation Area

Equipment & Supply Storage Area

Wheeled Stretcher Area

Decontamination Area for level

and 3

Holding Area for Infectious Cases

Doctors Quarter (with toilet)

34

3

OUTPATIENT DEPARTMENT (MAY BE

COMBINED WITH ER FOR LEVEL 1)

Waiting Area

Toilet (accessible)

Admitting and Records Area

Consultation Area (required)

Examination & Treatment Area

With Lavatory

35

OFFICE OF THE DEPT. HEADS

Medicine

Pediatrics

OB-GYNE

Surgery

(May be combined)

Anesthesia

Emergency Medicine

36

OPERATING ROOM (MAY BE

COMBINED WITH DELIVERY ROOM

I ONE COMPLEX FOR LEVEL 1)

Major OR

Minor OR

Recovery Room

Sub-Sterilizing/Work Areas

Sterile Instrument /Supply

Storage Area for sterile packs

Storage Area for supplies

Scrub-up Area

Clean-up Area

Male Dressing Room and Toilet

Female Dressing Room and Toilet

Nurse Station/Work Area

Wheeled Stretcher Area

Janitors Closet

33x1

37

OBSTETRICS OPERATING ROOM

(MAY BE COMBINED WITH SURGICAL

OPERATING ROOM FOR LEVEL 1)

33x1.a

38

DELIVERY ROOM

Labor Room with Toilet

Equipment and Supply Storage

Area for level

Sub-Sterilizing/Work Area

Equipment and Supply Storage

Area for level

Scrub-up Area

Clean-up Area

Male Dressing Room with Toilet

Female Dressing Room with Toilet

Wheeled stretcher area

Janitors Closet

3934x1

NEONATAL INTENSIVE CARE UNIT

Work Area with Sink

Newborn Care Area with Sink

Treatment Area

Viewing Area

Breastfeeding Area with lavatory

NURSING UNIT/WARD

Nurse Station

Toilet

Patient Area

Dressing Area

Equipment & Supply Storage Area

Patients Room (Separate Male from

Female)

Toilet ( Separate Male & Female)

Isolation Room with Toilet

Utility Area

Linen Area

Toilet

Treatment Area

Medication Area w/ lavatory

With Color-Coded Waste Bins

Janitors Closet

Nursing Office; Office of Chief

Nurse

Toilet

36x1

39

ISOLATION ROOM

Ante room with lavatory and PPE rack

Windows and doors including ante

room are closed and air tight or leak

proof

Handwashing Facility/Hand Disinfection

Toilet

37X1

40

DIALYSIS CLINIC (not required in levels 1 and 2)

Refer to A.O. 2012-0001, Regulation

of Dialysis Facilities in the Philippines

38X1

41

AMBULATORY SURGICAL CLINIC(not required in level 1 AND 2)

Required rooms /areas depend on the

surgical procedures the clinic is

capable of performing

43

PHYSICAL MEDICINE /REHABILITATION UNIT (not required in level 1)

40X 40 40X

44

DENTAL CLINIC

Consultation room

Toilet

3x1 41x1

45

CENTRAL SUPPLY ROOM

Receiving and Cleaning Area

Inspection Area

Packaging Area

Sterilizing Area

Sterile Supply Storage Area

Releasing Area

PRAYER ROOM, AREA FOR LEVEL 2

CODE

STANDARDS

CRITERIA

INDICATORS

SELF ASSESSMENT

DOH INSPECTION

MONITORING

EVIDENCE

AREA

REMARKS

41

41x1

B.HOSPITAL/ HEALTH

PROGRAMS:

1.Blood Services

Compliance to RA 7719

and its IRR, AO 2008-

0008 Levels 1 and 2,

should be at least a

Blood StationFacility and level 3, Blood Bank Facility

Documented policies:

To ensure adequate supply of safe blood and blood products.

blood and blood products obtained from blood service facilities licensed by DOH

for BC, blood and blood products collected, obtained from healthy voluntary

blood donors only

Actual implementation and evidence of continuous review of policies and procedures

41x1.a

1.2Level 3 hospital should be a Blood Bank (BB) facility

Documented policies:

To ensure adequate supply of safe blood and blood products

Blood and blood products obtained from blood service facilities licensed by DOH

For BC, blood and blood products collected, obtained from healthy voluntary blood donors only

41x2

41x2,a

2.Health Promotion

and Disease Prevention

2.1 Newborn Screening

- Compliance to

RA9288and its

IRR

Documented policies regarding Newborn

Screening

Logbook of Newborns who were tested and copies of waiver for those who were not screened

41x3

a)

b)

c)

41x3.a

2.2 Mother-Baby Friendly

Hospital Initiative

- Compliance to RA

7600 and its IRR

and R.A. 10028

and its IRR

- Milk Code (EO

No. 5

Documented policies regarding Rooming-In and practice of Breastfeeding

There should be no nursery for normal newborns

Breastfeeding area should be provided at the pathologic nursery

Certification as Mother Baby Friendly Hospital

Certification as Mother Baby Friendly

Workplace

41x4

2.3Healthy Lifestyle

Advocacy

Documented policies and SOPs specific to the program

41x5

41x6

41.7

2.4 Family Planning

2.5. Immunization

(Republic ActNo. 309)

2.6. Anti-Smoking

Program

(per RA 9211)

Documented implementation and practices

Documented implementation and practices

Documented policies

No smoking signages posted at conspicuous areas

41x8

41x8.a

41x9

41X9.a

3.Generics Act of 1988

(R.A.6675)

1. e-EDPMS- R.A.7581Price Act

of 1992; R.A. 9502Universally

Accessible Cheaper and Quality

Medicines Act of 2008

4. Health Emergency

Management

Service(HEMS)

A.O. No. 2004-0168, National

Policy on Health Emergencies

and Disasters

Documented policies

implementing the EDPMS

in compliance with DOH

A.O. No.2008-0014Guidelines on the

Pilot Implementation of the

e-EDPMS and A.O. No.

2011-0012 Implementing

Guidelines on Electronic Drug Price Monitoring System Version 2.0

Verifier:

Visit hospital pharmacy and document review, Validate

With designated HEMS

Coordinator

Documented Health

Emergency

Preparedness, Response and Recovery Plan

Conduct of

drills/exercisesi.e, Fire,

Earthquake, etc.

(For fire, it should be

supervised by the

Bureau of Fire

Protection).

Actual implementation and evidence of continuous review of policies and procedures; reports on uploading of essential drug prices, etc.

Hospital/Office order designating one

Proof of implementation of the plan.

Documentation of

drills/exercises conducted.

Evacuation Plan/Route posted in every room/area

Document review

CODE

42

C.HOSPITAL COMMITTEES:

Written Designation of Members and their roles/functions

Written Policies and Procedure

Updated and Relevant Minutes of Meeting

Reports/ Records of Implementation

REMARKS

42x1

1.Credentials

42x2

2.Blood transfusion

42x3

3.HIV/AIDS Core Team

42x4

4.Waste Management

42x5

5.Patient Safety

40x6

6.Infection Control

40x7

7.Pharmacologic/Therapeutics

428

8.Health Emergency/

Crisis Management

42x9

9.CQI

42x10

10.Tissue

(for levels 2 and 3 only)

42x11

11.Ethics

(for levels 2,and 3only)

42x12

12.Grievance

(for levels 2, and 3only)

42x13

Other committees, please

specify

Verifier: Documents review and Interview staff

CODE

43

D.HOSPITAL OPERATIONS:

(The following Criteria

Requirements are applicable

only to levels 2 and 3 ).

SERVICES (levels 1 & 2) / DEPARTMENT (level 3)

OPD

Emergency

Medicine

OB/ Gyne

(Delivery Room)

Pediatrics

OR

Surgery

Anesthesia

Rehab

REMARKS

43x1

1.Clinical Practice Guidelines

(CPG)

43x2

2.Recording, Reporting,

Records Keeping

43x3

3.Inter/Intra Departmental

Referrals

43x4

4.Disaster

Management/Crisis

Management

43x5

5.Infection Control

43x6

6.Drug Management and

Control

43x7

7.Blood Service

43x8

8.Pre-Operative and Post-Op

Care

43x9

9.Triaging (when applicable)

43x10

10.Referrals/ Transfer

43x11

11.Others, please specify

ASSESSED BY:

_______________________________

_______________________________

_______________________________

________________________________

Signature over Printed Name




_______________________________

_______________________________

_______________________________

________________________________

Position

Position

Position

Position

_______________________________

_________