Download - 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:
Documents review, Observe
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
documented and implementable policies and procedures
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:
Documents review, Interview staff,
Validate
Verifier:
Documents review, Interview staff,
Validate
Verifier:
Documents review, Observe
Interview staffValidate
Verifier:
Documents review, Interview staff,
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)
documented and implementable policies and procedures
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:
Documents review, Interview staff,
Validate
Verifier:
Documents review, Interview staff,
Validate
Verifier:
Documents review, Interview staff,
Validate
Verifier:
Documents review, Interview staff,
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
documented and implementable policies and procedures
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:
Documents review, Interview staff,
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
documented and implementable policies and procedures
Verifier:
Observe, Interview staff, Validate
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.
documented and implementable policies and procedures
Verifier:
Observe, Interview staff, Validate
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
14.Drugs are administered in a standardized and systematic manner in the provider organization
15.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
31.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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
32.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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
33.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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
34.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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.
Facilities and maintenance
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
42.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 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
43.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 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
Facilities and maintenance
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:
Documents review, Interview staff, Validate:
Diploma
Proof of
employment/appointment
Verifier:
Documents review, Interview staff, Validate:
Diploma
Proof of
employment/appointment
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:
Documents review, Interview staff, Validate:
Diploma/ Certificate of
units earned
Proof of
employment/appointment
Verifier:
Documents review, Interview staff, Validate:
Diploma/ Certificate of
units earned
Proof of
employment/appointment
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
1:12 beds at any time
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
1:3 beds at any time
1:3 beds at any time
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.
1:24 beds at any time
1:24 beds at any time plus 1 reliever
1:24 beds at any time plus 1 reliever
3.9 Nursing Attendant/ Midwife (CCUs)
-For every three (3) Nursing
Attendants/Midwives, there must be
one (1) reliever
1:15 beds at any time
1:15 beds at any time
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
12. Oxygen Unit (anchored)
1
1/OR
1/OR
13. Sphygmomanometer (non-mercurial)
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
16. Suction Apparatus
1
1/OR
1/OR
17. Thermometer, non-mercurial
1
1
1
17. Wheeled Stretcher
1
1
1
15x1
RECOVERY ROOM
1. Air-conditioning Unit
1
1
1
2. Bed with Guard Rail and wheel lock or anchor
1
1
1
3. Oxygen Unit (anchored)
1
1
1
4. Sphygmomanometer (non-mercurial)
1
1
1
Adult Cuff
1
1
1
Pediatric Cuff
1
1
1
5. Pulse Oximeter
1
1
1
6. Stethoscope
1
1
1
7. Suction Apparatus
1
1
1
LABOR ROOM
1.CTG Machine
2. Amniotome
3. Sphygmomanometer (non-mercurial)
4. Stethoscope
16x1DELIVERY ROOM ( IF APPLICABLE)
1. Air-conditioning Unit
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
3. Suction Apparatus
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
19. Suction Apparatus
1
1
2.7 19X1 INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1
1. Air-conditioning Unit
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
11. Sphygmomanometer (non-mercurial)
1
1
Adult Cuff (in adult units
1
1
Pediatric Cuff Set (in pediatric units)
1
1
12. Stethoscope
1
1
13. Suction Apparatus
1
1
14. Tracheostomy Set
1
1
15. Air-conditioning Unit
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
9. Sphygmomanometer (non-mercurial)
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
Not required if contracted out
Housekeeping
Area
WASTE HOLDING /STORAGE AREA (color coded)
28x1
DIETARY
29 29
NUTRITIONIST-DIETITIAN OFFICE OR AREA FOR LEVEL 2
Supply Receiving Area
Not required if contracted out
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
Signature over Printed Name
Signature over Printed Name
Signature over Printed Name
_______________________________
_______________________________
_______________________________
________________________________
Position
Position
Position
Position
_______________________________
_________