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Department of Health Bureau Of Health Facilities And Services (BHFS)

ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS

OUTLINE OF CONTENTS I. GENERAL INFORMATION(page 2)

II. HOSPITAL ADMINISTRATION

A. Services 1. Administrative Service (pages 3-8)

1.1. Human Resource1.2. Accounting1.3. Budget and Finance1.4. Billing and Claims1.5. Procurement1.6. Property and Supply Management1.8 Linen and Laundry

1.9 Housekeeping 1.7. Nutrition and Dietary1.8. Security Services1.9. Ambulance Services1.10. Central Information Management1.11. Medical Records (Including Dental

Records)1.12. Medical Social Services1.13. Nutrition and Dietetics1.14. Pharmacy

2. Patients Rights and Organizational Ethics (pages 9-10)

3. Patient Care (pages 11-13)4. Implementation of Care (pages 13-15)5. Evaluation of Care (page 15)6. Leadership and Management (pages 16-17)

7. External Services (page 17) 8. Human Resource Management (page 17-18) 9. Data Collection, Management and Use (pages18-19) 10. Safe Practice and Environment including Patient and Staff Safety (pages 20-25) 11. Maintenance of Environment of Care (pages 25-27) 12. Infection Control (pages 28-32)) 13. Energy and Waste Management (page 33) 14. Improving Performance (page 34)III. CLINICAL SERVICES (pages 35-36) IV. PERSONNEL

POSITION STAFFING REQUIREMENT(pages 37-43) 1. Top Management Personnel Qualification Standard 2. Administrative 3. Clinical 4. Nursing 5. Ancillary

IV. EQUIPMENT AND INSTRUMENTS (pages44-51) List of Equipment and Instrument Requirement

1. Administrative 2. Clinical

2.1. Emergency Room2.2. Outpatient Care2.3. Operating Room

2.4. Recovery Room2.5. High Risk Pregnancy Unit2.6. Delivery Room2.7. Neonatal Intensive care Unit2.8. Intensive Care Unit

3. Nursing Unit/Ward4. Isolation Room 5. Central Supply and Sterilization Unit/ Room6. Physical Medicine and Rehabilitation Unit7. Dialysis Clinic8. Ambulatory Surgical Clinic9. Dental Clinic

10. Dietary V. PHYSICAL PLANT REQUIREMENT(52-56) Required rooms/areas/offices

VI.HOSPITAL PROGRAMS (pages 57-59)1. Blood Services 2. Newborn Screening3. Mother-Baby Friendly Hospital Initiative4. Health Promotion and Disease Prevention 5. Generics Act 6. Health Emergency Management Services

VII. HOSPITAL COMMITTEES (page 60)

VII. HOSPITAL OPERATIONS CRITERIA (page 61) VIII. SIGNATURE PAGE (page 62)

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I. GENERAL INSTRUCTIONS:1. Check to make sure that you have the complete tool with a total of

sixty-three (63) 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 X instead.

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; write N.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 SOMForms 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 exit conference 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.

II. GENERAL INFORMATION:

Name of Hospital:

Address: (Number & Street) (Barangay/District)

(Municipality/City) (Province & Region)

Telephone No../ Fax No.

E-mail Address:

License No (for renewal):

Date Issued Expiry Date:

Hospital Category: Level 1 Level 2 Level 3

Philhealth Accreditation:Center of: Safety Quality Excellence

Classification According to Ownership: Government Private

No. of: Authorized Bed Capacity Implementing Beds

Name of Owner or Governing Body (if corporation):

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Name of Hospital Administrator, Medical Director or Chief of Hospital

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STANDARDS CRITERIA INDICATOR DO

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SPEC

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EVIDENCE AREA REMARKSHOSPITAL ADMINISTRATION:

To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.ADMINISTRATIVE AND FINANCE SERVICE: The AFS shall ensure adequate and timely financial and direct support services to all hospital units.

Administrative Group:Human Resource ManagementThere 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 proceduresApproved documented policies, guidelines and procedures on:a) Staffing planb) Recruitment and Selectionc) Hiring/Appointmentd) Orientation & Staff Development e) continuing education, and trainingApproved documented policies, guidelines and procedures ona) Staffing planb) Recruitment and Selectionc) Hiring/Appointmentd) Orientation & StaffDevelopmente) continuing education, and training

● Complete, updated and easily retrievable individual personnel file ● Evidence of continuous improvement

Financial Management

AccountingThere shall be a systematic recording of all financial transactions, preparation of financial statements and relevant reports, and maint-enance and safekeeping of Books of Accounts. BudgetThere 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 ClaimsThere shall be a system of

:f) Performance Evaluationg) Rotation/Transferh) Succession Plani) Merit, Promotion, Awards & Incentivesj) Resignation, Termination and Retirementk) 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

documented and implementable policies and procedures


Verifier:Documents review, Observe

Interview staff, Validate▪ List of personnel – check if Current

Verifier:Documents review,

Interview staff, Validate



Billing and ClaimsThere shall be a system of billing of 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

Property and Supply Management:There shall be a systematic way of receipt, storage, issuance and conduct of inventory .

Linen and LaundryThere shall be adequate supply of clean linens for patients and other hospital

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


●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.


● Sorting of soiled and contaminated linens in designated areas ● Systematic washing of laundry with safeguard against spread of infection● Disinfection of laundry

● Adequate housekeeping supplies.

Documents are readily available

Look for approved Work and Financial Plan and its implementation

Proof of transactionsDocuments are readily Available

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

●evidence of continuous review of policies and procedures




Interview staff Validate







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

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

Central Information ManagementThere 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.

●Security check for internal and external customers including use of visitor’s pass

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

●evidence of continuous review of 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

Verifier:Documents review, Observe, Interview staff&Validate

1.1.1.i.a

1.1.1.j

Medical Records (Including Dental 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, multisectoral networking and linkages in understanding the socio- behavioral and economic plight of patients and their families for the holistic approach in their management and treatment

● Documented and implementable policies and procedures

● ICD-10 reference books 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 payb) Continuity of carec) Counselling of patients/clients and their familiesd) 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:Observe, Interview staff, Validate

1.1.1.c.1.

1.1,1.k

1.1.1.b.

Nutrition And DieteticsThere 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



1.1.1.b. 1.1.1.l PharmacyThere 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.




STANDARDS CRITERIA

INDICATOR

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2.1PATIENTS’ RIGHTS AND ORGANIZATIONAL ETHICSGoal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations

2.1.11.Organizational policies and procedures respect and support patients' right to 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 different departments.

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 hospital’s level (e.g. level 1 surgical capability, level 2 – ICU, level 3– teaching and training hospital).

DOCUMENT REVIEWList 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 the hospital 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

ER OPD Wards ICU OR/RR/DR/PACU Imaging Laboratory

leading to the outside.(Reference: RA 6541 Building Code of the Philippines)

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.

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

ER OPD Wards Other Areas Lobby

2.2.1.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 and elevators) are available, clearly and prominently marked and free of any obstruction.

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

OBSERVATION 1.There are alternative passageways for patients with special needs. Check ER, OPD, wards and other areas 2. They are prominently marked and 3. They are free from obstruction

EROPD Wards Otherareas

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 INTERVIEWPatient 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 ASSESSMENTGoal: 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 recordsNote: The progress notes should be done regularly and documented in the patient chart either as separate “progress notes” sheet or side notes in the doctor’s 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 CAREGoal: Care is delivered to ensure the best possible outcomes for the patients

2.3.1 10.Diagnostic examinations appropriate to the provider organization's service capability and usual case mix are available and are 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

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.)

X-rayLaboratory

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

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

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

. 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

Chart Review

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

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

All doctors, dentists, nurses and pharmacists have updated licenses

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

WardsPharmacyOPDER

2.3.2.c 13.Drugs are administered Prescriptions or orders are Proof that the prescriptions DOCUMENT

2.3.2.d

2.3.2.e

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

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.

or orders are verified before medications are administered.

All charts have proper documentation of drug administration

.

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

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

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

CHART REVIEWMedication sheet in patient chart from the medical records.

Medical Records Room

2. EVALUATION OF CARE

Goal: Care is coordinated between the organization and other health care providers in the community to ensure that theneeds of the patient are continuously met.

2.4.1 16. The discharge plan is part of the patient's care plan and is documented in the patient chart.

All charts have discharge plans

CHART REVIEW Patient chart from medical records room, the discharge orders should contain the ff.: 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 discharge summary.

2.5 LEADERSHIP AND MANAGEMENT Management 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.

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 and Relationship by PositionsProof 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 outcomes2. Ask management team how targets are set.

2.6.1EXTERNAL SERVICES

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 out-sourced 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

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

Imaging

Laboratory Other areas

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 21. Planning ensures that appropriately trained and qualified (and where relevant, credentialed) staff are available to undertake the type and level of activity performed by the organization. This includes those who are consulted when suitable expertise is not available within the organization

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

Presence of policies and procedures for credentialing and privileging of staff

Policies and procedures for credentialing and privileging of staff

3.1.1.b

22.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.

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

Staff to bed ratio for licensed doctors, registered nurses and midwives/nursing aides follow the DOH prescribed ratio.

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

4.1 DATA COLLECTION, AGGREGATION AND USE

Goal: Collection and aggregation of data are done for patient care, management of services, education and research. RECORDS MANAGEMENT Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met. 4.2

4.2.1 Medical Record

4.2.1.a 23.Clinical records are readily accessible to

When patients are admitted or are seen for ambulatory or emergency care, patient

●Presence of policies and procedures on systematic filing, retrieval, retention,

DOCUMENT REVIEWPolicies and procedures on

facilitate patient care, are kept confidential and safe, and comply with all relevant statutory requirements and codes of practice

charts documenting any previous care can be quickly retrieved for review, updating and concurrent use.

storage, disposal and management of medical records. Patient’s chart contents include the following:-Doctor’s Progress Notes-Informed Consent-Problem List-Medication and Treatment Record-Laboratory and X-ray Reports-Dietary Assessment Clinical and Graphic Record of Vital Signs (TPR sheet)-Personal History and Physical Examination records-Newborn Record and Physical Maturity Rating, if warranted

systematic record filing, retrieval. retention, storage, safekeeping and maintenance and disposal.

24.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.

25.Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and comply with all relevant statutory require-ments 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.

-Doctor’s 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

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

DOCUMENT REVIEW

Note also the following:1. ICD-10Coding is being used. 2. Medical Records Officer is trained on ICD-10 Coding and Medical Records Management

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

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

6.1 SAFE PRACTICE AND ENVIRONMENT

6x1.1

PATIENT AND STAFF SAFETYGoal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care.

6.1.1.a

6.1.1.b

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

27.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 REVIEWManagement plan which includes polices, procedures and programs, risk assessment, hazards surveillance among others that address the following:1. Safety2. Security3. Disposal and control of hazardous materials/biologic wastes4. Emergency and disaster preparedness5. Fire safety6. Radiation safety7. Utility systemsNote: The hospital must have plans for all the elements enumerated in the criteria. Plans should have guiding policies and specific procedures.

ER OPD Wards ICU OR/DR/RR Facilities and maintenance Imaging Laboratory Others

6.1.1.c 28.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

DOCUMENT Operating manuals for the medical equipment

6.1.1.d 29.The organization provides a Policies and procedures that Proof of implementation of Document review

safe and effective environment of care consistent with its mission and services, and with laws and regulations.

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.

the policies, procedures and safety programs on

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 INTERVIEW1. 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-hazardous2. Hospital safety program3. 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 andmaintenance

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 receptacles4. 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. OBSERVATIONDOCUMENT REVIEWPresence of policies and procedures for the safe and efficient use of medical equipment (including the implementation of DOH AO#2008-0021on the

gradual phase-out of mercury)

ER

6.1.1.e30.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.

DOCUMENT1. Operating manual2. Preventive and corrective maintenance logbook

Wards

OR/RR/DR

3. Qualifications of staff handling medical equipment INTERVIEW 1. Ask staff in the ER,

Facilities and maintenance

Imaging

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

Laboratory

Other areas

6.1.1.f 31.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).

OBSERVATION 1. Adequate space 2. Adequate lighting (lights are working, lighting is adequate enough for conduct of general activities) 3. Adequate ventilation

ER OPD Wards ICU OR/RR/DR ImagingLaboratory Pharmacy Other areas

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.

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

Document review

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.

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 Policies and procedures on risk identification, assessment and control, security risks, use of personal protective equipment, etc.or Appointment of person in charge of security 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.

7.1 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. 7.1.1 34.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 com-munications/memoranda/orders or proceedings on sentinel events

"Sentinel event" refers to injuries caused by medical management (not necessarily the disease process) that either caused death, prolonged hospi-talization or produced a dis-ability during the time of con-

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

Wards ER ICU OR

finement or by the time of discharge.

7.1.2 35. 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 Preventive and corrective maintenance logbooks for generator/ emergency light/ water tanks/ airconditioners .

OBSERVATION 1. Presence of generator/emergency light, water tanks, adequate ventilation or air conditioning 2. Test if faucets and water closets are working


Other areas Facilities and maintenance

7.1.3 36.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,

Facilities and maintenance ImagingLaboratory

Certificate of Attendance, diploma, citation or MOA/Contract for outsourced services (verify qualification of technicians).

Other areas

7.1.4 37.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.

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

Presence of operating manuals equipment DOCUMENT Operating manual of generators, air conditioners and other non-medical equipment.

8.1 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and

8.1.1.a 38.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 quarterly activities4. Statistics on nosocomial infections INTERVIEW Ask a member of the ICC regarding infection control program of the hospital.

8.1.1.b 39.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,outbreak investigation,

preventive programs 8.1.2.a 40.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

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


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

DOCUMENT REVIEW Procedures on case containment of nosocomial infections Note: case containment - means prevention of spread of infection examples: reverse isolation, prophylaxis for exposed personnel, vaccination, immunization

Document review ER Wards

ICU

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

.

8.1.2.c 42.The organization uses a coordinated system-wide approach to reduce the risks 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

8.1.3.a 43.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 INTERVIEW Interview hospital staff on how they handle and dispose needlesOBSERVATION Presence of receptacles for proper disposal of sharps.

ER Wards

ICU Laboratory

8.1.3.b 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 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 2. Program for the protection of healthcare workers e.g. personal protective equipment (PPEs) 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. 4. Hand hygiene procedures 5. Environmental care and healthcare waste management

ER Wards

ICU Laboratory

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

8.1.4 45.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 and supplies.2. Policies on decontamination, disinfection, sterilization, disinfectants for specific medical equipment/items and area. 3. Housekeeping procedures in specific patient areas.

8.1.5 46.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 reuse3. Reporting4. Personnel in charge

9.1 ENERGY AND WASTE MANAGEMENT Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability

9.1.1 47.The handling, collection, and disposal of waste conform to relevant statutory requirements and codes

Presence of licenses/permits/ clearances from pertinent regulatory agencies implementing

DOCUMENT REVIEW Pertinent

of practice.

among others the following: RA 9003, RA 6969, RA 275, PD 1586 DOH Hospital Waste Management Manual, RA 8749 (Clean Air Act

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

9.1.2 48.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 2. Contracts with waste handlers or disposal contractors, (if applicable) 3. Hospital policy that conforms to the joint DOH-DENR circular on waste management for LGUs 1. Waste Segregation 2. Proper labeling of waste receptacles 3. Recyclable waste staging areas 4. Proper management of temporary storage areas prior to hauling for disposal.

ER

Wards ICU Imaging Laboratory


10.1 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.

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

Presence of Quality Improvement Program

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

10.1.2

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

Presence of patient satisfaction survey

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)Note: Look for analysis of the results of survey; correction, corrective and preventive actions done ii warranted.

CODE10.1 INDICATOR CODE REQUIRED CLINICAL SERVICES:

2.1 Level 1 (With Consulting Specialists in the four major specialties plus Anesthesia)

General MedicineGeneral PediatricsObstetrics and GynecologySurgeryAnesthesiaEmergencyOutpatient Service

2.2 Level 2 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus Anesthesia)

2.3. Level 3 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus and Anesthesia and other specialties and sub-

Accredited Residency Training Program for Physicians in the four major

Obstetrics and gynecology

General Nursing ( for all levels)

Highly Specialized Critical Care and Management in thefollowing areas: (for levels 2 and 3)

Obstetrics and Gynecology

Surgery and Anesthesia

In areas with other Specialties (aside from the five) and Subspecialties, there should be corresponding

Ancillary Services4.1. Clinical Laboratory

Category of laboratory must be Secondary for level 1, Tertiary for Level 2 And for level 3, Tertiary with histopathology.

4.2. Radiology Category of Radiology must be 1st level for Level 1, 2nd level with mobile Unit for Level 2, and 3rd level for level 3. 4.3 Pharmacy Other Services - Dental Services ( for all levels) - Ambulatory Surgical Clinic (for level 3)- Dialysis ( for level 3)

- Physical Medicine and Rehabilitation Services (for level 3)- Respiratory Unit for level 2 and 3.Verifier: Documents review, Observe, Interview staff & Validate

CODE10.1

POSITION STAFFING REQUIREMENT I:(Top Management

Positions)

CRITERIA INDICATOR

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10.1.1

10.1.2

Medical Director/ Chief of Hospital or Medical Center Chief

For level 1, 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 Master’s 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/appoint-ment

10.1.3

10.1.4

Chief of Clinics/Chief Medical Professional Services

Department Head

Training Officer

Chief Nurse/Director of Nursing/Deputy Director for Nursing

●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

●For level 3, must be a Diplomate/ Fellow in a Specialty Society.

●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


Diploma ● Proof of employment/appointment

Verifier:Documents review, Interview staff, Validate: ●Diploma ●Proof of employment/appointment


Diploma ● Proof of employment/appointment

Verifier:Documents review, Interview staff, Validate: ●Diploma/ Certificate of units earned ●Proof of employment/appointment

3.5 Administrative For level I, must have Verifier:

10.1.5

Officer 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 Master’s Degree in Hospital Administration or Related Course AND at least 5 years experience in a supervisory managerial position.

Documents review, Interview staff, Validate: ●Diploma/ Certificate of units earned ●Proof of employment/appointment

CODE STANDARD REQUIREMENT FOR PERSONNEL

NUMBER REQUIRED

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11.1 ADMINISTRATIVE

11.1.1 * Chief of Hospital /Medical Director/Medical Center Chief

1 1 1

11.1.2 Administrative Officer 1 1 1

11.1.3.a Clerk:

- Pool1:50 beds 1:50 beds 1:50 beds

11.1.3.b - Accounting 1 1 1 11.1.4 Medical Records Officer trained in

ICD-10 and Medical Records Management

1:50 beds 1:50 beds 1:50 beds

11.1.5 Cash Clerk 0 1 11.1.6 Accountant 1 1 1 11.1.7 Budget /Finance Officer 1 1 11.1.8 Bookkeeper 0 1 1 11.1.9 Billing Officer 1 1 1 11.1.10 Cashier 1 1 1 11.1.11 Human Resource Mgt. Officer 1(designate) 1 1 11.1.12 Training Officer 1(designate) 1 1 11.1.14 Supply Officer 1 1 1 11.1.15 Storekeeper/ Linen Custodian 1 1 1 11.1.16 Laundry Worker 1 1:50 beds 1:50 beds 11.1.17 Utility Worker 1/Shift 1:50 beds/shift 1:50 beds/shift

11.1.18 Security Guard 1/shift 1/entrance/exit per shift

1/entrance/exit per shift

11.1.19 Engineer 1 1

11.1.20 Medical Equipment/Biomedical Technician

1 1

11.1.1.21 Maintenance Personnel 1 1/shift 1/shift

11.1.1.22 Mechanic 0 0 1Driver 3 3 4

11.1.1.23 Nutritionist-Dietitian (for level 2 and in case of sharing, must be residing within

1 (sharing is allowed e.g.

1:100 beds 1:100 beds

the locality) hospital and municipal/city government)

11.1.1.24 Cook 1 1:100 beds 1:100 beds 11.1.1.25 Food Service Worker 0 1:50 beds 1:50 beds 11.1.1.26 Food Service Supervisor 0 1 1 11.1 Medical Social Worker (For level 1, may

be part time but the schedule should be specified in the MOA or Contract.)

1 1 1

11.2 CLINICAL: 11.2.1 * Chief of Clinics/Chief Medical

Professional Services0 1 1

11.2.2 * Department Head 0 1/department

1/department

11.2.3 * Consultant Staff and Medical Specialists in Ob-Gyn, Pediatrics, Medicine, Surgery and Anesthesia. (should be Diplomate/ Fellow of a Specialty/ Sub-Specialty Society after a formal residency training program)* Training Officer 0 0 1

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

* Shall be Philhealth Accredited.

1:20 beds at any time plus 1 reliever

50 beds = 6Every additional 50 beds = additional 2

1:10 beds/depart-ment (as suggested by specialty boards)

100 beds = 8Every additional 50 beds = additional 3 ( For Departments with accredited residency training program, number will depend on the requirement of specialty board concerned).1:10 beds/department (as suggested by specialty boards)

11.3 NURSING:

(number not prescribed)

11.3.1 Chief Nurse/Director of Nursing 1 1 1

11.3.2 Asst. Chief Nurse (maybe designated as Training Officer)

0 100 beds and above=1

100 beds and above=1

11.3.3 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

11.3.4 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

11.3.5 Head Nurse 1:15 RNs 1:15 RNs 1:15 RNs 11.3.6 Staff Nurse

-For every three (3) RNs, there must be one (1) reliever)

1:12 beds at any time



11.3.7

Staff Nurse (CCUs)-Base the ratio on the actual number of occupied CCU beds at the time of inspection



11.3.8

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.




11.3.9 Nursing Attendant/ Midwife (CCUs)-For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever



11.3.10 Operating 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)

11.3.11 Delivery Room Nurse 1 per/shift 1/shift( may 1/DR/shift( may

increase depending on the average number of deliveries per day)

increase depending on the average number of deliveries per day)

11.3.12 Emergency Room Nurse 1/ shift 1 shift 1/Dept/shift 11.3.13 Out-Patient Department Nurse 1 1 1/Dept.

11.4 ALLIED MEDICAL PERSONNEL

11.4.1 Pharmacist (full-time,registered);

Adequate Adequate Adequate

11.4.2 Pathologist 1 1 1

11.4.3 Med. Technologist (full-time, registered)

Adequate Adequate Adequate

11.4.4 Other Lab. Personnel (specify) Adequate Adequate Adequate

11.4.5 Dentist 1 1 2

11.4.6 Dental Aide 1 1 2

11.4.7 Radiologist 1 1 2

11.4.8 Radiology Technologist Adequate Adequate Adequate

11.4.9 Radiation Safety officer 1(designate) 1(designate) 1

11.4.10 Physical Therapist 0 1 11.4.11 Respiratory Therapist( may be “on call”

for level 2)1 1

REQUIRED NUMBER

CODE STANDARD REQUIREMENT Level 1 Level 2 Level 3

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REMARKS

12.1 EQUIPMENT/INSTRUMENT REQUIREMENT

12.1.1 1.ADMINISTRATIVE

12.1.1.1 Computer with Internet Access 1 1 or more depending on the need

1 or more depending on the need

12.1.1.2 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

12.1.1.3 Standby Generator with Automatic Transfer Switch (ATS) (KVA may depend on the load)

1 1 1

12.1.1.4 Emergency Light 1/station/lobby/stairways

1/station/lobby/stairways

1/station/lobby/ stairways

12.1.1.5 Fire Extinguisher 1/room/unit 1/room/unit 1/room/unit 12.1.1.6 Overhead Projector/ LCD 1 1 1

DIETARY Oven 1 1 1 Refrigerator/Freezer 1 1 1 Osterizer/Blender 1 1 1 Food Conveyor 1 1 1 Food Scale 1 1 1 Exhaust Fan 1 1 1 Utility Cart 1 1 1 Garbage Receptacle with Cover 1 1 1

13.1 13.1.1

CLINICAL EMERGENCY ROOM

13.1.1.1 Bag-valve-mask unit

13.1.1.1.a Adult 1 1 1

13.1.1.1.b Pediatric 1 1 1 13.1.1.2

Clinical Weighing Scale

13.1.1.3 Defibrillator 1 1 1

13.1.1.4 ECG Machine 1 1 1

13.1.1.5 EENT Diagnostic Set 1 1 1

13.1.1.6 Emergency Cart (complete with ER Medicines.) See annex for the list and quantity.

1 1 1

13.1.1.7 Examining Table 1 1 1

13.1.1.8 Examining Table with stirrup 1 1 1 13.1.1.9 Gooseneck Lamp/Examining Light 1 1 1 13.1.1.10 Instrument Table 1 1 1 13.1.1.11 Laryngoscope with Different sizes of Blades 1 1 13.1.1.12 Medicine Cabinet 1 1 1 13.1.1.13 Minor Surgery Instrument Set 1 1 1 13.1.1.14 Nebulizer 1 1 1 13.1.1.15 Neurological Hammer 1 1 1 13.1.1.16 Oxygen Unit (anchored) 1 1 1 13.1.1.17 Pulse oximeter 13.1.1.18 Sphygmomanometer (non-mercurial) 1 1 1

13.1.1.18a Adult Cuff 1 1 113.1.1.18b Pediatric Cuff 1 1 1 13.1.1.19 Stethoscope 1 1 1 13.1.1.20 Suction Apparatus 1 1 1 13.1.1.21 Suturing Set 1 1 1 13.1.1.22 Thermometer (non-mercurial) 13.1.1.23 Tracheostomy Set 1 1 1 13.1.1.24 Vaginal Speculum Set 1 1 1 13.1.1.25 wheelchair 1 1 1 13.1.1.26 Wheeled Stretchers with guard and wheel lock

or anchored.1 1 1

13.2.1

OUTPATIENT CARE

13.2.1.1 1. Clinical Weighing Scale 1 1 1 13.2.1.2 2. ECG Machine 1 1 1 13.2.1.3 3. EENT Diagnostic Set 1 1 1 13.2.1.4 4. Gooseneck Lamp/Examining Light 1 1 1 13.2.1 5 5. Examining Table with wheel lock or anchor 1 1 1 13.2.1.6 6. Instrument Table 1 1 1

13.2.1.7 7. Minor Surgery Instrument Set 1 1 1 13.2.1.8 8. Neurological Hammer 1 1 1 13.2.1.9 9. Oxygen Unit 1 1 1 13.2.1.10 10.Sphygmomanometer (non-mercurial) 1 1 1

Adult Cuff 1 1 1

Pediatric Cuff 1 1 1 13.2.1.11 11. Stethoscope 1 1 1 13.2.1.12 12. Suture Removal Set 1 1 1 13.2.1.13 13. Thermometer, non-mercurial 13.2.1.14 13. Vaginal Speculum Set 1 1 1 13.2.1.15 14. Wheelchair 1 1 1 13.3.1 OPERATING ROOM 13.3.1.1 1. Air-conditioning Unit 1 1/OR 1/OR 13.3.1.2 2. Anesthesia Machine 1 1/OR 1/OR 13.3.1.3 3. Cardiac Monitor with pulse oximeter Pulse

Oximeter1/OR 1/OR

13.3.1.4 4. C/S Set 1 1 1 13.3.1.5 5. Instrument Table 1 1/OR 1/OR 13.3.1.6 6. Laparotomy Set 1 1/OR 1/OR 13.3.1.7 7. Laryngoscope with Blades 1 set 1 set/OR 1 set/OR 13.3.1.8 8. Major Surgical Instrument Set 1 1/OR 1OR 13.3.1.9 9. OR Light 1 1/OR 1/OR13.3.1.10 10.OR Table 1 1/OR 1/OR13.3.1.11 11. Ortho Instrument Set 1 1 113.3.1.12 12. Oxygen Unit (anchored) 1 1/OR 1/OR13.3.1.13 13. Sphygmomanometer (non-mercurial) 1 1/OR 1/OR13.3.1.13a Adult Cuff 1 1/OR 1/OR 13.3.1.1b Pediatric Cuff 1 1/OR 1/OR 13.3.1.14 14. Spinal Set 1 1/OR 1/OR 13.3.1.15 15. Stethoscope 1 1/OR 1/OR 13.3.1.16 16. Suction Apparatus 1 1/OR 1/OR 13.3.1.17 17. Thermometer, non-mercurial 1 1 1 13.3.1.18 17. Wheeled Stretcher 1 1 1 13.4.1 RECOVERY ROOM/ POST ANESTHESIA CARE UNIT (PACU)

13.4.1.1 1. Air-conditioning Unit 1 1 1 13.4.1.2 2. Bed with Guard Rail and wheel lock or anchor 1 1 1 13.4.1.3 3. Oxygen Unit (anchored) 1 1 1 13.4.1.4 4. Sphygmomanometer (non-mercurial) 1 1 1 13.4.1.4a Adult Cuff 1 1 1 13.4.1.4b Pediatric Cuff 1 1 1 13.4.1.5 5. Pulse Oximeter 1 1 1

13.4.1.6 6. Stethoscope 1 1 1 13.4.1.7 7. Suction Apparatus 1 1 1

13.5.1 LABOR ROOM

13.5.1.1 1. CTG Machine 1 1 1 13.5.1.2 2. Amniotome (Optional) 1 1 1 13.5.1.3 3. Sphygmomanometer (non-mercurial) 1 1 1 13.5.1.4 4. Stethoscope 1 1 1

13.6.1 DELIVERY ROOM ( IF APPLICABLE)

13.6.1.1 1. Air-conditioning Unit 1 1/DR 1/DR 13.6.1.2 3. D/C Set 1 1/DR 1/DR 13.6.1.3 4. Delivery Set 1 1/DR 1/DR 13.6.1.4 5. DR Light 1 1/DR 1/DR 13.6.1.5 6. DR Table with Stirrup 1 1/DR 1/DR 13.6.1.6 7. Foetoscope (Doppler) 1 1 1/DR 13.6.1.7 8. Instrument Table 1 1/DR 1/DR 13.6.1.8 9. Kelly Pad 1 1/DR 1/DR 13.6.1.9 10.Oxygen Unit, Anchored 1 1/DR 1/DR 13.6.1.10 11.Sphygmomanometer (non-mercurial) 1 1/DR 1/DR 13.6.1.11 12.Stethoscope 1 1/DR 1/DR 13.6.1.12 13.Suction Apparatus 1 1/DR 1/DR 13.6.1.13 14.Wheeled Stretcher 1 1 1 13.6.1.14 15.Bassinet 1 1 1 13.6.1.15 16.Infant Weighing Scale 1 1 1 13.7.1 HIGH RISK PREGNANCY UNIT ( Not required in Level 1) 13.7.1.1 1. Cardiac Monitor No need for separate

equipment if patient is placed in ICU.

1 1 13.7.1.2 2. Suction Apparatus 1 1 13.7.1.3 3. Oxygen Unit, Anchored 1 1

4. Fetal Monitor (CTG Machine)

NEONATAL INTENSIVE CARE UNIT 13..8.1.1 1. Bassinet 1 1 13..8.1.2 2. Bili Light 1 1 13..8.1.3 3. Cardiac Monitor 1 1 13..8.1.4 4. Emergency Cart 1 1 13..8.1.5 5. Umbilical Cannulation Set 1 1 13..8.1.6 6. Laryngoscope with Neonatal Blades 1 1 13..8.1.7 7. Examining Light 1 1

13..8.1.8 8. Incubator 1 1

1 13..8.1.9 9. Infant Bag valve mask unit 1 1

13..8.1.10 10. Infant Weighing Scale 1 1

13..8.1.11 Oxygen Unit, anchored 1 1

13..8.1.12 Respirator/Mechanical Ventilator 1 1

13..8.1.13 Radiant Warmer 1

13..8.1.14 Infusion Pump/Syringe Pump 1 1

13..8.1.15 Glucometer 1 1

13..8.1.16 Nebulizer 1 1

13..8.1.17 Pulse Oximeter 1 1

13..8.1.18 Neonatal Stethoscope 1 1

13..8.1.19 Suction Apparatus 1 1

Air-conditioning unit 1 1INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1 Air-conditioning Unit 1 1Bag-valve-mask unit 1 1 Adult (in adult units) Pediatric (in pediatric units)Bed with Guard RailCardiac Monitor 1 1Defibrillator 1 1ECG Machine 1 1Emergency Cart with emergency Medicines(Refer to annex for medicines and supplies)

1 1

Laryngoscope with Blades of different sizes 1 1Endotracheal Tubes of different sizes 1 1Oxygen Unit, anchored 1 1Sphygmomanometer (non-mercurial 1 1 Adult Cuff (in adult units) Pediatric Cuff Set (in pediatric units)Stethoscope 1 1Suction Apparatus 1 1Tracheostomy Set 1 1Pulse Oximeter 1 1Mechanical Ventilator 1 1Infusion Pump 1 1NURSING UNIT OR WARDBag-valve-mask unit 1 1 1 Adult (if Adult ward)

Pediatric ( if Pediatric ward)Clinical Weighing Scale (per nursing unit) 1 1 1ECG Machine 1 1 1

Emergency Cart or its equivalent (per nursing unit)

1 1 1

Mechanical Bed/Patient Bed with Side Rails (include beds in Critical care Areas).(Patient beds in ER, Labor Room, and Recovery room and bassinets are not included in the count)

Actual bed count should correspond to ABC applied for.



Bedside Table should correspond to total bedsLaryngoscope with different Sizes of Blades 1` 1 1Nebulizer 1 1/Medical/

Pedia ward1/Medical/

Pedia wardNeurological Hammer 1 1 1

Oxygen Unit, Anchored (may increase depending on the need)

1 1 1

Sphygmomanometer (non-mercurial) 1 1 1 Adult Cuff Pediatric Cuff

Stethoscope 1 1 1Suction Apparatus 1 1 1Thermometer (non- mercurial) 1 1 1CENTRAL STERILIZING & SUPPLY ROOM

Autoclave ( may increase depending on the need)

1 1 1

Steam Sterilizer ( may increase depending on the need)

DENTAL CLINIC

0 1 1

Dental Chair Unit 1 1 1Operating Stool per Dental Chair 1 1 1Autoclave 1 1 1Air Compressor 1 1 1Dental X-ray 1Mouth Mirror Explorer 1 1 1Explorer, double end 1 1 1Scaler jacquettes set No. 1,2,3 1 1 1Low speed hand piece (angled head) 1 1 1Cotton pliers 1 1 1High speed hand piece with bur remover 1 1 1No.150 forceps (maxillary universal forceps) 1 1 1 No.151 forceps (lower universal) 1 1 1No.150 S forceps (primary teeth) 1 1 1No. 8L and No18R forceps(upper molar) 1 1 1No.151A forceps (mandibular premolar) 1 1 1No.17 forceps 1 1 1No.15 S forceps (lower primary teeth) 1 1 1Rongeur forceps 1 1 1Surgical chisel and mallet 1 1 1Bone file 1 1 1Surgical Scissor 1 1 1Root elevator 1 1 1Periostal elevator No. 9 double end 1 1 1Gum Separator double end 1 1 1Cowhorn forceps 1 1 1Bonefile Stainless end 1 1 1

DIALYSIS CLINIC- Not required for Levels 1 and 2. (Refer to AO 2012-0001 “ New Rules and Regulations Governing the Licensure and Regulation of Dialysis Facilities in the Philippines”Use checklist for Dialysis facility( Can be Hemodialysis or Peritoneal Dialysis)

AMBULATORY SURGICAL CLINICUse checklist for Ambulatory Surgical Clinic

Level 3 should have access to CT Scan and Endoscopy.(With MOA, and not necessarily within the hospital premises).

PHYSICAL MEDICINE AND REHABILITATION UNIT

Ultrasound 1TENS 1Electric Stimulator 1Exercise plinth/bed 1Overhead pulley 1Exercise stair with rails 1Paraffin wax 1Parallel bars with postural mirrors 1

RESPIRATORY/PULMONARY UNIT

ABG machine

Spirometer

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)• Medical Records Office/Room• Business Office with the following sections• 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 1 Laundry and Linen Room or Area

• Receiving and Releasing Area not required

• Sorting and Washing Area if contracted-• Pressing and Ironing Area out.• Storage Area Engineering /Maintenance Office for Level 2

• Maintenance Area not required

• Motor Pool Area if contracted-• Housekeeping Area out. WASTE HOLDING /STORAGE AREA (color coded)

NUTRITIONIST-DIETITIAN OFFICE ( AREA FOR LEVEL 1) DIETARY• Supply Receiving Area not required

• Cold and Dry Storage Area if contracted-• Food Preparation Area out.• Cooking and Baking Area• Washing Area• Serving and Food Assembly• Dining Area• Garbage and Disposal Area• ToiletSOCIAL WELFARE/SERVICE • Social Worker’s Office • Counselling AreaMORGUE for Level 3, Cadaver Holding Area for Level 1 and 2 • Pathologist Office • Autopsy Area • Shower Area • ToiletCLINICAL SERVICEEMERGENCY ROOM • Waiting Area • Toilet (adjacent or w/in ER) • Nurse Station • Examination & Treatment Area with Lavatory • Observation Area • Minor Operating Room • Resuscitation Area for Level 2 and 3 • Equipment & Supply Storage Area • Wheeled Stretcher Area • Decontamination Area for level 3 • Holding Area for Infectious Cases awaiting transfer to other hospital for level 1 and 2

• Doctor’s Quarter (with toilet)

OUTPATIENT DEPARTMENT

• Waiting Area • Toilet (accessible) • Admitting and Records Area • Consultation Area (required) • Examination & Treatment Area With Lavatory

OFFICE OF THE DEPT. HEADS

• Medicine • Pediatrics • OB-GYNE

May be combined

• Surgery • Anesthesia • Emergency MedicineOPERATING ROOM (MAY BE COMBINED IN ONE COMPLEX WITH DELIVERY ROOM FOR LEVEL 1) • Major OR • Minor OR • Sub-Sterilizing/Work Areas • Storage Area for Sterile Instruments And 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 • Janitor’s ClosetRECOVERY ROOM/POST ANESTHESIA CARE UNIT

• Nurse’s Station with : - Medication area - Cabinets - Toilet

OBSTETRICS OPERATING ROOM (MAY BE COMBINED WITH SURGICAL OPERATING ROOM FOR LEVEL 1)DELIVERY ROOM • Transvaginal Ultrasound Room for Level 3 • Equipment and Supply Storage Area • Scrub-up Area • Clean-up Area • Male Dressing Room with Toilet • Female Dressing Room with Toilet • Wheeled stretcher area • Janitor’s Closet HIGH RISK PREGNANCY UNIT (May be put up as part of the Labor room or patient may be placed in ICU)LABOR ROOM• Patient bed areas• ToiletNEONATAL INTENSIVE CARE UNIT• Work Area with Sink

• Incubator Area• bassinet Areas• Treatment Area• Viewing Area• Breastfeeding Area with lavatoryINTENSIVE CARE UNIT• Nurses’ station with sink• Medication Area with sink• Patient Area• ToiletNURSING UNIT/WARD• Medication Area w/ lavatory• Dressing Area• Equipment & Supply Storage Area• Patients Room/Area (Separate Male from Female)• Toilet ( Separate Male & Female)• Utility Area• Linen Area• Toilet• Treatment Area• Internal examination area for OB-GYNE ward• With Color-Coded Waste Bins• Janitor’s Closet• Nursing Office; Office of Chief Nurse with toilet

ISOLATION ROOM

• Ante room with lavatory and PPE rack• Windows and doors including are closed and air tight or leak proof• With negative pressure for infectious case and positive pressure for immuno-compromised cases.• Handwashing Facility/Hand Disinfection • Toilet

DIALYSIS CLINIC (not required in levels 1 and 2)

• Refer to A.O. 2012-0001, “ Regulation of Dialysis Facilities in the Philippines AMBULATORY SURGICAL CLINIC(not required in level 1 AND 2) –May use the hospital’s OR as long as Policies in Sterilization and Infection Control are in place and implemented.

• Required rooms /areas depend on the surgical procedures the clinic is authorized to perform.PHYSICAL MEDICINE /REHABILITATION UNIT (not required in level 1) DENTAL CLINIC • Dental Chair Unit A • Consultation room • ToiletCENTRAL STERILIZING AND SUPPLY UNIT/ROOM • Receiving and Cleaning Area • Inspection Area • Packaging Area • Sterilizing Area • Sterile Supply Storage Area • Releasing AreaPRAYER ROOM/AREA

CODE STANDARDS CRITERIA INDICATORS

SELF

–

ASS

ESSM

ENT

DO

H

INSP

ECTI

ON

MO

NIT

OR

ING EVIDENCE AREA REMARKS

41

41x1

41x1.a

B.DOH Programs Implemented in the Hospital>

1.Blood ServicesCompliance to RA 7719 and its IRR, AO 2008- 0008 Levels 1 and 2, should be at least a Blood Station Facility .

1.2 Level 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•

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 are collected/ obtained from healthy voluntary blood donors only


Verifier:Documents review, Observe Interview staff Validate


41x2

41x2,a

2.Health Promotion and Disease Prevention

2.1 Newborn Screening- Compliance to

RA9288 and it’s IRR

• Documented policies regarding NewbornScreening

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


41x3

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 NICU

• Certification as “Mother –Baby Friendly Hospital”• Certification as “Mother –Baby Friendly Workplace”


2.5 Immunization (Republic Act No. 309)

• Documented policies and SOPs

Records of Immunizations given to newborn:BCG, Hepa-B Vaccine


41x5 2.4 Family Planning • Documented policies and SOPs specific to the program

Records of Counselling and motivations done; Records of Acceptors i.e. BTL, Vasectomy, IUDs, Pills, etc.


41x4 2.3 Healthy Lifestyle Advocacy

• Documented policies and SOPs specific to the program


2.6. Anti-Smoking Program (per RA 9211)

• 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.7581”Price Act of 1992; R.A. 9502”Universally 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.2008-0014”Guidelines 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”

• With designated HEMS Coordinator • Documented Health Emergency Preparedness, Response and Recovery Plan

• Conduct of drills/exercises i.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



Written Designation of

Written Policies and Procedure

Updated and Relevant Minutes

Reports/ Records of Implementation

CODE 42 C.HOSPITAL COMMITTEES:

Members and their

roles/functions

of MeetingREMARKS

42x11.Credentials

42x22.Blood transfusion

42x33.HIV/AIDS Core Team

42x44.Waste Management

42x5 5.Patient Safety40x6 6.Infection Control40x7 7.Pharmacologic/Therapeutics

4288.Health Emergency/

Crisis Management

42x9 9.CQI

42x1010.Tissue

(for levels 2 and 3 only)

42x1111.Ethics (for levels 2,and 3 only)

42x1212.Grievance

42x13

Other committees, please specify

Verifier: Documents review and Interview staff

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

CODE

43

D.HOSPITAL OPERATIONS:

OPD

Emer

genc

y

Med

icin

e

OB

/ G

yne

(Del

iver

y R

oom

)Pe

diat

rics

OR

Surg

ery

Ane

sthe

sia

Reh

ab REMARKS

43x1

1.Clinical Practice Guidelines (CPG)

43x2

2.Recording, Reporting, Records Keeping

43x3 3.Inter/Intra Departmental Referrals

43x44.Disaster

Management/Crisis Management

43x55.Infection Control

43x66.Drug Management and

Control

43x77.Blood Service

43x88.Pre-Operative and Post-Op

Care43x9 9.Triaging (when applicable)

43x1010.Referrals/ Transfer

43x1111.Others, please specify

ASSESSED BY:

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CONCURRED BY:

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_______________________________Position/Designation

_______________________________Date