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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) 8. Human Resource Management (page 18) 2.6. Delivery Room
9. Data Collection, Management and Use 2.7. Neonatal Intensive care Unit
II. HOSPITAL ADMINISTRATION (pages18-19) 2.8. Intensive Care Unit
10. Safe Practice and Environment including 3. Nursing Unit/Ward
A. Services Patient and Staff Safety (pages 20-25) 4. Isolation Room
1. Administrative Service (pages 3-8) 11. Maintenance of Environment of Care (pages 5. Central Supply and Sterilization Unit/ Room
1.1. Human Resource 26-27) 6. Physical Medicine and Rehabilitation Unit
1.2. Accounting 12. Infection Control (pages 28-32)) 7. Dialysis Clinic
1.3. Budget and Finance 13. Energy and Waste Management (page 33) 8. Ambulatory Surgical Clinic
1.4. Billing and Claims 14. Improving Performance (page 34) 9. Dental Clinic
1.5. Procurement 10. Dietary
1.6. Property and Supply Management III. PERSONNEL V. PHYSICAL PLANT REQUIREMENT(53-57)
1.8 Linen and Laundry Required rooms/areas/offices
1.9 Housekeeping POSITION STAFFING REQUIREMENT(pages 35-43)
1.7. Nutrition and Dietary 1. Top Management Personnel Qualification VI.HOSPITAL PROGRAMS (pages 58-60)
1.8. Security Services Standard 1. Blood Services
1.9. Ambulance Services 2. Administrative 2. Newborn Screening
1.10. Central Information Management 3. Clinical
4. Nursing 3. Mother-Baby Friendly Hospital Initiative
1.11. Medical Records (Including Dental 4. Health Promotion and Disease Prevention
Records) 5. Ancillary
1.12. Medical Social Services 5. Generics Act
1.13. Nutrition and Dietetics IV. EQUIPMENT AND INSTRUMENTS (pages44-52) 6. Health Emergency Management Services
1.14. Pharmacy List of Equipment and Instrument Requirement
2. Patients Rights and Organizational Ethics 1. Administrative VII. HOSPITAL COMMITTEES (page 61)
(pages 9-10) 2. Clinical
3. Patient Care (pages 10-13) 2.1. Emergency Room VII. HOSPITAL OPERATIONS CRITERIA (page 62)
4. Implementation of Care (pages 13-15) 2.2. Outpatient Care
5. Evaluation of Care (page 16) 2.3. Operating Room VIII. SIGNATURE PAGE (page 63)
6. Leadership and Management (pages 16-17) 2.4. Recovery Room
7. External Services (page 17) 2.5. High Risk Pregnancy Unit

Assessment Tool for


Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 1 of 60
I. GENERAL INSTRUCTIONS: II. GENERAL INFORMATION:
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. Name of Hospital:
2. Assign sections of the tool to corresponding team members.
3. To properly fill-out this tool, the Regulatory Officer shall make use of: Address:
INTERVIEWS,  REVIEW OF DOCUMENTS, OBSERVATION (Number & Street) (Barangay/District)
and VALIDATION of findings.
4. If the corresponding items are present or available, place a ✔on each (Municipality/City) (Province & Region)
of the appropriate boxes alongside each corresponding item. If not,
Telephone No../ Fax No.
put an X instead.
5. The REMARKS column shall document relevant observations both
positive and negative, including innovations and initiatives undertaken E-mail Address:
by those responsible in the facility.
6. Make sure to fill-in the blanks with the needed information. Do not License No (for renewal):
leave any items blank; write N.A. if not applicable.
7. (Sh shaded cell means that specific items are not applicable to the
Date Issued Expiry Date:
hospital level.
8. means the service can be outsourced but must be inside hospital
premises. Hospital Category: Level 1 Level 2 Level 3
9. The Team Leader shall at the end of the inspection or monitoring visit,
make sure that the team members complete their respective tool Philhealth Accreditation:Center of:  Safety  Quality  Excellence
section and proceed to accomplish the Summary of Evaluation (SOE)
or Summary of Monitoring (SOM) Form and if warranted, the Notice of Classification According to Ownership:  Government  Private
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 No. of: Authorized Bed Capacity Implementing Beds
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. Name of Owner or Governing Body (if corporation):
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,
Name of Hospital Administrator, Medical Director or Chief of Hospital
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.

Assessment Tool for


Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 2 of 60
SELF-ASSESSMENT

DOH INSPECTION

DOH MONITORING
CODE STANDARDS CRITERIA INDICATOR EVIDENCE AREA REMARKS
HOSPITAL ADMINISTRATION:
Goal- 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 ●Documented and
1.1.1 and timely financial and implementable policies and
direct support services to all procedures
hospital units. Approved documented policies,
guidelines and procedures on:
Administrative Group: a) Staffing plan
Human Resource b) Recruitment and ● Complete, updated and
Management Selection easily retrievable
There shall be a c) Hiring/Appointment individual personnel file
comprehensive human d) Orientation & Staff ● Evidence of continuous
1.1.1.a resource management plan Development improvement
1.1.1.a.1 which includes recruitment, e) continuing education, and
selection, promotion, training
separation, welfare and Approved documented policies,
benefits in accordance with guidelines and procedures on
applicable laws. a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training

Assessment Tool for


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Effectivity date: 10/01/12
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:
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 Verifier:
●record of schedule of duties Documents review,
●appointment/employment Observe
contract, if valid  Interview staff,
● updated health certificate (as Validate
required) ▪ List of personnel –
● orientation plan/program of check if
new employees implemented Current

Financial Management
1.1.1.b
Group
Accounting
1.1.1.b.1
There shall be a systematic  documented and
recording of all financial implementable policies and Verifier:
transactions, preparation of procedures Documents review, 
financial statements and Interview staff,
relevant reports, and maint- Validate
enance and safekeeping of
Books of Accounts.
Budget
1.1.1.b.2
There shall be a
consolidation and
preparation of the Budget  documented and
Proposal, Work and implementable policies and Verifier:
Financial/ Operational procedures Documents review, 
Plans including its Interview staff,
implementation and Validate
monitoring by the hospital
staff concerned.

Billing And Claims


There shall be a system of Assessment Tool for
Licensure of Hospitals
billing patients and Revision: 00
processing of claims Effectivity date: 10/01/12
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 documented and
implementable policies and
1.1.1.b.3 Billing and Claims documented and implementable
there shall be a system of policies and procedures Verifier:
billing of patients and Documents review, 
processing of claims Interview staff,
Validate
Procurement: ●Policies, guidelines and
1.1.1.c There shall be a procedures on requisition, Documents are readily
comprehensive plan of purchase, issuance and available Verifier:
systematic management of inventory; disposal of non- Documents review,
procurement and functional equipment, Observe
acquisition of supplies, instruments, supplies, expired  Interview staff
materials, drugs and medicines and Validate
healthcare equipment, reagents are in place.
vehicles, services,
infrastructure work and Look for approved Work
other required logistics for and Financial Plan and its
the effective and efficient implementation
delivery of quality services

Verifier:
Property and Supply documented and implementable Proof of transactions Documents review, 
1.1.1.d Management: policies and procedures Documents are readily Interview staff,
There shall be a systematic Available Validate
way of receipt, storage,
issuance and conduct of
inventory .

Linen and Laundry ● Sorting of soiled and Policies, procedures and


1.1.1.e There shall be adequate contaminated linens in guidelines in cleaning and Verifier:
supply of clean linens for designated areas washing of soiled linens Documents review, 
patients and other hospital ● Systematic washing of laundry Interview staff,
units. with safeguard against spread of Validate
infection
● Disinfection of laundry

 Housekeeping ●evidence of continuous Verifier:


1.1.1.f There shall be provision ● Adequate review of policies and Documents review, 
and maintenance of clean, housekeeping procedures Interview staff,
safe and sanitary facilities supplies. Validate
and environment for
hospital personnel, patients
and clients
Assessment Tool for
Licensure of Hospitals
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Effectivity date: 10/01/12
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1.1.1.g . Security
There shall be order within ●Security check for internal and ●evidence of continuous Verifier:
the hospital premises and external customers including use review of policies and Documents review, 
protection of lives, of visitor’s pass procedures Interview staff,
properties and critical Validate
infrastructure from threats,
harm and losses

1.1.1.h  Ambulance Services


(Compliance to A.O. 2010- ●Documented and approved With appropriate Verifier:
0003- National Policy on policies and procedures on manpower, equipment and Documents review,
Ambulance Use and patient transport to and from the supplies during patient Observe,
Services) facility transport  Interview
●24 hour availability of staff&Validate
ambulance for ready use If contracted out; note
●Available contract/ MOA, if specifications in contract or
contracted out MOA
●Logbook on transport of
patients/clients by ambulance to
and from the facility

1.1.1.i Central Information


Management
There shall be a
comprehensive plan of ●documented and Verifier:
systematic management of implementable policies and Documents review,
data and research for the procedures Observe,
improvement of acquisition,  Interview
utilization of finances, staff&Validate
assets and development of
human resources,
operating systems and
procedures.

Assessment Tool for


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Effectivity date: 10/01/12
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1.1.1.i.a Medical Records ● Documented and Verifier:
(Including Dental implementable policies and Documents review, 
Records) procedures Interview staff,
Validate
There shall be an organized ● ICD-10 reference books with
system of recording, additional ICD-10 modification
processing, analyzing,
maintaining and ● Logbooks on: Verifier:
safekeeping of all patients' Admission Documents review, 
records through the written OR Interview staff,
data in sequence of events DR Validate
covering the diagnosis, ER
treatment and discharge of OPD
patients

1.1.1.j Medical Social Services ● Approved documented Verifier:


There shall be policies and policies and procedures and Observe,  Interview
procedures in place records on: staff, Validate
pertaining to social case a)Patient classification according
work, multisectoral to their capacity to pay
networking and linkages in b) Continuity of care
understanding the socio- c) Counselling of patients/clients
behavioral and economic and their families
plight of patients and their d) Records of pre-admission and
families for the holistic pre- discharge assessment, and
approach in their discharge plan
management and treatment
●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)

Assessment Tool for


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Effectivity date: 10/01/12
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1.1,1.k  Nutrition And Dietetics
There shall be maintenance  Actual implementation and  documented and Verifier:
and provision of safe, high evidence of continuous implementable policies Observe,  Interview
quality and nutritious food review of policies and and procedures staff, Validate
to patients and personnel. procedures
 If contracted out; note
specifications in contract or
MOA

1.1.1.l  Pharmacy
There shall be 24 hours, 7  Actual implementation and  documented and
days a week provision of evidence of continuous implementable policies Verifier:
safe, affordable and review of policies and and procedures Observe,  Interview
efficacious drugs and procedures staff, Validate
medicines in accordance
with the Generics Act,
PNDF and DOH policies,
rules and regulations.

Assessment Tool for


Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
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DOH MONITORING
ASSESSMENT

INSPECTION
SELF-

DOH
CODE EVIDENCE
STANDARDS CRITERIA INDICATOR AREA REMARKS
PATIENTS’ RIGHTS AND ORGANIZATIONAL ETHICS
2.1 Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations

2.1.1 DOCUMENT
1.Organizational policies Informed consent is obtained All patient charts have Patient charts – sample Wards
and procedures respect and from patients prior to initiation signed consent. charts of patients currently (sample
support patients' right to of care. admitted. If hospital is size-10
quality care and their department-alized, get charts, if
responsibilities in that care. samples during tour of the department-
different departments. alized, get
two from
Note: *Informed consent - each depart-
includes a patient-doctor ment; when
discussion of the following a chart is
issues: the nature of the found to
decision or procedure; have no
reasonable alternatives to consent
the proposed intervention; before you
the relative risks, benefits, reach 10,
and uncertainties related to you do not
each alternative; have to go
assessment to patient further.)
understanding; and
patient's acceptance or
refusal of the intervention.

Assessment Tool for


Licensure of Hospitals
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Effectivity date: 10/01/12
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2.1.2 2.The organization informs Clinical services are Presence of facilities DOCUMENT REVIEW
the community about the appropriate to patients' needs consistent with clinical List of services available
services it provides and the and the former's availability is service capability based on OBSERVATION:
hours of their availability. consistent with the DOH license in accordance Look at the facilities, ER
organization's service with the hospital’s level (e.g. structure, manpower,
capability and role in the level 1 surgical capability, equipment and supply. OPD
community. level 2 – ICU, level 3– Check if the service
teaching and training capability of the hospital is ICU
hospital). in accordance with
the hospital level. OR

RR

PACU

Assessment Tool for


Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
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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 Entrances and exits are Presence of entrances and OBSERVATION ER
the organization and its clearly and prominently exits that are readily Entrances and exits are OPD
services is facilitated marked, free of any accessible and free from accessible and free from Wards
and is appropriate to obstruction and readily obstruction. any obstruction. ICU
patients' needs. accessible. Note: Exit signs should be OR/RR/
luminous or illuminated DR/PACU
and prominently marked. Imaging
There should be exit signs
Laboratory
in major areas of the
hospital and all doors
leading to the
outside.(Reference: RA
6541 Building Code of the
Philippines)
2.2.1.b 4.Physical access to the Directional signs are Presence of directional ER
organization and its services prominently posted to help signages to locate service OPD
is facilitated and is locate service areas within areas. Wards
appropriate to patients' the organization. Other Areas
needs. Directional signs are Lobby
prominently posted. Check
ER, OPD, wards and lobby.

Alternative passageways for .Presence of alternative OBSERVATION ER


2.2.1.c 5.Physical access to the patients with special passageways (ramps and 1.There are alternative OPD
organization and its services needs(e.g.ramps and elevators) that are passageways for patients Wards
is facilitated and is elevators) are available, prominently marked and with special needs. Check Other
appropriate to patients' clearly and prominently free from obstruction for ER, OPD, wards and areas
needs. marked and free of any patients with special needs. other areas
obstruction. 2. They are prominently
marked and
3. They are free from
obstruction

Assessment Tool for


Licensure of Hospitals
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Effectivity date: 10/01/12
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2.2.2. ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment

6.The organization uniquely All patients are correctly All patients are correctly DOCUMENT and ER
2.2.2.a identifies all patients identified by their patient identified by their charts. INTERVIEW
including newborn infants, charts. Patient chart from ER,
and creates a specific ward, OPD and ICU and
patient chart for each verify with patient if he/she OPD
patient that is readily really is the person Wards
accessible to authorized indicated in the chart. ICU
personnel.

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, An appropriately All patients have CHART REVIEW Wards
psychological and social comprehensive history and comprehensive history and
status is assessed. physical examination is PE within 24 hours from
performed on very patient admission.
within 24 hours from
ER
admission. The history
includes present illness, past DOCUMENT
medical, family, social and
personal history. Patient chart from wards
or ER.

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

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Effectivity date: 10/01/12
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2..2.3.b 8.Appropriate professionals Previously obtained All patient charts have CHART REVIEW Medical
perform coordinated and information is reviewed at progress notes by doctors. Records
sequenced patient every stage of the Office
assessment to reduce assessment to guide future Patient chart from medical
waste and unnecessary assessments. records
repetition. 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
doctor’s order sheet.

2.2.3.c 9.Assessments are Qualified personnel give All patients for surgery have CHART REVIEW
performed regularly and patients for surgery pre- undergone pre-operative Note: Look for pre-
are determined by patient's operative physical and pre- anesthetic assessment. operative anesthetic
evolving response to care. anesthetic assessment. 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

2.3.1 10.Diagnostic examinations Policies and procedures for Proof of monitoring of the DOCUMENT REVIEW X-ray
appropriate to the provider the standard performance, implementation of the Monitoring reports, Laboratory
organization's service monitoring and quality control policies and procedures on e.g..utilization review of
capability and usual case of diagnostic examinations quality control of diagnostic diagnostics exams done,
mix are available and are are documented and examinations audit reports, manual of
performed by qualified monitored. procedures, or DOH
personnel. monitoring reports e.g..
Quality control diagnostic
reports (QC reports on
softwares, calibration of
diagnostic equipment, film
reject analysis, etc.)

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Licensure of Hospitals
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Effectivity date: 10/01/12
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2.3.2.a 11.Drugs are administered Drugs are administered in a All drugs are administered in . For the timeliness of Chart
in a standardized and timely, safe, appropriate and a timely, safe, appropriate drug administration, check Review
systematic manner in the controlled manner. and controlled manner to the the hospital policy. If
provider organization. right patient 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
2.3.2.b 12.Drugs are administered Only qualified personnel All doctors, dentists, nurses Randomly check the Wards
in a standardized and order, prescribe, prepare, and pharmacists have licenses of Pharmacy
systematic manner in the dispense and administer updated licenses doctors,dentists, nurses OPD
provider organization. drugs. and pharmacists. ER

2.3.2.c 13.Drugs are administered Prescriptions or orders are Proof that the prescriptions DOCUMENT
in a standardized and verified and patients are or orders are verified before Procedures on verification
systematic manner in the identified before medications medications are of orders. INTERVIEW
provider organization are administered. administered. Observe 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

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Licensure of Hospitals
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Effectivity date: 10/01/12
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INTERVIEW
2.3.2.d 14.Drugs are administered Prescriptions or orders are Verify from patients if they Medical
in a standardized and verified and patients are were correctly identified Records
systematic manner in the identified before medications prior to drug Room
provider organization are administered. administration.

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

2.3.2.e 15.Drugs are administered Drug administration is All charts have proper CHART REVIEW
in a standardized and properly documented in the documentation of drug Medication sheet in
systematic manner in the patient chart. administration patient chart from the
provider organization medical records.

.
2. EVALUATION 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 All charts have discharge CHART REVIEW
part of the patient's care plans Patient chart from medical
plan and is documented in records room, the
the patient chart. 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.

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Licensure of Hospitals
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Effectivity date: 10/01/12
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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.

17.The organization regularly ● Strategically Posted Vision OBSERVATION


2.5.1.a reviews and updates its and Mission of all the
policies, guidelines and Services
procedures ●Approved Manual of
Operations and/ or Written
Policies, Guidelines and
Procedures on Clinical
Services Offered
●Strategically Posted
2.5.1.b 18.Terms of reference, Functional and
membership and procedures Organizational Chart with
are defined for the meetings Photos Showing Names and
of all committees within the Relationship by Positions
organization. Minutes of Proof of the creation of all
meetings are recorded and committees within the
approved. organization which includes DOCUMENT REVIEW
the terms of reference for
membership

INTERVIEW
1. Ask the management
2.5.1.c Presence of evaluation and team about priorities for
monitoring activities to performance improvement
19.The organization's assess management and that relate to hospital wide
management team regularly organizational performance activities and patient
assesses its own outcomes
performance and the 2. Ask management team
performance of the how targets are set.
organization.

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Effectivity date: 10/01/12
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20. Documented Presence of MOA/ contract DOCUMENT REVIEW
2.6.1 agreements and contracts for all out-sourced services 1.Contracts/MOA for Document
cover external service (e.g. dialysis unit, dietary, outsourced services. review
providers and specify that the laboratory, radiology). 2. Valid licenses of all
quality of services provided (Outsourced are services/ providers of the
must be consistent with facilities provided by third outsourced services.
appropriate set standards. party but are inside the
hospital)

OBSERVATION
Actual presence of the
Imaging
outsourced services within
the hospital if applicable
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 Human Resource Management
3.1.1 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 The organization Presence of policies and Policies and procedures
appropriately trained and documents and follows procedures for for credentialing and
qualified (and where relevant, policies and procedures credentialing and privileging of staff
credentialed) staff are for hiring, credentialing, privileging of staff
available to undertake the
type and level of activity
and privileging of its staff.
performed by the
organization. This includes
those who are consulted
when suitable expertise is
not available within
the organization

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Effectivity date: 10/01/12
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3.1.1.b 22.Workload is monitored Staff numbers and skill Staff to bed ratio for DOCUMENT REVIEW
and appropriate guidelines mix are based on actual licensed doctors, 1. List of total number
consulted to ensure that clinical needs. registered nurses and of licensed doctors and
appropriate staff numbers midwives/nursing aides dentists, registered
and skill mix are available to nurses and midwives/
achieve desired patient and
follow the DOH nursing aides based on
prescribed ratio. HR records and
organizational outcomes.
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.
4.2 RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.
4.2.1 Medical Record
4.2.1.a 23.Clinical records are When patients are admitted ●Presence of policies and DOCUMENT REVIEW
readily accessible to or are seen for ambulatory or procedures on systematic Policies and
facilitate patient care, are emergency care, patient filing, retrieval, retention, procedures on
kept confidential and safe, charts documenting any storage, disposal and systematic record filing,
previous care can be quickly management of medical retrieval. retention,
and comply with all retrieved for review, updating records. Patient’s chart storage, safekeeping
relevant statutory and concurrent use. contents include the and maintenance and
requirements and codes following: disposal.
of practice -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

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Effectivity date: 10/01/12
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24.There shall be an -Doctor’s Progress Notes DOCUMENT REVIEW
organized -Medication and Treatment
system of processing, Record Note also the following:
-Laboratory and X-ray Reports
analyzing, maintaining and 1. ICD-10Coding is being
-Dietary Assessment Nurses
safekeeping of all patients' Progress Notes used.
records through the written -Records of Transfer/Referral to 2. Medical Records
data in sequence of events another Physician or Health Officer is trained on ICD-
covering the diagnosis, Facility 10 Coding and Medical
treatment and discharge of -Inpatient Referral/Consultation Records Management
patients. Notes of Other Physicians
-Final Diagnosis
-Advance Directive, if any

25.Clinical records are readily The organization has policies DOCUMENT REVIEW
Presence of procedures to
accessible to facilitate patient and procedures and devotes Polices and procedures
protect records and patients
care, are kept confidential resources including on records management
charts against loss,
and safe, and comply with all infrastructure to protect for the entire hospital to
destruction, tampering and
relevant statutory require- records and patients charts maintain privacy,
unauthorized access or use
ments and codes of practice against loss, destruction, accuracy and prevent
tampering and unauthorized loss and destruction.
access or use. Only
authorized individuals make OBSERVATION
entries in the patient chart. Observe 20 nurses in the
wards and records
personnel on how they
protect patient chart
against loss, tampering
and unauthorized use.

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Effectivity date: 10/01/12
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6.1 SAFE PRACTICE AND ENVIRONMENT
6x1.1 PATIENT AND STAFF SAFETY
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective
environment of care.
If facility has nuclear ER
6.1.1.a 26.The organization plans a The organizational medicine, ask for the OPD
safe and effective environment environment complies with certificate issued by the Wards ICU OR/
of care consistent with its structural standards and Philippine Nuclear DR/RR
mission, services, and safety codes as prescribed by Research Institute Facilities and
with laws and regulations. law. (PNRI). maintenance
Imaging
Laboratory
Others
6.1.1.b 27.The organization plans a There are management plans Presence of a management DOCUMENT REVIEW
safe and effective environment which address safety, plan addressing safety, Management plan which
of care consistent with its security, disposal and control security, disposal and includes polices,
mission, services, and with of hazardous materials and control of hazardous procedures and
laws and regulations. biological wastes materials and biologic programs, risk
wastes, emergency and assessment, hazards
disaster preparedness, fire surveillance among
Emergency and disaster safety, radiation safety and others that address the
preparedness, fire safety, utility systems. following:
radiation safety and utility 1. Safety
systems. 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
specific procedures.

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Effectivity date: 10/01/12
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6.1.1.c 28.The organization plans a There are management plans Presence of operating DOCUMENT REVIEW
safe and effective environment for the safe and efficient use manuals of the medical
of care consistent with its of medical equipment equipment.
mission, services, and with according to specifications. DOCUMENT
laws and regulations. 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 address safety, security, the policies, procedures and 1. Water safety - water
of care consistent with its control of hazardous safety programs on analysis results for the past
mission and services, and with materials and biological 6 months.
laws and regulations. wastes, emergency and
disaster preparedness, fire
safety, radiation safety and
utility systems are
documented and
implemented.
1. electrical safety 2. Fire and emergency
preparedness - check for
2. medical device safety ER
exit plans, plans for
3. chemical safety earthquake and other
disasters. OPD
4. radiation safety Wards
3. Control of hazardous
5. mechanical safety Imaging
materials - MOA/Contract
of outsourced services for
6. water safety waste management Laboratory
INTERVIEW
1. Ask staff from ER, Wards,
7. combustible material OPD, Laboratory, Pharmacy
safety Pharmacy, and facilities
8. waste management and maintenance on the Facilities and
manner of waste maintenance
segregation and disposal
(general waste, liquid &
solid waste, infectious
waste; non-infectious,
9. hospital safety program hazardous and non- Other areas
(fire, emergency and hazardous
disaster preparedness) 2. Hospital safety program
3. Mechanical safety
program of the hospital

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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

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Effectivity date: 10/01/12
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management program
particularly manner of
radiologic waste
disposal.
OBSERVATION
DOCUMENT REVIEW
Presence 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 ER
mercury)
30.The organization provides a Policies and procedures for Proof of the implementation DOCUMENT
6.1.1.e safe and effective environment the safe and efficient use of of the policies and 1. Operating manual Wards
of care consistent with its medical equipment according procedures for the safe and 2. Preventive and
mission and services, and with to specifications are efficient use of medical corrective maintenance OR/RR/DR
laws and regulations. documented and equipment. logbook
implemented 3. Qualifications of staff Facilities and
handling medical maintenance
equipment
INTERVIEW Imaging
1. Ask staff in the ER,
ICU, wards, OR/RR/DR, Laboratory
facilities and
maintenance, imaging
Other areas
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.

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6.1.1.f 31.The organization provides a The design of patient areas Presence of adequate OBSERVATION ER
safe and effective environment provides sufficient space for space, lighting and 1. Adequate space OPD
of care consistent with its safety, comfort and privacy of ventilation in compliance 2. Adequate lighting Wards
mission and services, and with the patient and for emergency with structural requirements (lights are working, ICU
laws and regulations. care. (for patient safety and lighting is adequate OR/RR/DR
privacy). enough for conduct of Imaging
general activities) Laboratory
3. Adequate ventilation
Pharmacy
Other areas

6x1.1.g 32.The organization provides a Risks are identified, assessed Presence of policies and DOCUMENT REVIEW Document
safe and effective environment and appropriately controlled. procedures on risk policies and procedures review
of care consistent with its Where elimination or identification, assessment on risk identification,
mission and services, and with substitution is not possible, and control. assessment and control,
laws and regulations. adequate warning and security risks and use of
protection devices are used. personal protective
equipment, etc.

33. The organization provides A coordinated security Presence of an appointed Hospital order or Memo.
a safe and effective arrangements in the personnel in charge of
environment of Care consistent organization assures DOCUMENT REVIEW
security.
with its mission and services, protection of patients, staff Policies and procedures on
and with laws and regulations. and visitors. risk identification,
assessment and control,
security risks, use of
personal protective

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equipment, etc.
or Appointment of person
in charge of security
INTERVIEW
Ask the personnel in
6x1.1.h 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 An incident reporting system Presence of incident DOCUMENT REVIEW
collects and evaluates identifies potential harms, reporting system/sentinel ●Minutes of Leadership
information to improve the evaluates causal and event monitoring system meeting
safety and adequacy of the contributing factors for the (which may include ●Incident/sentinel event
environment of care necessary corrective and nosocomial infections, reports or com-
preventive action. unexpected deaths, adverse munications/memoranda/o
drug reactions, flood rders or proceedings on
transfusion reactions, falls, sentinel events
etc).
"Sentinel event" refers to INTERVIEW Wards
injuries caused by medical Ask readers and staff from ER
management (not necessarily wards and ER how the ICU
the disease process) that either incident reporting system OR
caused death, prolonged hospi- works.
talization or produced a dis-
ability during the time of con-
finement or by the time of
discharge.
7.1.2 35. Emergency light and / or Presence of DOCUMENT Facilities and
power supply, water and generator/emergency light, Preventive and corrective maintenance
ventilation systems are water system, adequate maintenance logbooks
provided for, in keeping with ventilation or air for generator/ emergency
relevant statutory requirements conditioning. light/ water tanks/

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and codes of practice. airconditioners . Other areas

OBSERVATION
1. Presence of Facilities and
generator/emergency maintenance
light, water tanks,
adequate ventilation or
air conditioning
2. Test if faucets and
water closets are
working
7.1.3 36.Equipment is serviced only Proof of training of the staff Facilities and
by people trained in the who is in charge of the DOCUMENT REVIEW
maintenance of that maintenance of the Proof of training of service maintenance
equipment. Registers and equipment. personnel if in-house or Imaging
records of equipment and Certificate of Training, Laboratory
related maintenance are kept. attendance sheet,
Certificate of Attendance,
diploma, citation or Other
MOA/Contract for areas
outsourced services
(verify qualification of
technicians).

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7.1.4 37.Current information and INTERVIEW
scientific data from
manufacturers concerning their Ask about how
products are available for equipment (generator,
reference and guidance in the airconditioner, medical
operation and maintenance of devices and other
plant and equipment. 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

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8.1.1.a 38.An interdisciplinary infection Presence of an Infection DOCUMENT
control program ensures the Control REVIEW
prevention and control of Committee (ICC) with DOCUMENT REVIEW
infection in all services. defined goals, objectives, 1. ICC composition (for a
strategies and priorities or primary hospital - proof of
for a primary hospital - a designation of a doctor and
designated doctor and nurse nurse in-charge of = in2.
in-charge of infection ICC functions and activities
control. fection control)
3. Minutes of meeting, at
least quarterly activities
4. 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 DOCUMENT REVIEW
control program ensures the Presence of an infection 1. Policies and procedures
prevention and control of control program ensuring on prevention and control
infection in all services. prevention and control of of nosocomial infection or
infections on all services. 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 The organization takes steps Presence of coordinated Document
coordinated system-wide to prevent and control system-wide procedure for review
approach to reduce the risks of outbreaks of nosocomial isolation of nosocomial
nosocomial infections. infections. infections.
DOCUMENT REVIEW

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Procedures on isolation of ER
nosocomial infections

INTERVIEW Wards
Ask= staff in ER, wards and ICU
ICU the procedures on
isolation
isolation - physical isolation
of a patient with infection

8.1.2.b 41.The organization uses a The organization takes steps Presence of coordinated DOCUMENT Document
coordinated system-wide to prevent and control system-wide procedure for REVIEW Procedures on review
approach to reduce the risks of outbreaks of nosocomial case containment of case containment of
nosocomial infections. infections. nosocomial infections. nosocomial infections ER
Note: case containment Wards
- means prevention of ICU
spread of infection
examples: reverse isolation,
prophylaxis for exposed
personnel, vaccination,
immunization
INTERVIEW
Validate from staff in ER,
.
wards and ICU the
procedures on case
containment
8.1.2.c 42.The organization uses a The organization takes steps Presence of coordinated DOCUMENT REVIEW ER
coordinated system-wide to prevent and control system-wide procedure for Procedures on asepsis Wards
approach to reduce the risks of outbreaks of nosocomial asepsis. INTERVIEW
nosocomial infections. infections. Ask staff from ER, wards, ICU
laboratory and ICU about Laboratory
the approaches for asepsis
during diagnostic and
treatment procedures.
8.1.3.a 43.The organization uses a There are programs for Presence of policies and DOCUMENT REVIEW
coordinated system-wide prevention and treatment of procedures on the 1. Policies and procedures
approach to reduce the risks of needle stick injuries, and prevention and treatment of for prevention and
infection the staff are exposed policies and procedures for needle stick injuries and treatment of needle stick
to in the performance of their the safe disposal of used safe disposal of needles. injuries

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duties. needles are documented and 2. Policies and procedures
monitored. on proper handling and
. safe disposal of ER
sharps/needle sticks Wards
INTERVIEW ICU
Interview hospital staff on Laboratory
how they handle and
dispose needles
OBSERVATION
Presence of receptacles for
proper disposal of sharps.
8.1.3.b 44.The organization uses a There are programs for the Presence of program on DOCUMENT REVIEW
coordinated system-wide prevention of transmission of prevention of transmission of 1. Infection control ER
approach to reduce the risks of airborne infections, and risks airborne infections and risks procedures on isolation Wards
infection the staff are exposed from patients with signs and from patients with signs and and universal precaution ICU
to in the performance of their symptoms suggestive of symptoms suggestive of 2. Program for the Laboratory
duties. tuberculosis or other tuberculosis or other protection of healthcare
communicable diseases are communicable diseases . workers e.g. personal
managed according to
protective equipment
established protocols.
(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
6. Procedures on recycling
& reuse of equipment i.e.
personal protective
equipment

INTERVIEW

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

OBSERVATION
1. Observe for use of OR/DR
gloves, surgical masks.

3. Look for separate


holding area/room for
highly infectious cases.

4. Ask a hospital staff to Ward


demonstrate hand washing ER
technique. OR/DR

8.1.4 45.Cleaning, disinfecting, Presence of policies and DOCUMENT REVIEW


drying, packaging and procedures on cleaning, 1. Policies and procedures
sterilizing of equipment, and disinfecting, drying, on cleaning, disinfecting,
maintenance of associated packaging and sterilizing of drying, packaging and
environment, conform to equipment, instruments and sterilizing of equipment,
relevant statutory requirements supplies. (Refer to Annex__ instruments and supplies.
and codes of practice. Sterilization Guidelines in 2. Policies on
Hospital Setting)
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 Presence of policies and DOCUMENT REVIEW
organization reports procedures on reporting of
information about infections to infections to personnel and
personnel and public health public health agencies.
agencies.

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Presence of policies, DOCUMENT REVIEW
procedures and guidelines INTERVIEW
for safe reuse of items which Ask heads and staff about
comply with relevant the following:
statutory requirements. 1. Policy on reuse of items
2. SOPs on reuse
3. Reporting
4. 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, Presence of

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collection, and disposal licenses/permits/ DOCUMENT
of waste conform to clearances from
relevant statutory
REVIEW
pertinent regulatory Pertinent
requirements and codes agencies implementing
of practice.
among others the licenses/permits
following: RA 9003, RA from regulatory
6969, RA 275, PD 1586 agencies (LGU,
DOH Hospital Waste DENR, etc.)
Management Manual,
RA 8749 (Clean Air Act
9.1.2 48.The organization Proof of implementation of DOCUMENT
implements a waste policies and procedures
disposal program which on waste disposal.
REVIEW
involves reuse, reduction 1. Issuances - memos,
and recycling. guidelines on waste
disposal
2. Contracts with waste
handlers or disposal ER
contractors, (if Wards
applicable) ICU
3. Hospital policy that Imaging
conforms to the joint Laboratory
DOH-DENR circular on
waste management for Facilities and
maintenance
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.

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.

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10.1.1 DOCUMENT REVIEW
49.The organization has 1. Policy creating the QI
a planned systematic program
organization- wide Presence of Quality 2. Proof of meetings or
approach to process Improvement Program similar documents of QA
design and performance Committee activities
measurement, 3. Policies and
assessment and procedures on a
improvement performance
measurement and
improvement

INTERVIEW
50.The organization Validation of alI activities
provides better care Presence of patient thru interview of
10.1.2 service as a result of satisfaction survey pertinent staff including
continuous quality frontliners and
improvement activities. Committee members.
DOCUMENT REVIEW
1. Patient satisfaction
survey results
2.Patient satisfaction
survey
questionnaire(may check
on the domains and
items)

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ASSESSMENT

MONITORING
INSPECTION
CODE POSITION STAFFING CRITERIA INDICATOR EVIDENCE AREA REMARKS
10.1 REQUIREMENT I:

SELF-

DOH

DOH
(Top Management
Positions)

Hospital Administrator
10.1.1 (Optional)

Medical Director/ Chief of  For level 1, must have Verifier:


Hospital or Medical completed at least 20 Documents review, 
10.1.2 Center Chief units towards a Interview staff,
Masters Degree in Validate:
Hospital Administration  Diploma/ Certificate
or Related Course of units earned
AND at least 3 years ● Proof of
experience in a employment/appoint-
supervisory/ ment
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

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Verifier:
10.1.3 Chief of Clinics/Chief  For levels 2 and
Medical Professional 3,must be a Diplomate/ Documents review, 
Services Fellow in a Specialty Interview staff,
area AND at least 5 Validate:
years experience in a  Diploma
supervisory/manageria ● Proof of
l position employment/appointment

10.1.4 Department Head For levels 2 and 3, must be Verifier:


a Diplomate/ Fellow in a
Specialty Society of the Documents review, 
Specialty Department Interview staff,
he/she heads Validate:
●Diploma
●Proof of
employment/appointment

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Chief Nurse/Director ●For level 1, must Verifier:
10.1.5 of Nursing/Deputy have completed at Documents review, 
Director for Nursing least 9 units towards a Interview staff,
Masters Degree in Validate:
Nursing AND at least 2 ●Diploma/ Certificate of
years experience in units earned
nursing ●Proof of
supervisory/managerial
position employment/appointment
●For levels 2 and 3, must
have a Masters Degree in
Nursing AND at least 5
years experience in a
nursing supervisory
position

10.1.6 3.5 Administrative For level I, must have Verifier:


Officer completed at least 20 units Documents review, 
towards a Masters Degree Interview staff,
in Hospital Administration Validate:
or Related Course AND at ●Diploma/ Certificate of
least 3 years experience in units earned
a supervisory /managerial ●Proof of
position.
For levels 2 and 3, must employment/appointment
have completed a Master’s
Degree in Hospital
Administration or Related
Course AND at least 5
years experience in a
supervisory managerial
position.

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SELF – ASSESSMENT
REMARKS

DOH MONITORING
DOH INSPECTION
CODE POSITION STAFFING REQUIREMENT LEVEL 1 LEVEL 2 LEVEL 3
II

11.1 ADMINISTRATIVE
Chief of Hospital /Medical 1 1 1
11.1.1 Director/Medical Center Chief
11.1.2 Administrative Officer 1 1 1
Clerk: 1:50 beds 1:50 beds 1:50 beds
11.1.3.a - Pool
11.1.3.b - Accounting 1 1 1
11.1.4 Medical Records Officer trained in ICD- 1:50 beds 1:50 beds 1:50 beds
10 and Medical Records Management
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 1 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
Medical Records Officer (ICD- 10 and 1 1 1
11.1.13 Medical Records Management trained)
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 1/entrance/exit per
per shift shift
11.1.19 Engineer 1 1
11.1.20 Medical Equipment/Biomedical 1 1
Technician
11.1.1.21 Maintenance Personnel 1 1/shift 1/shift

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11.1.1.22 Mechanic 0 0 1
11.1.1.23 Nutritionist-Dietitian (for level 2 and in 1 (sharing is 1:100 beds 1:100 beds
case of sharing, must be residing within allowed e.g.
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, If 1 1 1
there is MOA with DSWD-LGU, the
Medical Social Worker should be
physically present in the hospital)
11.2 CLINICAL:
11.2.1 Chief of Clinics/Chief Medical 1 1
Professional Services
11.2.2 Department Head 1/ 1/
department department
11.2.3 Consultant Physician (Diplomate/
Fellow of a Specialty/ Sub-Specialty
Society after a formal residency training (number not prescribed)
program)
11.2.4 Physician (must not go on duty more 1:20 beds at any  50 beds = 6  100 beds = 8
than forty-eight (48) hours continuous time plus 1 Every additional Every additional
duty) reliever 50 beds = 50 beds =
additional 2 additional 3
( For
Departments with
accredited
residency training
program, number
will depend on
the requirement
of specialty board
concerned).

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11.3 NURSING:
11.3.1 Chief Nurse/Director of Nursing 1 1 1

11.3.2 Asst. Chief Nurse (maybe 0 100 beds and 100 beds and
designated as above=1 above=1
Training Officer)

11.3.3 Supervising Nurse 1:50 beds 50 beds and


below = 1,
51-100 beds =
1 per department
2,
/special area
101-150 beds =
3,
151 beds and
above = 4
11.3.4 Supervising Nurse (Critical Care
Units) 1 per critical 1 per critical care
-CCUs include all types of ICUs, care unit unit
including Post-Anesthesia Care
Unit
(PACU) and RR

11.3.5 Head Nurse 1:15 RNs 1:15 RNs 1:15 RNs


11.3.6 Staff Nurse 1:12 beds at any 1:12 beds at 1:12 beds at any
-For every three (3) RNs, there time any time time
must be one (1) reliever)
Staff Nurse (CCUs) 1:3 beds at any 1:3 beds at any
-Base the ratio on the actual number time time
of occupied CCU beds at the time of
11.3.7 inspection

Nursing Attendant/ Midwife 1:24 beds at any 1:24 beds at 1:24 beds at any
-Optional if the Authorized Bed time any time plus 1 time plus 1
11.3.8 Capacity (ABC) is less than twenty- reliever reliever
four (24) beds. If the ABC is 24
beds and above, the ratio will apply.
11.3.9 Nursing Attendant/ Midwife (CCUs) 1:15 beds at 1:15 beds at any
-For every three (3) Nursing any time time
Attendants/Midwives, there must be
one (1) reliever
11.3.10 Operating Room Nurse 1/shift 1/shift( may 1/OR/shift( may
increase increase

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depending on depending on the
the average average number
number of OR of OR cases per
cases per day) day)
11.3.11 Delivery Room Nurse 1 per/shift 1/shift( may 1/DR/shift( may
increase increase
depending on depending on the
the average average number
number of of deliveries per
deliveries per day)
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, Adequate Adequate Adequate


registered)

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 1

11.4.11 Respiratory Therapist( may be “on call”


for level 2)

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REQUIRED NUMBER

FINDINGS

ASSESSMENT

MONITORING
INSPECTION
(Indicate actual
no.

SELF –

DOH

DOH
CODE STANDARD REQUIREMENT Level 1 Level 2 Level 3 equipment REMARKS
& instruments)

12.1 EQUIPMENT/INSTRUMENT REQUIREMENT


1.ADMINISTRATIVE
12.1.1
12.1.1.1 Computer with Internet Access 1 1 or more 1 or more
depending on the depending on
need the need
12.1.1.2 Ambulance (Available 24 hours, 7 days a week and 1 1 1
physically present) (Refer to A.O. 2010-0003-
National Policy on Ambulance Use and Services)

12.1.1.3 Standby Generator with Automatic Transfer 1 1 1


Switch (ATS) (KVA may depend on the load)
12.1.1.4 Emergency Light 1/station/ 1/station/lobby/st 1/station
lobby/ airways /lobby/
stairways 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
Refrigerator/Freezer
Osterizer/Blender
Food Conveyor
Food Scale
Exhaust Fan
Utility Cart
Garbage Receptacle with Cover

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13.1 CLINICAL
13.1.1 EMERGENCY ROOM
13.1.1.1 Ambu Bag

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 1 1 1


Medicines.) See annex for the list and
quantity.
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 1
13.1.1.18b  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 1 1 1

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Or anchor.
OUTPATIENT CARE
13.2.1
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 1/OR 1/OR
Oximeter
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/OR
13.3.1.10 10.OR Table 1 1/OR 1/OR
13.3.1.11 11. Ortho Instrument Set 1 1 1
13.3.1.12 12. Oxygen Unit (anchored) 1 1/OR 1/OR
13.3.1.13 13. Sphygmomanometer (non-mercurial) 1 1/OR 1/OR
13.3.1.13a  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

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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

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 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

1.3.7.1 HIGH RISK PREGNANCY UNIT ( Not required in Level 1)


13.7.1.1 1. Cardiac Monitor 1 1
13.7.1.2 2. Fetal Monitor (CTG Machine) 1 1

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13.7.1.3 3. Suction Apparatus 1 1
13.7.1.4 4. Oxygen Unit, Anchored 1 1

13..8.1 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 Ambu Bag 1 1
13..8.1.10 10. Infant Weighing Scale
13..8.1.11 Oxygen Unit
13..8.1.12 Respirator/Mechanical Ventilator
13..8.1.13 Radiant Warmer
13..8.1.14 Infusion Pump/Syringe Pump
13..8.1.15 Glucometer
13..8.1.16 Nebulizer
13..8.1.17 Pulse Oximeter
13..8.1.18 Neonatal Stethoscope
13..8.1.19 Suction Apparatus
INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1
Air-conditioning Unit
Ambu Bag
Adult (in adult units)
Pediatric (in pediatric units)
Bed with Guard Rail
Cardiac Monitor
Defibrillator
ECG Machine
Emergency Cart with emergency
Medicines(Refer to annex for medicines and
supplies)
Laryngoscope with Blades
Endotracheal Tube

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Oxygen Unit
Sphygmomanometer (non-mercurial
Adult Cuff (in adult units
Pediatric Cuff Set (in pediatric units)
Stethoscope
Suction Apparatus
Tracheostomy Set
Pulse Oximeter
Mechanical Ventilator
Infusion Pump
NURSING UNIT OR WARD
Ambu Bag
Adult (if Adult ward)
Pediatric ( if Pediatric ward)
Clinical Weighing Scale (per nursing unit)
ECG Machine
Emergency Cart or its equivalent (per
nursing unit)
Mechanical Bed/Patient Bed with Side Rails Actual bed Actual bed count Actual bed
(Patient beds in ER, Labor Room, and Critical count should should count should
Areas are not included in the count) correspond to correspond to correspond to
ABC applied ABC applied for. ABC applied
for. for.
Bedside Table should correspond to total beds
Laryngoscope with different Sizes of Blades
Nebulizer 1 1/Medical/ 1/Medical/
Pedia ward Pedia ward
Neurological Hammer

Oxygen Unit, Anchored


(may increase depending on the need)
Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
Stethoscope
Suction Apparatus
Thermometer (non- mercurial)
CENTRAL STERILIZING & SUPPLY ROOM

Autoclave ( may increase depending on

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the need)
Steam Sterilizer ( may increase depending 0 1 1
on the need)

DENTAL CLINIC

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

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AMBULATORY SURGICAL CLINIC
Use checklist for Ambulatory Surgical Clinic

PHYSICAL MEDICINE AND REHABILITATION UNIT

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

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LEVEL 1 LEVEL 2 LEVEL 3
PHYSICAL PLANT-
REQUIRED ROOMS AND AREAS:

• 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
 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)

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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
• Toilet
SOCIAL WELFARE/SERVICE
• Social Worker’s Office
• Counselling Area
MORGUE for Level 3, Cadaver Holding Area
for Level 1 and 2
• Pathologist Office
• Autopsy Area
• Shower Area
• Toilet
CLINICAL SERVICE
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
• 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 (MAY BE

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COMBINED WITH ER FOR LEVEL 1)
• 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
• Surgery May be
• Anesthesia combined
• Emergency Medicine
OPERATING 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 Closet
RECOVERY ROOM
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

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• Janitor’s Closet

LABOR ROOM
• Toilet

NEONATAL INTENSIVE CARE UNIT


• Work Area with Sink
• Newborn Care Area
• Treatment Area
• Viewing Area
• Breastfeeding Area with lavatory
INTENSIVE CARE UNIT
• Nurses’ station with sink
• Medication Area with sink
• Patient Area
• Toilet
NURSING UNIT/WARD
• Nurse Station
• Toilet
• Patient Area
• Dressing Area
• Equipment & Supply Storage Area
• Patients Room (Separate Male from
Female)
• Toilet ( Separate Male & Female)
• Utility Area
• Linen Area
• Toilet
• Treatment Area
• Medication Area w/ lavatory
• With Color-Coded Waste Bins
• Janitor’s Closet
• Nursing Office; Office of Chief Nurse
• Toilet
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

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• 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)

• 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

• Consultation room
• Toilet
CENTRAL SUPPLY ROOM
• Receiving and Cleaning Area
• Inspection Area
• Packaging Area
• Sterilizing Area
• Sterile Supply Storage Area
• Releasing Area
PRAYER ROOM (AREA FOR LEVEL 1)

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ASSESSMENT
CODE STANDARDS CRITERIA INDICATORS EVIDENCE AREA REMARKS

MONITORING
INSPECTION
SELF –

DOH
41 B.DOH Programs • Documented policies: Actual implementation and Verifier:
Implemented in the  To ensure adequate evidence of continuous Documents review,
Hospital> supply of safe blood review of policies and Observe
41x1 1.Blood Services and blood products. procedures  Interview staff
Compliance to RA 7719  blood and blood Validate
and its IRR, AO 2008- products obtained from
0008 Levels 1 and 2, blood service facilities
should be at least a licensed by DOH
Blood Station Facility and  for BC, blood and
level 3, Blood Bank Facility blood products
collected, obtained
from healthy voluntary
 blood donors only

41x1.a 1.2 Level 3 hospital should • Documented policies: Verifier:


be a Blood Bank (BB)  To ensure adequate Documents review,
facility supply of safe blood Observe
and blood products  Interview staff
Validate
 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

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2.Health Promotion Verifier:
41x2 and Disease • Documented policies Documents review,
Prevention regarding NewbornScreening Observe
41x2,a 2.1 Newborn Screening  Interview staff
- Compliance to • Logbook of Newborns who Validate
RA9288 and it’s were tested and copies of
IRR waiver for those who were not
screened

41x3 2.2 Mother-Baby Friendly • Documented policies Verifier:


Hospital Initiative regarding Rooming-In and Documents review,
practice of Breastfeeding Observe
• There should be no nursery  Interview staff
- Compliance to RA for normal newborns Validate
41x3.a 7600 and its IRR • Breastfeeding area should
and R.A. 10028 be provided at the pathologic
and its IRR nursery
- Milk Code (EO • Certification as “Mother –
No. 5 Baby Friendly Hospital”
• Certification as “Mother –
Baby Friendly
Workplace”

• Documented policies and Verifier:


41x4 2.3 Healthy Lifestyle SOPs specific to the program Documents review,
Advocacy Observe
 Interview staff
Validate

41x5 2.4 Family Planning • Documented policies and Verifier:


SOPs specific to the program Documents review,
Observe
2.5. Immunization  Interview staff
(Republic Act No. Validate
309)
• Documented policies
2.6. Anti-Smoking • No smoking signages posted
Program at conspicuous areas
(per RA 9211)

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3.Generics Act of • Documented policies
41x8 1988 implementing the EDPMS Actual implementation and
(R.A.6675) in compliance with DOH evidence of continuous Verifier:
41x8.a A.O. No.2008-0014”Guidelines review of policies and Documents review,
1. e-EDPMS- on the procedures; reports on Observe
R.A.7581”Price Act Pilot Implementation of the uploading of essential drug  Interview staff
of 1992; R.A. e-EDPMS and A.O. No. prices, etc. Validate
9502”Universally 2011-0012 “Implementing
Accessible Cheaper and Guidelines on Electronic
Quality Drug Price Monitoring
Medicines Act of 2008” System Version 2.0”
Verifier:
Visit hospital pharmacy and
document review, Validate

4. Health Emergency • With designated HEMS ●Hospital/Office order


41x9 Management Coordinator designating one Verifier:
Service(HEMS) • Documented Health Documents review,
A.O. No. 2004-0168, “ Emergency Preparedness, ●Proof of implementation of Observe
National Response and Recovery Plan the plan.  Interview staff
Policy on Health Validate
Emergencies
and Disasters”

41X9.a
• Conduct of drills/exercises ● Documentation of
i.e, Fire,Earthquake, etc. (For drills/exercises conducted.
fire, it should be supervised by
the Bureau of Fire Protection). ● Evacuation Plan/Route
posted in every room/area

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Written Written Policies Updated and Reports/ Records
Designation of and Procedure Relevant Minutes of Implementation
CODE Members and of Meeting
42 C.HOSPITAL COMMITTEES: their REMARKS
roles/functions

1.Credentials
42x1
2.Blood transfusion
42x2
3.HIV/AIDS Core Team
42x3
4.Waste Management
42x4
42x5 5.Patient Safety
40x6 6.Infection Control
40x7 7.Pharmacologic/Therapeutics

8.Health Emergency/
428 Crisis Management

42x9 9.CQI
10.Tissue
42x10 (for levels 2 and 3 only)

11.Ethics
42x11 (for levels 2,and 3 only)

12.Grievance
42x12

Other committees, please


42x13 specify

Verifier: Documents review and  Interview staff

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SERVICES (levels 1 & 2) / DEPARTMENT (level 3)
CODE D.HOSPITAL OPERATIONS:
(The following Criteria
43 Requirements are applicable

Emergency

Anesthesia
OB/ Gyne

Pediatrics
Medicine

(Delivery
only to level 3 ).

Surgery
Room)
REMARKS

Rehab
OPD

OR
1.Clinical Practice Guidelines
(CPG)
43x1
2.Recording, Reporting,
Records Keeping
43x2
43x3 3.Inter/Intra Departmental
Referrals

4.Disaster
43x4 Management/Crisis
Management
5.Infection Control
43x5
6.Drug Management and
43x6 Control
7.Blood Service
43x7
8.Pre-Operative and Post-Op
43x8 Care
43x9 9.Triaging (when applicable)
10.Referrals/ Transfer
43x10
11.Others, please specify
43x11

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ASSESSED BY:

_______________________________ _______________________________ _______________________________ ________________________________


Signature over Printed Name Signature over Printed Name Signature over Printed Name Signature over Printed Name

_______________________________ _______________________________ _______________________________ ________________________________


Position Position Position Position

_______________________________ _______________________________ _______________________________ ________________________________


Date Date Date Date

_______________________________ _______________________________ ________________________________


Signature over Printed Name Signature over Printed Name Signature over Printed Name

_______________________________ _______________________________ ________________________________


Position Position Position

_______________________________ _______________________________ ________________________________


Date Date Date

CONCURRED BY:

_______________________________
Signature over Printed Name

_______________________________
Position/Designation

_______________________________
Date

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