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Annex K - 1 Level 1- Hospital
DOH assessment tool for licensing a hospital
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
ANNEX K - 1
AO No. 2012-0012
ASSESSMENT TOOL FOR LICENSING A HOSPITAL
GENERAL INSTRUCTIONS IN FILLING OUT THE TOOL:
1. The team shall make sure they have the complete set with the following:
Standards/Indicators for a specific Level of hospital, Attachments A, B and C.
2. The team leader shall assign sections of the assessment tool to corresponding team
members.
3. The Licensing Officer shall make use of: DOCUMENT REVIEW, INTERVIEW AND
OBSERVATION to validate findings. The team members should not limit their tour to
the areas suggested under Column "AREAS".
4. If the corresponding items are present or available, place a check (√) on the column
“COMPLIED” opposite each box alongside each corresponding item; if not, put an
(X).
5. The team shall document relevant observations both positive and negative, including
innovations and initiatives undertaken by the facility under "REMARKS" Column.
Indicate also if the service/s is/ are “ADD ON” in this column.
6. The Team Leader shall at the end of the inspection or monitoring visit, make sure that
the team members complete their respective tool sections.
7. The team leader shall ensure that all team members write down their printed names,
designation and affix their signature and indicate the date of inspection or monitoring at
the last page of the Assessment Tool.
8. The Team Leader shall make sure that the Head of the facility or, when not available,
the authorized 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.
9. The team shall provide a copy of the accomplished and signed assessment tool to the
facility.
10. The assessment tool shall be used for self-assessment, inspection and monitoring
activities.
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ANNEX K - 1
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I. HEALTH FACILITY INFORMATION
Name of Facility: _____________________________________________________________________________
Address:
_____________________________________________________________________________
_____________________________________________________________________________
Geographic Coordinates of the Facility:
Latitude: _______________
Longitude: _______________
Email Address: _____________________________________
Tel. / Fax Nos.: __________________________
Name of Owner: ____________________________________
Tel. / Fax Nos.: __________________________
Hosp. Administrator: _________________________________ Tel. / Fax Nos.: __________________________
Chief of Hospital/Med. Director: _______________________
Tel. / Fax Nos.: __________________________
License To Operate: _________________________________
Authorized Bed Capacity: __________________
Classification:
General
Government:
Private:
National
Single Proprietorship
Local
Corporation
Others: (specify) ____________________
Type of application:
Specialty
Initial
Others: (specify) ____________________
Renewal
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ANNEX K - 1
AO No. 2012-0012
DOH STANDARDS (Indicators) for LEVEL 1 HOSPITAL
CRITERIA
(This refers to the specific
and measurable indicators
that help determine
whether or not the
standard has been met.)
INDICATOR
(This is the
REQUIREM ENT of the
standard. This is what
Licensing Officers will
look for. It refers to
measurable variables or
characteristics used to
determine the degree of
adherence to a standard.)
EVIDENCE
(Proof of compliance to
the indicator: document,
interview or observation)
AREAS
(Not limited
to the
suggested
areas)
Put a check
if complied.
REMARKS
I.
PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other
organizations
Standard: Organizational policies and procedures respect and support patients' rights to quality care and their
responsibilities in that care. (A standard shall be expressed as a general statement. This is the ideal
performance.)
1. Informed consent is
All patient charts have
DOCUMENT
Wards
obtained from patients
signed consent.
Patients charts – get
prior to initiation of
charts of patients
care.
currently admitted. If
hospital is
departmentalized, get
Note: *Informed consent samples during tour of
includes a patient-doctor
the different
discussion of the nature of
departments.
the decision or
procedure; alternatives to
INTERVIEW
Ask patient/family from the
the proposed
wards/ICU if they were
intervention; the risks,
appropriately informed by
benefits, and uncertainties
authorized personnel
related to each
(doctor or nurse) about
alternative; assessment to
their disease, condition or
patient understanding;
disability, its severity,
and patient's acceptance
prognosis, benefits and
or refusal of the
possible adverse effects of
intervention.
treatment options and the
likely cost of treatment.
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ANNEX K - 1
AO No. 2012-0012
CRITERIA
2. Policies and
procedures which
identify and address
patients’ rights and
responsibilities are
documented and
monitored.
INDICATOR
EVIDENCE
Presence of policies and
procedures to identify
and address patients'
rights (including rights
of incompetent patient,
i.e. minors):
DOCUMENT
REVIEW
Policies and procedures
on patients' rights, i.e.
use of restraints,
patient’s refusal, etc.
1. Right to information
2. Right to refuse
treatment
3. Right to privacy
4. Right to personal
choice
5. Right to care and
security of personal
belongings
6. Right to freedom
from restraint
7. Right to freedom
from abuse,
mistreatment and
abuse, etc.
AREAS
COMPLIED
REMARKS
Wards
INTERVIEW
May ask a staff (doctor
or nurse) to enumerate
patients’ rights or ask
some patients at random
if their rights were
explained to them.
OBSERVE
If patients’ rights are
posted in conspicuous
places.
II. PATIENT CARE
A. ACCESS
Goal: The organization is accessible to the community that it aims to serve.
Standard: The organization informs the community about the services it provides and the hours of their
availability.
3. 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.
4. A multi-level ramp
shall have a minimum
clear width of 1.22
meters in one direction
and slope is 1:12; an
elevator which can
accommodate at least a
patient bed, provided if
there is no ramp; Ramp
is provided at the
entrance if it is not at
the same level with the
inside
Presence of facilities
consistent with clinical
service capability as
stipulated in its DOH
LTO which is posted and
displayed in a
conspicuous area visible
to clients.
Presence of ramp or
elevator
DOCUMENT
REVIEW
1. List of services
available
2. DOH LTO (updated,
valid and original).
3. PNRI certification
(when applicable)
ER
OPD
OR/RR
OBSERVE
The facilities, and
structure. Check if the
service capability of the
hospital is in accordance
with the health facility
level. including “Add
On” Services
OBSERVE
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ANNEX K - 1
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CRITERIA
5. LEVEL 1
CLINICAL AND
FACILITIES FOR
IN PATIENTS Intensive to highly
specialized care and
management
6. NURSING
SERVICES
Moderate Nursing Care
and Management
INDICATOR
Clinical services at least
for:
- Medicine
- Pediatrics
- Obstetrics and
Gynecology
- Surgery
- Anesthesia
Licensed and
appropriately trained
nursing personnel
assigned in special and
critical areas
7. OTHER CLINICAL
SERVICES – “ADD
ONS”
8. 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
9. Directional signs are
prominently posted to
help locate service
areas within the
organization.
Presence of directional
signages to locate
service areas
10. Alternative
passageways for
patients with special
needs (e.g. ramps) are
available, clearly and
prominently marked
and free of any
obstruction.
Presence of alternative
passageways (ramps,
elevators) that are
prominently marked and
free from obstruction for
patients with special
needs
EVIDENCE
AREAS
COMPLIED
REMARKS
DOCUMENT
REVIEW
OBSERVE
DOCUMENT
REVIEW
PRC Valid license
Certificate of relevant
training
Use applicable
Assessment tools of
other health facilities, if
merited. (i.e. ASC,
Dialysis clinic)
Refer to separate
checklist for other
services
OBSERVE
1. With entrance and
exit signs. Check ER,
OPD and wards
2. Entrances and exits
are accessible and free
from any obstruction
Note: Exit signs should
be luminous or
illuminated and
prominently marked.
There should be exit
signs in major areas of
the hospital and all
doors leading to the
outside.(Reference: RA
6541 Building Code of
the Philippines)
OBSERVE
Directional signs are
prominently posted.
OBSERVE
Check:
1. Alternative
passageways for
patients with special
needs.
2. They are
prominently marked
3. They are free from
obstruction.
Wards,
ER, OPD
ER
OPD
Wards
OR/RR/DR
Imaging
ER
OPD
Wards
Others
(Lobby)
ER
OPD
Wards
Other areas
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CRITERIA
INDICATOR
EVIDENCE
11. Corridors conform
with standard
measurement
Corridors used as access
for patients using bed or
stretcher are at least 2.44
meters while in areas not
commonly used for bed
or stretcher are at least
1.83 meters
The contents of patient's
charts
are the following:
1. Summary or face
sheet
2. Informed Consent
3. History and Physical
Examination
4. Doctor's order
5. Nurses Notes
6. TPR Sheet
7. Laboratory report
8. Imaging reports
9. Maternal Record with
Partograph (if
warranted)
10. Newborn record and
maturity rating, (if
warranted)
11. Medication and/or
treatment record
12. Operative and
anesthesia record (if
warranted)
13. Record of
interdepartmental
referral/consultation
to other physicians,
including notes
14. Record of referral or
transfer of patient to
other
facility/service/doctor
including notes
15. Discharge summary
16. Clinical abstract
17. Advance directive,
DOCUMENT
Patient chart from ER,
ward, and OPD
COMPLIED
REMARKS
OBSERVE
12. All patients are
correctly identified by
their patient charts,
including newborn
AREAS
ER
OPD
Wards
INTERVIEW
verify with patient if
he/she really is the
person indicated in the
chart.
OBSERVE
Check newborn tags if
compatible with the
mother
whenever
applicable
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AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals.
Standard: The care plan addresses patient's relevant clinical, social, emotional and religious needs
13. The plan of care,
Presence of
DOCUMENT
Wards
aside from delineating adopted/developed
Adopted/developed
ER
responsibilities,
protocols, CPGs or
protocols, CPGs or
OPD
includes goals to be
pathways containing
pathways containing
ICU
achieved, services to
goals to be achieved,
goals to be achieved
be provided, patient
services to be provided,
services to be provided
education strategies to patient education
patient education.
be implemented, time
strategies to be
frames to be met, and
implemented, time
OBSERVE
resources to be used.
frames to be met and
Check if medicines and
resources to be used
treatment prescribed are
in accordance with
adopted CPGs/protocols
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care
Standard: Each patient's physical, psychological and social status is assessed
14. An appropriate
All patients have
DOCUMENT
Wards
comprehensive
comprehensive history
Patient chart from wards
history and physical
and PE within 48 hours
or Medical Records have Medical
examination is
from admission.
complete history and
Records
performed on every
P.E.
Office
patient within 48
hours from admission.
The history includes
present illness, past
medical, family,
social and personal
history.
Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and
unnecessary repetition.
15. Previously obtained
All patient charts have
CHART REVIEW
Medical
information is
progress notes by
Patient chart from
records
reviewed at every
doctors and other health
medical records/wards.
room
stage of the
professionals.
assessment to guide
Note: The progress notes Wards
future assessments
should be done regularly
and documented in the
patient chart either as
separate progress notes'
sheets or separate
column
16. Nurses make use of
Charts have progress
CHART REVIEW
Wards
Nursing Process in
notes by nurses as
Patients’ charts from
the care of patients
evidenced by their
medical records or wards Medical
nurses’ notes
have nurses’ notes
Records
Office
Presence of Nursing
DOCUMENTS
manual and properly
Patients’ charts
utilized Kardex
Kardex
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ANNEX K - 1
AO No. 2012-0012
CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Standard: Assessments are performed regularly and are determined by patients’ evolving response to care.
17. Qualified personnel
give patients for
surgery pre-operative
physical and preanesthetic assessment
All patients for surgery
have undergone preoperative physical and
pre-anesthetic
assessment
CHART REVIEW
Patients’ charts of
surgery / OB-Gyne
patients who have
undergone surgery and
presently admitted.
Surgical /
OB-Gyne
Wards
Note: Look for written and
legible pre-operative
physical and (e.g.. Cardiopulmonary clearance if
warranted) pre-operative
anesthetic evaluation and
surgical safety checklist in
the patient's chart. Preoperative assessment
should be done for patients
requiring more than local
anesthesia.
B. IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients
Standard: Medicines are administered in a standardized and systematic manner. Diagnostic examinations
appropriate to the provider organization’s service capability and usual case mix are available and are
performed by qualified personnel
18. Policies and
There is Quality control
DOCUMENT
Laboratory
procedures for the
on diagnostic
REVIEW
X-ray
standard performance, examinations including
Proof of monitoring of
CSSD
monitoring and
film reject analysis, etc.
implementation of the
quality control of
and
policies and procedures
diagnostic
calibration of diagnostic
on quality control of
examinations
equipment
diagnostic examinations
19. Medicines are
administered in a
timely, safe,
appropriate and
controlled manner
All medicines are
administered observing
the five (5) R's of
medication which are:
1. Right
2. Right
3. Right
4. Right
5. Right
20. Only qualified
personnel order,
prescribe, dispense
prepare, and
administer drugs.
patient
medication
dose
route
time
All doctors, pharmacists
and nurses have updated
licenses
CHART REVIEW
Check patients charts
from the wards:
For the accuracy of
medicine administration
INTERVIEW
Ask patients if the five
(5) R’s were observed
during administration of
any IM, IV and oral
medications
INTERVIEW
Randomly check the
licenses of some doctors,
nurses and pharmacists if
they are updated.
ER
Wards
Wards
Pharmacy
ER
OPD
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CRITERIA
21. Prescriptions or
orders are verified
and patients are
identified before
medications are
administered
INDICATOR
Proof that prescriptions
or orders are verified
before medications are
administered
EVIDENCE
DOCUMENT
REVIEW
Procedures on
verification of
prescriptions and orders
AREAS
COMPLIED
REMARKS
Wards
ER
INTERVIEW
Ask staff how they
verify orders from
doctors prior to
administration of
medicines.
22. Patients are identified
before medicines are
administered
23. Medicine
administration is
properly documented
in the patient chart
Proof that patients are
correctly identified prior
to administration of
medications
All charts have proper
documentation of
medicine administration.
OBSERVE
How staff verifies the
prescriptions or orders
for medicines with the
doctor’s order.
INTERVIEW
Verify from patients if
they were correctly
identified prior to drug
administration.
OBSERVE
if the staff verifies the
identity of patient prior
to administration of
medications (patient
should be the one to state
his/her name.)
CHART REVIEW
Medication sheet in
patient chart from
medical records or from
the wards
Wards
ER
Medical
records
office
wards
OBSERVE
Note if complete doses
were given
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CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
C. EVALUATION OF CARE
Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of
care delivered to patients.
Standard: The discharge plan is part of the patient's care plan and is documented in the patients’ chart.
24. Discharge plans for
All charts have discharge CHART REVIEW
Medical
patients to ensure
plans.
Patients' charts from
records
continuity of care.
medical records, look at
room
the discharge orders. It
wards
should contain all of the
following:
1. May go home order
2. Home medications
(if applicable)
3. Follow up
visits/schedule
4. Home care/advise
Note: Discharge plan is
not synonymous with
discharge summary.
III. LEADERSHIP AND MANAGEMENT
A. MANAGEMENT REVIEW
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
Standard: The provider organization's management team provides leadership, acts according to the
organization's policies and has overall responsibility for the organization's operation, and the quality of its
services and its resources
25. Organizational
Structure/Chart
26. The organization and
its services develop
their vision, mission
and corporate goals
based on agreed-upon
values
27. The organization and
its services develop
their policies and
procedures.
Presence of
organizational structure
Presence of written
vision, mission, and
goals of the hospital and
all services/departments
Written policies and
procedures manual for
all services / departments
/ units
OBSERVE
Observe if the
organizational structure /
chart is posted in
appropriate area.
DOCUMENT
REVIEW
Written vision, mission
and goals
DOCUMENT
REVIEW
1.Written Policies
2.Procedure manual
Other Areas
Lobby
Medical,
Nursing and
Administrative
Services
Laboratory
Medical,
Nursing and
Administrative
Services
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ANNEX K - 1
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CRITERIA
INDICATOR
EVIDENCE
AREAS
28. Committees within
the organization
which includes the
terms of reference for
membership
Proof of the creation of
all committees within the
organization which
includes the terms of
reference for
membership.
DOCUMENT
REVIEW
Proof of the creation of
all committees which
includes the terms of
reference for
membership e.g. memo,
office order, etc.
- written policies and
procedures
- minutes of meetings of
the different committees
Administrative office
29. Evaluation and
monitoring activities
to assess management
and organizational
performance
The following are the
committees required:
1. Credentialing and
privileging
2. Blood Transfusion
3. Healthcare Waste
Management
4. Patient Safety
5. Infection Prevention
and Control
6. Antimicrobial
Stewardship
(functional by 2018)
7. Pharmacologic and
Therapeutic
8. Emergency and
Disaster
Preparedness
9. CQI
10. Grievance
Presence of evaluation
and monitoring activities
to assess management
and organizational
performance
COMPLIED
REMARKS
INTERVIEW
Ask members of the
different committees
their functions, how
often they meet, etc.
DOCUMENT
REVIEW
Evaluation activities to
assess management and
organizational
performance such as
semestral or annual
reports or Performance
and Budget Utilization
Review
Administrative
Office
INTERVIEW
1. Ask the management
team about priorities
for performance
improvement that
relate to hospital wide
activities and patient
outcomes
2. Ask how targets are
set.
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CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
B. OUTSOURCED SERVICES
30. Outsourced services
are within the facility
1.
Presence of all
outsourced services
DOCUMENT
REVIEW
1. Contracts/MOA for
outsourced services
2. Valid licenses of all
providers
3. Check contracts / job
orders
Administrative
Office
ADMINISTRATIVE SERVICES
A. Dietary
B. Linen/ Laundry
There shall be provision
of safe, quality and
nutritious food to
patients.
Diet prescription or diet
counselling is provided
to patients
If not contracted out,
there shall be:
DOCUMENT
REVIEW
- Check policies and
procedures in the dietary.
- Monthly menu for
patients
DOCUMENT
REVIEW
Check procedures on
how soiled linens are
collected disinfected and
washed.
C. Security
Policies and procedures
on security of patients,
visitors and hospital staff
DOCUMENT
REVIEW
Security check for
internal and external
customers including use
of visitor’s pass
D. Housekeeping /
Janitorial
There shall be provision
and maintenance of
clean, safe and sanitary
facilities and
environment for hospital
personnel, patients and
clients
E. Proper Waste
Disposal
Policies and
procedures on proper
waste disposal.
F. Maintenance
Proof of implementation
of policies and
procedures
Administrative Office
- Sorting of soiled and
contaminated linens in
designated areas
- Systematic washing of
laundry with safeguard
against spread of
infection
- Disinfection of laundry
DOCUMENT
REVIEW
Proof of implementation
of policies and
procedures on proper
waste disposal.
OBSERVE
INTERVIEW
Lobby
ER / OPD
Wards
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CRITERIA
G. Ambulance
INDICATOR
(Use separate assessment
tool for Ambulance)
EVIDENCE
AREAS
COMPLIED
REMARKS
OBSERVE
INTERVIEW
2.
ANCILLARY SERVICES
A. Secondary Clinical
Laboratory
(Use separate tool for
Clinical Laboratory)
B. Level 1 Imaging
Facility
C. Pharmacy
D. Blood Station for
Level 1
DOCUMENT
REVIEW
Open 24/7, providing
safe, affordable and
efficacious medicines
There shall be 24 hours /
7 days a week provision
of safe blood
Check for Certificate of
Compliance or License
To Operate, whichever is
applicable, from Center
for Device Regulation,
Radiation Health and
Research (CDRRHR),
FDA
DOCUMENT
REVIEW
Check for Certificate of
Compliance or License
To Operate, whichever is
applicable, from Center
for Drug Regulation and
Research (CDRR), FDA
DOCUMENT
REVIEW
IV. HUMAN RESOURCE MANAGEMENT
A. HUMAN RESOURCES PLANNING
Standard: 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.
31. The organization
documents and
follows policies and
procedures for hiring,
credentialing, and
privileging of its staff.
Presence of policies and
procedures for hiring,
credentialing and
privileging of staff
32. Staff numbers and
skill mix are based on
actual clinical needs.
Staff to bed ratio for
licensed doctors,
registered nurses and
midwives/nursing aides
follows the DOH
prescribed ratio. (Refer
to Attachment of
Assessment Tool for
Personnel)
(Trainees, except
physicians
undergoing residency
training and
volunteers not
included)
DOCUMENTREVIEW
Policies and procedures
for hiring, credentialing
and privileging of staff
INTERVIEW
DOCUMENTREVIEW
1. List of licensed doctors
and nurses based on
HR records
2. Payroll
3. Schedule of duties for
the previous and
current month
4. Number of beds
authorized by DOH
and actual beds being
used
Personnel
/Administrative office
Personnel
/Administrative office
Wards
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CRITERIA
INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
B. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES
Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are consistent
with the organization's human resource policies.
Standard: There are relevant orientation, training and development programs to meet the educational needs of
management and staff.
33. Professional
qualifications are
validated, including
evidence of
professional
registration /license
where applicable,
prior to employment
Presence of Qualification
Standards
34. The staff are provided
with a documented
job description
outlining
accountabilities and
responsibilities
Staff provided with job
description outlining
their accountabilities and
responsibilities
DOCUMENT
REVIEW
Check Qualification
Standards; procedures in
hiring.
OBSERVE
Check PRC License of
some MDs. Nurses,
Pharmacists
DOCUMENT
REVIEW
Written job descriptions
with conforme
Personnel
/Administrative office
Personnel
/Administrative office
C. STAFF TRAINING AND DEVELOPMENT
Goal: A comprehensive program of staff training and development meets individual and organizational needs.
Standard: There are relevant orientation, training and development programs to meet the educational needs of
management and staff.
35. New personnel , new
graduates and external
contractors- are
adequately supervised
by qualified staff
Proof that new personnel
are adequately oriented
and supervised
DOCUMENT
REVIEW
Documentation of
orientation conducted
Personnel
/Administrative office
INTERVIEW
Ask new personnel about
the lines of authority and
supervision and if the
supervision is adequate
36. Annual plan on
training activities
Presence of annual plan
on training activities
OBSERVE
DOCUMENT
REVIEW
Personnel
/Administrative office
Annual plan (including
resource/budgetary
allocation) on training
activities
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INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
V. INFORMATION MANAGEMENT
A. DATA COLLECTION AND AGGREGATION
Goal: Collection and aggregation of data are done for patient care, management of services, education and
research.
Standard: Relevant, accurate, quantitati ve and qualitative data are collected and used in a timely and efficient
manner for delivery of patient care and management of services
37. Records are stored,
retained and disposed
of in accordance with
the guidelines set by
National Archives of
the Philippines (NAP)
Policies and procedures
on record storage,
retention and disposal.
38. The organization
defines data sets, data
generation, collection
and aggregation
methods and the
qualified staff who
are involved in each
stage
Presence of annual
statistical reports and
other additional hospital
statistics as determined
by the management
Presence of qualified
staff involved in data
definition, generation,
collection and
aggregation
DOCUMENT
REVIEW
Policies and procedures
on record storage,
retention and disposal.
OBSERVE
DOCUMENT
REVIEW
1. Compilation of
Annual Hospital
Statistical Report
2. Other additional
statistics as
determined by the
management or
hospital forms that
serve as instruments
for data collection
and aggregation
3. Proof of
training/seminar on
Basic Records
Management and ICD
10 Coding of staff in
charge
Medical
records
room
Medical
records
room
B. RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.
Standard: Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and
comply with all relevant statutory requirements and codes of practice.
39. When patients are
admitted or are seen
for ambulatory or
emergency care,
patient charts
documenting any
previous care can be
quickly retrieved for
review, updating and
concurrent use.
Presence of policies and
procedures on filing and
retrieval of charts
DOCUMENT
REVIEW
Policies and procedures
on systematic filing,
retrieval and
management of medical
records
Medical
Records
Room /
Office
OBSERVE
Ask the medical records
officer to retrieve a
chart, then note the
actual length of time of
retrieval
Note: If organization
has not set a time
interval, use 5 minutes
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40. The organization has
policies and
procedures, and
devotes resources,
including
infrastructure, to
protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access
or use. Only
authorized individuals
make entries in the
patient chart.
INDICATOR
Presence of procedures
to protect records and
patient charts against
loss, destruction,
tampering and
unauthorized access or
use
EVIDENCE
DOCUMENT
REVIEW
Policies and procedures
on records management
to maintain
confidentiality/privacy,
accuracy and prevention
of loss and destruction,
tampering and
unauthorized access.
AREAS
COMPLIED
REMARKS
Medical
Records
Room /
Office
Wards
DOCUMENT
Logbooks for borrowing
and retrieval of charts
OBSERVE
Nurses in the wards and
records personnel on
how they protect patient
chart against loss,
tampering and
unauthorized
VI. SAFE PRACTICE AND ENVIRONMENT
A. PATIENT AND STAFF SAFETY
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective
environment of care
Standard: The organization plans a safe and effective environment of care consistent with its mission, services,
and with laws and regulations
41. Hospital has a valid
Presence of updated
DOCUMENT
Adminislicense
DOH license to operate
REVIEW
trative office
1. Updated DOH license
2. If facility has nuclear
medicine, check
certificate issued by
PNRI
42. Hospital is free from
undue noise, pollution
and from foul odor
OBSERVE
1. Ask staff at random:
their manner of waste
segregation and
disposal; safe storage
and disposal of
reagents.
2. Check presence of
MSDS (Material
Safety Data Sheet) in
the laboratory and
Engineering
3. Record of disposal of
radiologic wastes
Hospital
surroundings
Laboratory
Pharmacy
and other
part of the
facility and
Maintenance
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43. Presence of a
management plan,
policies and
procedures
addressing safety
44. Policies and
procedures for the
safe and efficient use
of medical equipment
according to
specifications are
documented and
implemented.
45. Patient areas provide
sufficient space for
safety, comfort and
privacy of the patient
and for emergency
care.
INDICATOR
Presence of a
management plan,
policies and procedures
addressing:
1. Safety
2. Security
3. Disposal and control
of hazardous
materials and biologic
wastes
4. Emergency and
disaster preparedness
Presence of policies and
procedures for:
- Quality Control
- Corrective and
Preventive
Maintenance Program
for medical
equipment
Presence of adequate
space, lighting and
ventilation in compliance
with structural
requirements (for patient
safety and privacy)
EVIDENCE
DOCUMENT
REVIEW
Management plan,
policies and procedures
INTERVIEW
Ask about the frequency
of the following:
1. Fire drill conducted in
the past 12 months
2. Earthquake drill
conducted in the past
12 months
DOCUMENT
REVIEW
1. Presence of operating
manuals of the
medical equipment
2. Preventive and
corrective
maintenance logbook
3. Film reject analysis
4. Quality control tests
results
OBSERVE
How staff performs
necessary precaution or
safety procedures such
as: red light is on while
x-ray procedure is being
done.
Note: Look into their
storage of mercury
containing devices which
are no longer allowed to
be used
OBSERVE
Observe for the
following:
1. Adequate space
2. Adequate lighting
(lights are working,
lighting is adequate
enough for conduct of
general activities)
3. Adequate ventilation
AREAS
COMPLIED
REMARKS
Administrative office
Maintenance
office,
ER
Wards
ER
OPD
Wards
DR
Laboratory
Pharmacy
Maintenance
Office
Other areas
ER
OPD
Wards
DR
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INDICATOR
EVIDENCE
46. A coordinated
security arrangement
in the organization
assures protection of
patients, staff and
visitors.
Presence of an appointed
personnel in charge of
security.
AREAS
COMPLIED
REMARKS
DOCUMENT
REVIEW
Contract or Appointment
of person in charge of
security.
INTERVIEW
Ask the personnel in
charge of security what
the policies on security
are.
OBSERVE
Security measures
Standard: The organization plans a safe and effective environment of care consistent with its mission, services,
and with laws and regulations.
47. 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
hospital associated
infections, unexpected
deaths, adverse drug
reactions, blood
transfusion reactions,
falls, etc.)
DOCUMENT
REVIEW
Incident/sentinel event
reports or
communications/
memoranda/orders or
proceedings on sentinel
events
Infection
Control
Committee
office
CQI Office
Wards
ER
ICU
OR
INTERVIEW
Ask at random any staff
from wards and ER:
- how the incident
reporting system
works
- correction, corrective
and preventive
actions
B. MAINTENANCE OF THE ENVIRONMENT OF CARE
Goal: A comprehensive and maintenance program ensures a clean and safe environment
Standard: Emergency light and / or power supply, water and ventilation systems are provided for, in keeping
with relevant statutory requirements and codes of practice.
48. Generator /
Presence of generator /
DOCUMENT
Engineering/
emergency light,
emergency light, water
REVIEW
Maintenance
water system,
system, adequate
- Check result of water Other
adequate ventilation
ventilation or air
analysis for the last 6
Relevant
or air conditioning
conditioning.
months.
Areas
- Preventive and
corrective
maintenance
logbooks
OBSERVE
1. Test if faucets and
water closets are
working
2. If emergency lights
and generators are
functional.
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INDICATOR
EVIDENCE
49. Equipment are
regularly maintained
with plan for
replacement
according to expected
life span or when no
longer serviceable.
Presence of policies and
procedures on preventive
and corrective
maintenance and
replacement if warranted
DOCUMENT
REVIEW
Records of preventive
and corrective
maintenance and plan for
replacement
50. Training of the staff
who is in charge of
the maintenance of
the equipment
Proof of training of the
staff who is in charge of
the maintenance of the
equipment
DOCUMENT
REVIEW
For in-house: Certificate
of training of service
personnel or Certificate
of training
For outsourced service:
MOA/Contract (verify
qualification of
technicians)
AREAS
COMPLIED
REMARKS
Engineering/
Maintenance
Office
Laboratory
Imaging
Other Areas
INTERVIEW
Ask about how
equipment (generator,
A/C, Medical and nonmedical devices, etc.) are
maintained
Standard: 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.
51. Operating manuals of
equipment
Presence of operating
manuals equipment
DOCUMENT
REVIEW
Operating manual of
Medical equipment,
generators, air
conditioners and other
non-medical equipment.
Engineering/
Maintenance
Office
Imaging,
Laboratory
C. INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other
personnel, visitors and trainees are identified and reduced
Standard: An interdisciplinary infection control program ensures the prevention and control of infection in all
services.
52. Infection Prevention
Presence of an Infection
DOCUMENT
Infection
and Control
Prevention and Control
REVIEW
Control
Committee
Committee (IPCC) with
1. IPCC composition
Committee
defined roles and
2. Full time Infection
Office
responsibilities
Control Nurse (1:100
beds)
3. IPCC functions and
activities
4. Minutes of meetings.
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INDICATOR
53. Infection Prevention
and Control Program
EVIDENCE
AREAS
COMPLIED
REMARKS
Presence of an infection
control program ensuring
prevention and control of
infections on all services.
DOCUMENT
Nurse
REVIEW
Super1. IPC Manual.
visor’s
2. Policies on rational
Office
antimicrobial use
based on the hospital
antibiogram and
surveillance of AMR
3. Reports of infection
control activities e.g.
surveillance, training,
outbreak
investigation, etc.
4. Policies and
procedures on
disposition of dead
bodies with dangerous
communicable
disease.
Standard: The organization uses a coordinated system-wide approach to reduce the risks of healthcareassociated infections.
54. Organization takes
Presence of a
DOCUMENT
ER
steps to prevent and
coordinated system-wide REVIEW
Wards
control outbreaks of
procedure for prevention Validate hospital policies Laboratory
healthcare associated
of hospital associated
on infection control such
infections.
infections
as use of PPEs, isolation
precautions and hand
washing.
INTERVIEW
Ask staff in ER and
wards the procedures on
isolation
(Isolation - physical
isolation of a patient
with infection and
reverse isolation).
Presence of a
coordinated system-wide
procedure for asepsis.
Ask staff from ER,
wards and laboratory
about the approaches for
asepsis during diagnostic
and treatment procedures
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INDICATOR
EVIDENCE
55. 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 on needle
stick injuries.
2. Policies and
procedures on proper
handling and safe
disposal of
sharps/needles.
AREAS
COMPLIED
REMARKS
ER
Wards
Laboratory
INTERVIEW
Interview hospital staff
on how they handle and
dispose needles.
56. 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
OBSERVE
Presence of receptacles
for proper disposal of
sharps
DOCUMENT
REVIEW
1. Policies and
procedures on
isolation.
2. Occupational Health
and Safety Program
for employees
3. Policies on timely
referral and case
reporting of highly
transmissible and
notifiable infectious
disease
e.g.meningococcemia, SARS, avian flu,
etc.
4. Procedures on
recycling & reuse
ER
Wards
Isolation
room
Laboratory
OBSERVE
1. Use of gloves,
surgical masks
2. Lavatories or
designated areas for
hand washing or
dispenser for hand
sanitizers
3. Separate holding
room for highly
infectious cases.
4. Ask a staff to
demonstrate hand
washing technique
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INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Standard: When needed, the organization reports information about infections to personnel and public health
agencies.
57. Policies and
procedures in
reporting notifiable
diseases (Refer to AO
No. 2008-0009).
Presence of policies and
procedures in reporting
notifiable diseases
DOCUMENT
REVIEW
Copy of reports
submitted to Philippine
Integrated Disease
Surveillance and
Response (PIDSR)
Standard: Cleaning, disinfecting, drying, packaging and sterilizing of equipment, and maintenance of associated
environment, conform to relevant statutory requirements and codes of practice.(Annex B of A.O. No. 2012 0012: DOH Guidelines in the Cleaning, Disinfecting, Drying, Packaging and Sterilizing of Reusable Items in
Hospitals and Other Health Facilities).
58. Policies and
Presence of policies and
DOCUMENT
CSSU
procedures on
procedures on cleaning,
REVIEW
cleaning, disinfecting, disinfecting, drying,
Policies and procedures
drying, packaging and packaging and sterilizing on cleaning, disinfecting,
sterilizing of
of equipment,
drying, packaging and
equipment,
instruments and supplies sterilizing of equipment,
instruments and
instruments and supplies
supplies.
OBSERVE
D. ENERGY AND WASTE MANAGEMENT
Standard: The handling, collection and disposal of waste conform with relevant statutory requirements and code
of practice
59. Licenses/permits/
clearances from
pertinent regulatory
agencies
Presence of
licenses/permits/
clearances from pertinent
regulatory agencies, if
applicable
DOCUMENT
REVIEW
1. Pertinent licenses /
permits from
regulatory agencies
(LGU, DENR, etc.)
2. Proof of compliance
i.e., generator permit,
elevator permit, etc.
Administrative office
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60. Policies and
procedures on waste
disposal
INDICATOR
Proof of implementation
of policies and
procedures on waste
disposal
EVIDENCE
AREAS
COMPLIED
REMARKS
DOCUMENT
REVIEW
1. Issuances - memos,
guidelines on waste
segregation, treatment
and disposal.
2. Contracts with waste
handlers or disposal
contractors, (if
applicable)
OBSERVE
1. Segregation of waste
2. Proper labelling of
waste receptacles
3. Recyclable waste
staging areas
4. Proper management
of temporary storage
areas prior to hauling
for disposal.
INTERVIEW
Ask staff regarding
SOPs on actual
procedure on waste
disposal
VII. 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 its internal and external clients.
Standard: The organization has a planned systematic organization- wide approach to process design and
performance measurement, assessment and improvement.
61. Continuous Quality
Presence of Quality
DOCUMENT
AdminisImprovement
Improvement Program
REVIEW
trative
Program
1. Policies on CQI
Office
2. Proof of meetings or
similar documents on
CQI activities
3. Policies and
procedures on
Performance
measurement and
improvement
4. Performance
appraisal for
employees at least
once a year.
INTERVIEW
Validation of CQI
activities thru interview
of staff at random.
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INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
Standard: Management is primarily responsible for developing, communicating, and implementing a
comprehensive quality improvement program throughout the organization and delegating responsibilities to
appropriate personnel for its day-to-day implementati on
62. Comprehensive
Proof that the
DOCUMENT
quality improvement
management is primarily
REVIEW
program throughout
responsible for
1. Memoranda/orders
the organization and
developing,
creating the QI
delegating
communicating and
team/Quality circle
responsibilities to
implementing a
2. Minutes of
appropriate personnel comprehensive quality
meetings/extracts of
for its day-to-day
improvement program
minutes relating to
implementation
implementation
concerned topic,
documentation of
activities
3. Monitoring reports on
CPG use or similar
QI activities
4. Designation of a
point person for the
CQI
INTERVIEW
Validate the activities by
asking the management
team or officer involved
in CQI program
Standard: The organization provides better care service as a result of continuous quality improvement activities
63. Customer satisfaction
survey
CRITERIA
64. Better patient
outcome.
Presence of customer
satisfaction survey
INDICATOR
Proof of better patient
outcomes
DOCUMENT
REVIEW
1. Domains of the
survey form used.
2. Survey results and
how complaints /
comments are acted
upon.
EVIDENCE
DOCUMENT
REVIEW
Documentation of better
outcomes for patients as
a result of CQI activities
(Correction, corrective
and preventive actions of
problems identified)
Administrative
Office
AREAS
COMPLIED
REMARKS
Administrative
Office
Validation and resolution
of client concern
(Patient response time,
Compare infection rate
of previous and current
years, ALOS, complaints
from Customer
Satisfaction Survey,
declining trends of
hospital associated
infections and increase
in patient satisfaction
rating.)
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INDICATOR
EVIDENCE
AREAS
COMPLIED
REMARKS
VIII. DOH PROGRAMS IMPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES
65. Newborn Screening
Newborn Screening – in
compliance to RA 9288
and its IRR
66. Hospital is Certified
on MBFHI
Mother- Baby Friendly
Hospital Initiative – in
compliance to RA 7600
and RA 10028 and its
IRR, and Executive
Order No. 51 (Milk
Code)
67. Immunization of
newborn babies with
BCG and first dose
Hepatitis B vaccine
Newborn Screening
being implemented.
Proof of implementation
of Rooming-in and
Breastfeeding
Newborn babies given
BCG and first dose
Hepatitis B vaccine
Generic Prescribing – in
compliance to RA 6675
(Generics Act of 1988)
OB Ward
OBSERVE
- Breastfeeding area
should be provided at
the NICU
- There shall be no
nursery for normal
newborns
DOCUMENT
REVIEW
Records of Newborns
given BCG and first dose
Hepa-B vaccine
OB Ward
OBSERVE
Policies and procedures
on anti-smoking
Anti-smoking – in
compliance to RA 9211
69. Generic prescribing
and recording
OB Ward
(Rooming
In)
(MOU for those who are
not certified yet).
Immunization – in
compliance to RA No.
306
68. Hospital is a “No
Smoking zone
DOCUMENT
REVIEW
- Policies and
procedures on
Universal Newborn
Screening
- Logbook of Newborns
who were tested and
copies of waiver for
those who were not
screened
- OR of filter papers
DOCUMENT
REVIEW
MBFHI Certificates:
- MBF Hospital
- MBF Workplace
Actual implementation
of policies and
procedures on generic
prescribing
INTERVIEW STAFF
DOCUMENT
REVIEW
Policies and procedures
on anti-smoking
OBSERVE
“No Smoking” signages
DOCUMENT
REVIEW
- Prescriptions filled in
the Pharmacy
- Physicians’ orders in
patients’ charts
- Documentation of
nurses on medicines.
Hallways
Pharmacy
Wards
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70. Emergency
Preparedness,
Response and
Recovery Plan
INDICATOR
Proof of implementation
of the plan
Health Emergency
Management Services
(HEMS) – in compliance
to AO 2004-0168
"National Policy on
Health Emergencies and
Disasters"
71. Newborn Hearing
Screening
Universal Newborn
Hearing Screening – in
compliance to RA 9709
(Universal Newborn
Hearing Screening Act)
72. Family planning
service
NTP – in compliance
with RA 10767
(Comprehensive TB
Elimination Plan Act)
DOCUMENT
REVIEW
- Self-assessment for
disaster readiness using
the “Safe Hospital
Checklist” available at
the HEMB website.
- Result of selfassessment and how
gaps were resolved
AREAS
COMPLIED
REMARKS
ER
Wards
Offices
OBSERVE
Exit plans posted in all
hallways and rooms
Newborn Hearing
Screening being
implemented
DOCUMENT
REVIEW
- Logbook of Newborns
who were tested on
hearing
- Proof of referral if
service is not available
Newborn
hearing
screening
room
Presence of Family
planning services
DOCUMENT
REVIEW
- List of FP acceptors
- Evidence as
conscientious objector
if FP services are not
provided
- Referral System to
other facilities for FP
if conscientious
objector.
DOCUMENT
REVIEW
- Presence of Hospital
TB Referral Logbook
- List of Diagnosed TB
Cases Notified (with
received remarks by
DOH-Regional Office)
OPD
OB wards
Family planning – in
compliance to RA
10354 (Responsible
Parenthood and
Reproducti ve Health
Act of 2012)
73. National Tuberculosis
Program
EVIDENCE
Implementation of
National TB Program
OPD
Wards
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ASSESSMENT TOOL FOR LEVEL 1 HOSPITAL
ATTACHMENT A - PERSONNEL
POSITION
QUALIFICATION
EVIDENCE
NUMB ER /
RATIO
COMPLIED
REMARKS
TOP MANAGEMENT
Chief of Hospital
/Medical Director
Must have completed
at least twenty (20)
units towards a
Masteral Degree
AND at least three (3)
years experience in a
supervisory or
managerial position
Chief Nurse /
Director of Nursing
Master’s Degree in
Nursing
Chief
Administrative
Officer
20 Units towards
Master’s Degree in
Hospital
Administration or
related course AND at
least five (3) years
experience in a
supervisory /
managerial position.
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
1
1
1
1
INTERVIEW
ADMINISTRATIVE SERVICES
Accountant or
Accounting Clerk
Billing Officer
Budget / Finance
Officer
Cashier
Human Resources
Management
Officer / Personnel
Officer
Clerk, pool
Bachelor’s Degree in
Accountancy
With Bachelor’s
Degree relevant to the
job
1
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license (if
CPA)
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
1
1
1
1
1:50 beds
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POSITION
QUALIFICATION
Building Man
Supply Officer/Storekeeper
Laundry Worker
Medical Records
officer
With appropriate
training and
experience
Bachelor's Degree
And Training in ICD
10 and Medical
Records Management
EVIDENCE
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license (if
Engineer)
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
INTERVIEW
DOCUMENT REVIEW
- Diploma / Certificate of
units earned
- Updated PRC license
Certificates of Trainings
attended
- Proof of Employment /
Appointment
Medical Social
worker
NutritionistDietician
NUMB ER /
RATIO
COMPLIED
REMARKS
1
1
1
1
1
1
INTERVIEW
Driver
Cook
Building
May be outsourced
Maintenance
Man/Utility
Worker
Security Guard
CLINICAL SERVICES
Consultant Staff in
Ob-Gyn,
Pediatrics,
Medicine, Surgery
and Anesthesia
Physician
(Shall not go on
duty for more than
48 hours straight).
Certificate of
Residency Training /
Medical Specialists
Updated PRC license
1
1
1 per shift
DOCUMENT REVIEW
Certificates of Trainings
attended
1 per shift
DOCUMENT REVIEW
- Diploma / Certificate
from Specialty society, if
applicable
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
At least one
(1) per
specialty
1:20 beds at
any time
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ANNEX K - 1
AO No. 2012-0012
POSITION
QUALIFICATION
EVIDENCE
NUMB ER /
RATIO
COMPLIED
REMARKS
NURSING SERVICES
Supervising
Nurse/Nurse
Managers
With updated PRC
license, with at least
nine (9) units of
Master's Degree in
Nursing with 3 years
hospital experience.
Head Nurse/Senior
Nurse
UpdatedPRC License
With at least 3 years
hospital experience
Updated PRC License
BLS certified
Staff Nurse
Nursing Attendant
/ Midwife
With relevant training
(may be in house
training)
Operating Room
Nurse
DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificate oftrainings
attended
- Proof of employment
With updated PRC
license
Training OR Nursing
Scrub Nurse
Circulating Nurse
Delivery Room
Nurse
With updated PRC
license
Certificate of Training
in Maternal and Child
Nursing (may be in
house training or
training in EINC)
Emergency Room
With updated PRC
Nurse
license
Certificate of Training
in Trauma Nursing,
ACLS and other
relevant training
Out-patient
With updated PRC
Department Nurse
license
ANCILLARYS ERVICES
Medical
With updated PRC
Technologists
license
Medical
Laboratory Aide
Pathologist
Pharmacist
Radiologist
Radiologic
Technologist
Radiation Safety
Officer
With updated PRC
license;
Fellow / Diplomate in
Pathology
With updated PRC
license
DOCUMENTS REVIEW
Certificates of Trainings
attended
DOCUMENT REVIEW
- Diploma
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
1:50 RNs
1:15 Nurses
1:12 Beds at
any time (1
reliever for
every 3 RNs)
1:24 beds at
any time(1
reliever for
every 3
NA/MWs)
1 ORN, SN,
CN per
functioning
OR per shift
1 per
functioning
DR per shift
1 per shift
1
DOCUMENT REVIEW
- Diploma
- Updated PRC license, if
applicable
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
2 in AM and
2 in PM shift;
1 in the
evening shift
Adequate
1
1 per shift
1
1 per shift
1
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ANNEX K - 1
AO No. 2012-0012
ASSESSMENT TOOL FOR LEVEL 1 HOSPITAL
ATTACHMENT B - PHYSICAL PLANT
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
ADMINISTRATIVE SERVICE
DESCRIPTION
COMPLIED
REMARKS
Lobby
Waiting Area
Information and Reception
Office of the Chief of Hospital /
Medical Director
Office of Administrative /
Personnel Officer
Accounting Office
Budget and Finance Office
Billing / Cashier
Public Toilet
(Male/Female/PWD)
Provided with water; clean and
free from foul odor
Supply/Storekeeper Room
Linen and Laundry room
Receiving Area
Sorting Area and Disinfection
Area
Washing Area
Clean Linen Storage and
Release Area
Housekeeping room for cleaning
tools and supplies
Not required if outsourced
Parking Area for transport vehicle
Central Waste Storage Area
Staff Toilet
Shall have color-coded
segregation; clean and free from
foul odor
Provided with water; clean and
free from foul odor
Kitchen
Supply receiving Area
Dry and Cold Storage Area
Food preparation Area
Cooking Area
(not required if contracted-out)
Shall have adequate space, clean
and Free from foul odor; no insects
and rodents.
Dishwashing Area
Assembly Area
Dining Area
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ANNEX K - 1
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
Garbage Area
Medical Records Office
DESCRIPTION
COMPLIED
REMARKS
With area for completion of
patients' charts by physicians and
other professionals
Storage Room
Cadaver Holding Area
PRAYER ROOM
CLINICAL SERVICE
EMERGENCY ROOM /
EMERGENCY
DEPARTMENT
(May be combined with OPD),
Examination and Treatment
Area
Area for Minor Surgical
Procedures
Adequate privacy for patients is
provided such that sensitive or
private discussion, examination,
and/or procedures are conducted in
a manner or environment where
these cannot be observed or the
risk of being overheard by others is
minimized.
Shall be provided with hand
washing/hand disinfection facility
Observation Area /Ward
Waiting area
Shall have adequate lighting and
ventilation.
Nurses' station
Equipment and supply storage
area
Wheeled Stretcher and
Wheelchair Area
Doctor's On-Duty Room
Admitting Office
Toilet for patients and
companions
Separate Male from Female; Clean
and Free from foul odor; no insects
and rodents
Staff Toilet
OUTPATIENT
DEPARTMENT
(May be combined with ER)
Waiting area
Adequate privacy for patients is
provided such that sensitive or
private discussion, examination,
and/or procedures are conducted in
a manner or environment where
these cannot be observed or the
risk of being overheard by others is
minimized.
Shall have adequate lighting and
ventilation.
Consultation Area
Examination and Treatment
Area
Shall be provided with hand
washing/hand disinfection facility
Nurse’s counter
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ANNEX K - 1
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
DESCRIPTION
COMPLIED
REMARKS
Patients’ Area
Nurse’s station with medication
area
Toilet for patients and
companions
Separate Male from Female; Clean
and Free from foul odor; no insects
and rodents
Staff Toilet
OPERATING ROOM /
COMPLEX
Shall have control door or
demarcation line between dirty to
clean area
Major OR
Dressing Room
Nurses’ Station with work Area
Sub-sterile Area
Sterile Area
Scrub up Area
Clean up Area
Storage Area for Sterile packs
and supplies
Wheeled Stretcher Area
Janitors’ Closet with slop sink
POST ANESTHES IA CARE UNIT / RECOVERY ROOM
Patients Area
Nurses’ Station with Medication
Area
DELIVERY ROOM
Labor Room (provided with
toilet)
Delivery Room proper
Scrub Up Area
Dressing Room
Nurse’s Station
Birthing Room
Newborn Resuscitation Area
Equipment and Supply Area
Clean – Up and Sterilization
Room
Janitor’s Closet
Wheeled Stretcher Area
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ANNEX K - 1
AO No. 2012-0012
PHYSICAL FACILITY
(Specify “ADD ON” Services, if
any)
NURSING SERVICE / WARD
Patient Rooms with Toilet
Nurses’ Station with Lavatory
DESCRIPTION
COMPLIED
REMARKS
Adequate space is provided to
allow patients and personnel to
move safely around patient bed
areas
All point of care areas should be
provided with hand-washing / hand
disinfection facility.
Medication preparation area
with lavatory
Treatment area with Lavatory
Equipment and Supply Area
Staff Toilet
Linen Area
Waste bins
Color-coded
Janitor’s Closet
ISOLATION ROOM
Hand-washing / Hand
disinfection facility in all point
of care areas
CENTRAL STERILIZING AND SUPPLY UNIT
Receiving and Cleaning Area
Inspection and Packaging Area
Sterilizing Area
Storage and Releasing Area
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ANNEX K - 1
AO No. 2012-0012
ASSESSMENT TOOL FOR LEVEL 1 HOSPITAL
ATTACHMENT C –EQUIPMENT/INSTRUMENT
(Indicate in REMARKS Column if service is “Add On” and check applicable equipment or instrument for such
service.)
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
QUANTITY
AREA
COMPLIED
REMARKS
ADMINISTRATIVE SERVICE
Ambulance, available 24/7 and physically
present; if outsourced, shall be on call
1
Computer with Internet Access
1
Emergency Light
Fire Extinguishers
LCD Projector
Generator set with Automatic Transfer
Switch (ATS)
KITCHEN/DIETARY
Exhaust fan
Food Conveyor or equivalent
Food Scale
Blender/Osterizer
Stove
Refrigerator/Freezer
Utility cart
Garbage Receptacle with Cover colorcoded)
Bag-valve-mask Unit
- Adult
- Pediatric
Calculator for dose computation
Clinical Weighing scale
Defibrillator
Delivery set, primigravid
Metzenbaum scissors, straight
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
Needle Holder
Tissue forceps
Delivery set, multigravid
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
ECG Machine
1 per unit or
area
1
1
Parking
Administrative
Office
lobby, hallway,
nurses' station,
office/unit and
stairways
lobby, hallway,
nurses' station,
office/unit and
stairways
Conference
Room
Genset house
1
1
1
1
Kitchen
1
1
1
1 for each
color
EMERGENCY ROOM
1
1
1
1
1
2 sets
1 per set
1 per set
ER
2 per set
1 per set
1 per set
2 sets
1 per set
2 per set
1
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ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
EENT Diagnostic Set with
Ophthalmoscope and Otoscope
Emergency Cart (for contents, refer to
separate list).
Examining table
Examining table (with Stirrups for OBGyne
Gooseneck lamp/Examining Light
Instrument/Mayo Table
Laryngoscope with different sizes of
blades
Minor Instrument Set
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Mayo scissors – straight
Metzenbaum scissors – curved
Mosquito forceps – curved
Mosquito forceps – straight
Needle holder
Scalpel handle No. 3
Scalpel handle No. 4
Skin retractor
Tissue forceps
Thumb forceps
Nebulizer
Negatoscope
Neurologic Hammer
OR Light (portable or equivalent)
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Pulse Oximeter
Sphygmomanometer, Non-mercurial
- Adult Cuff
- Pediatric Cuff
Stethoscope
Suction Apparatus
Suturing Set
Mayo scissors
Mosquito forceps
Needle holder
Tissue forceps
Thermometer, non-mercurial
- Oral
- Rectal
Vaginal Speculum, Different Sizes
Wheelchair
Wheeled Stretcher with guard/side rails
and wheel lock or anchor.
QUANTITY
AREA
COMPLIED
REMARKS
1
1
1
1
1
1
1 set
2 sets
2 per set
2 per set
1 per set
1 per set
4 per set
4 per set
1 per set
1 per set
1 per set
1 pair
1 per set
1 per set
1
1
1
1
ER
2
1
1
1
1
1
2 sets
1 per set
1 per set
1 per set
1 per set
1
1
1 set of
different sizes
1
1
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ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Clinical Height and Weight Scale
EENT Diagnostic Set with
ophthalmoscope and otoscope
Gooseneck lamp/Examining Light
Examining table with wheel lock or
anchor
Instrument/Mayo Table
Minor Instrument Set:
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Mayo scissors – straight
Metzenbaum scissors – curved
Mosquito forceps – curved
Mosquito forceps – straight
Needle holder
Scalpel handle No. 3
Scalpel handle No. 4
Skin retractor
Tissue forceps
Thumb forceps
Neurologic Hammer
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Peakflowmeter
- Adult
- Pediatric
Sphygmomanometer, Non-mercurial
- Adult cuff
- Pediatric cuff
Stethoscope
Thermometer, non-mercurial
- Oral
- Rectal
Suture Removal Set
Wheelchair / Wheeled Stretcher
Air conditioning Unit
Anesthesia Machine
Cardiac Monitor with Pulse Oximeter
Ceasarian Section Instrument
Emergency Cart (for contents, refer to
separate list).
Instrument / Mayo Table
Laparotomy pack (Linen pack)
QUANTITY
AREA
COMPLIED
REMARKS
OUT- PATIENT DEPARTMENT
1
1
1
1
1
1
2 per set
2 per set
1 per set
1 per set
4 per set
4 per set
1 per set
1 per set
1 per set
1 pair
1 per set
1 per set
1
OPD
1
1
1
1
1
1
1
1
1
1
OPERATING ROOM
1
1
1
1
OR
1
1
1 set per OR
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ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Laparotomy / Major Instrument Set
Towel Clamp
Scalpel handle No. 3
Scalpel handle No. 4
Army-navy retractor
Richardson retractor – double-end
Self-retraining retractor (Balfour)
Kelly hemostatic forceps – curved
Kelly hemostatic forceps – straight
Halsted mosquito forceps – straight
Allis forceps
Mixter – curved
Mixter – straight
Needle holder
Tissue forceps
Thumb forceps
Metzenbaum scissors – curved
Mayo scissors – curved
Mayo scissors – straight
Orthopedic Instrument Set
Periosteal elevator
Bone chisel / osteotome
Bone mallet
Bone Rongeur
Bone holder
Bone drill with different sizes of drill
bits
Gigli saw (handle and wire)
Pin / Wire cutter
Pin / Wire puller
Bone curette
Cast spreader
Bone clamp
Zimmer
Screw driver
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Rechargeable Emergency Light (in case
generator malfunction)
Sphygmomanometer, Non-mercurial
- Adult cuff
- Pediatric cuff
Spinal Set
Stethoscope
Suction Apparatus
QUANTITY
1 set per OR
4 per set
1 per set
1 per set
1 pair per set
1 per set
1 per set
4 per set
4 per set
4 per set
4 per set
1 per set
1 per set
2 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 set
1 per set
1 per set
1 per set
1 per set
1 per set
AREA
COMPLIED
REMARKS
OR
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per set
1 per OR
1 per OR
1 per OR
1 per OR
1
1
1
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ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
QUANTITY
COMPLIED
AREA
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Thermometer, non-mercurial
- Oral
1
- Rectal
1
OR
Wheeled Stretcher with guard/side rails
1
and wheel lock or anchor.
POST ANESTHES IA CARE UNIT / RECOVERY ROOM
Air conditioning Unit
1
Cardiac Monitor
1
Mechanical / patient bed, with guard
1
side rails and wheel lock or anchored
Oxygen Unit
Tank is anchored/chained/ strapped or
1
PACU/RR
with tank holder if not pipeline
Sphygmomanometer, Non-mercurial
- Adult cuff
1
- Pediatric cuff
1
Stethoscope
1
Thermometer, non-mercurial
1
LABOR ROOM
Fetal Doppler
1
Oxygen Unit
Tank is anchored/chained/ strapped or
1
with tank holder if not pipeline
Patient Bed
1
Labor Room
Pulse Oximeter
1
Sphygmomanometer, Non-mercurial
1
Stethoscope
1
Thermometer, Non-mercurial
1
DELIVERY ROOM
Air-conditioning Unit
1
Bag valve mask unit (Adult and
1
pediatric)
Bassinet
1
Clinical Infant Weighing Scale
1
Dilatation/Curettage set
1 set
Uterine Sound / Hysterometer
1 per set
Uterine forceps
1 per set
Dull Uterine curette
1 per set
Sharp Uterine curette
1 per set
Vaginal Retractor
1 per set
DR
Vaginal Speculum
1 per set
Ovum forceps
1 per set
Hegars dilator, graduated sizes
1 per set
Sponge forceps
1 per set
Delivery set, primigravid
1 set
Metzenbaum scissors, straight
1 per set
Mayo scissors, straight
1 per set
Kelly hemostatic forceps, curved or
2 per set
straight
Needle Holder
1 per set
Tissue forceps
1 per set
REMARKS
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ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Delivery set, multigravid
Mayo scissors, straight
Kelly hemostatic forceps, curved or
straight
DR Light
DR Table
Emergency Cart (for contents, refer to
separate list).
Instrument/Mayo Table
Kelly Pad or equivalent
Laryngoscope
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Rechargeable Emergency Light (In case
of generator malfunctions)
Sphygmomanometer -Non-mercurial
Stethoscope
Suction Apparatus
Wheeled Stretcher
QUANTITY
AREA
COMPLIED
REMARKS
2 sets
1 per set
2 per set
1
1
1
(if DR is
separate from
OR Complex)
1
1
1
DR
1
1
1
1
1
1
NURSING UNIT/WARD
Bag-Valve-Mask Unit
- Adult
1
- Pediatric
1
Clinical Height and Weight Scale
1
Emergency cart or equivalent (refer to
1
separate list for the contents)
EENT Diagnostic Set with
1
ophthalmoscope and otoscope
Laryngoscope with different sizes of
1
blades
Mechanical/Patient bed with lock, if
ABC
wheeled; with guard or side rails
NURSING
Bedside Table
ABC
UNIT/WARD
Nebulizer
1
Neurologic Hammer
1
Oxygen Unit
1
tank is anchored/chained if not pipeline
Sphygmomanometer, Non- Mercurial
- Adult cuff
1
- Pediatric cuff
1
Stethoscope
1
Suction Apparatus
1
Thermometer, non-mercurial
- Oral
1
- Rectal
1
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave/Steam Sterilizer
1
CSSR
CADAVER HOLDING AREA/ROOM
CADAVER
Bed or stretcher for cadaver
1
HOLDING
AREA
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ANNEX K - 1
AO No. 2012-0012
EMERGENCY CART CONTENTS
EQUIPMENT/ INSTRUMENT
QUANTITY
COMPLIED
REMARKS
MEDICINES
Β-adrenergic agonists (i.e. Salbutamol 2mg/ml)
20
5 Caloric agent (D50W 50mg/vial)
10
20
Activated charcoal sachet
10
Amiodarone 150mg/ampule
5
Anti-rabies vaccine (active)
5
Anti-rabies vaccine (passive)
Anti-tetanus serum (either equine-based antiserum or
40
human antiserum)
Anti-venims* (for centres with high incidence of
poisonous animal bites)
20
Aspirin USP grade (325 mg/tablet)
15
Atropine 1mg/ml ampule
Benzodiazipine (Diazepam 10mg/2ml ampule and/or
10
Midazolam)
10
Calcium (usually calcium gluconate 10mg/ampule)
10
D5 0.3 NaCl 500ml/bottle
10
D5 LR 1L/bottle
10
D5 NSS 1L/bottle
10
Digoxin 0.5mg/ampule
10
Diphenhydramine 50mg/ampule
10
Dobutamine 250mg/20ml vial
10
Dopamine 20mg/vial
30
Epinephrine 1mg/ml ampule
20
Furosemide 20mg/2ml ampule
10
Haloperidol 50mg/ampule
10
Hydrocortisone 250mg/vial
5
Hyoscine N-butyl-bromide 20mg/vial
20
Lidocaine 5% solution vial 1g/50ml
10
Magnesium sulfate 1g/ampule
10
Mannitol 20% solution 500ml/vial
10
Mefenamic Acid 500mg/tablet
10
Methylprednisolone 4mg/tablet
5
Metoclopramide 10mg/ampule
10
Morphine sulfate 10mg/ampule
Nitroglycerin spray or Isosorbide dinitrate 5mg
10
tablet/ampule
5
Noradrenaline 2mg/ampule
10
Oral Rehydration Solution salt preparation sachet
15
Paracetamol 300mg/ampule (IV preparation)
15
Phenobarbital 30mg/ml IV or 30mg tablet
15
Phenytoin 300mg/capsule or IV preparation
10
Plain LRS 1L/bottle
10
Plain NSS 1L/bottle
15
Potassium Chloride 40mEq/vial
10
Pyridoxine 1g/ampule
10
Sodium bicarbonate 50mEq/ampule
5
Succinylcholine 200mg/vial
20
Tetanus Toxoid 0.5ml/vial
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ANNEX K - 1
AO No. 2012-0012
QUANTITY
EQUIPMENT/ INSTRUMENT
Thiamine (usually in parenteral Vitamin B complex
10
preparation)
10
Tramadol 50mg/capsule
10
Verapamil 5mg/2ml ampule
BASIC ER SUPPLIES
Airway adjuncts (oropharyngeal and nasopharyngeal
airways)
Airway / Intubation Kit
Alcohol disinfectant
Arm sling (or sling and swathe bandages)
Aseptic bulb syringe
Biomedical refrigerator (for storage of biological and
other heat-sensitive drugs)
Calculator
Cardiac Board
Cardiac / EKG Leads
Cervical collars (different sizes)
Different sets of Bins (including puncture-proof sharp
containers)
Elastic Bandages (different sizes)
Flashlights or Pen lights
Gloves (examination and sterile, different sizes)
Hydrogen peroxide solution
Nasal cannula
Povidine iodine wound and cleaning solutions
Protective face shield or mask
Pulmonary Function Test (PFT) or Peak Expiratory
Flow Rate (PEFR) Tube
Spine board with straps
Splinting / immobilization devices
Standard face mask
Sterile gauze
Sutures
Syringes (different volumes)
Urethral catheter
Urine collection bag
Waterproof aprons
X-ray reading lamp or negatoscope
COMPLIED
REMARKS
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ANNEX K - 1
AO No. 2012-0012
ASSESSMENT TOOL FOR LEVEL 1 HOSPITAL
ATTACHMENT D – ADD-ON SERVICES CHECKLIST
A. INTENSIVE CARE UNIT (ICU)
1.
PERSONNEL
POSITION
1. Intensivist
Certificate of
Fellowship Training
NUMB ER /
RATIO
EVIDENCE
3. Nursing
Attendants
DOCUMENT REVIEW
- Diploma / Certificate
from Specialty society
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENT REVIEW
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
DOCUMENTS REVIEW
Certificates of Trainings
attended
REMARKS
1:3 beds
(1 reliever for
every 3 RNs)
With Relevant
Training
COMPLIED
1
(May be part
time or
visiting
consultant)
With training in
Critical Care Nursing
2. Nurse
2.
QUALIFICATION
1:12 beds
(1 reliever for
every 3 NAs)
PHYSICAL PLANT
PHYSICAL FACILITY
DESCRIPTION
COMPLIED
REMARKS
Approved PTC for ICU
- Dressing Room
- Nurse’s Station
With Lavatory
- Medication Preparation
Area
- Patient Bed Area
Tertiary Clinical Laboratory
With Space for required
equipment per bed
Health Facility should have a
Tertiary Clinical Laboratory
or a MOA with Hospitalbased Tertiary Clinical Lab.
See Assessment Tool for
Clinical Laboratory
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ANNEX K - 1
AO No. 2012-0012
3.
EQUIPMENT
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Air Conditioning Unit
Bag-valve-mask Unit
- Adult
- Pediatric
Cardiac Monitor with Pulse Oximeter
Defibrillator
EENT Diagnostic Set with
ophthalmoscope and otoscope
Emergency Cart (for contents, refer to
separate list).
QUANTITY
COMPLIED
REMARKS
1
1
1
1
1
1
1
Infusion pump
1
Laryngoscope
1
Depending on
the number of
beds applied
Mechanical Bed
Mechanical Ventilator (May be
outsourced)
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
Sphygmomanometer, Non-mercurial
- Adult Cuff
- Pediatric Cuff
1
1
1
1
Stethoscope
1
Suction Apparatus
1
Thermometer, Non-mercurial
1
B. NEONATAL INTENSIVE CARE UNIT (NICU)
1.
PERSONNEL
POSITION
1. Neonatologist
2. Nurse
QUALIFICATION
Certificate of
Fellowship Training
With training in
Neonatal Critical Care
Nursing
EVIDENCE
NUMB ER /
RATIO
DOCUMENT REVIEW
- Diploma / Certificate
from Specialty society
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
REMARKS
1
(May be part
time or
visiting
consultant)
DOCUMENT REVIEW
- Updated PRC license
- Certificates of Trainings
attended
- Proof of Employment /
Appointment
COMPLIED
1:3 beds
(1 reliever for
every 3 RNs)
DOH-HOS-LTO-AT-L1
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ANNEX K - 1
AO No. 2012-0012
POSITION
3. Nursing
Attendants
2.
EVIDENCE
NUMB ER /
RATIO
DOCUMENTS REVIEW
Certificates of Trainings
attended
1:12 beds
(1 reliever for
every 3 NAs)
QUALIFICATION
With Relevant
Training
COMPLIED
REMARKS
PHYSICAL PLANT
PHYSICAL FACILITY
DESCRIPTION
COMPLIED
REMARKS
COMPLIED
REMARKS
Approved PTC for ICU
- Dressing Room
- Nurse’s Station
With Lavatory
- Medication Preparation
Area
- Incubator Area
Tertiary Clinical Laboratory
With Space for required
equipment
Health Facility should have a
Tertiary Clinical Laboratory
or a MOA with Hospitalbased Tertiary Clinical Lab.
See Assessment Tool for
Clinical Laboratory
3.
EQUIPMENT
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Air Conditioning Unit
Bag-valve-mask Unit
- Pediatric
Cardiac Monitor with Pulse Oximeter
Defibrillator
EENT Diagnostic Set with
ophthalmoscope and otoscope
Emergency Cart (for contents, refer to
separate list).
Incubator
QUANTITY
1
1
1
1
1
1
Depending on
the number of
beds applied
Infusion pump
1
Laryngoscope
1
Mechanical Ventilator (May be
outsourced)
1
DOH-HOS-LTO-AT-L1
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08/09/2016
Page 44 of 47
ANNEX K - 1
AO No. 2012-0012
EQUIPMENT/ INSTRUMENT
(Functional)
(Use separate sheet if equipment is for
a specific “ADD ON” Service/s).
Oxygen Unit
Tank is anchored/chained/ strapped or
with tank holder if not pipeline
QUANTITY
COMPLIED
REMARKS
1
Sphygmomanometer, Non-mercurial
- Pediatric Cuff
1
Stethoscope
1
Suction Apparatus
1
Thermometer, Non-mercurial
1
C. AMBULATORY SURGICAL CLINICS (ASC)
- Refer to assessment tool for ASCs
D. DIALYSIS CLINICS
- Refer to assessment tool for Dialysis Clinics
DOH-HOS-LTO-AT-L1
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ANNEX K - 1
AO No. 2012-0012
Name of Health Facility:
_______________________________________________________________________
Date of Inspection:
_______________________________________________________________________
RECOMMENDATIONS:
A.
For Licensing Process
[ ]
For Issuance of License To Operate as HOSPITAL
Validity from _________________________
[ ]
to
__________________________
Issuance depends upon compliance to the recommendations given and submission of the following within
____________________ days from the date of inspection
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
[ ]
Non-issuance. Specify reason/s: ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Inspected by:
Printed name
Signature
Position/Designation
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received by:
Signature: ___________________________________
Printed Name: ___________________________________
Position/Designation: ___________________________________
Date: ___________________________________
DOH-HOS-LTO-AT-L1
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ANNEX K - 1
AO No. 2012-0012
Name of Health Facility:
______________________________________________________________________
Date of Monitoring:
______________________________________________________________________
RECOMMENDATIONS:
B.
For Monitoring Process
[ ]
Issuance of Notice of Violation
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
[ ]
Non-issuance of Notice of Violation
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
[ ]
Others. Specify: ______________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Monitored by:
Printed name
Signature
Position/Designation
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Received by:
Signature: _________________________________
Printed Name: _________________________________
Position/Designation: _________________________________
Date: _________________________________
DOH-HOS-LTO-AT-L1
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