New Assessment Tool for Hospitals

Assessment Tool for

Licensure of Hospitals Revision: 00

Effectivity date: 10/01/12

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OUTLINE OF CONTENTS

I. GENERAL INFORMATION(page 2)

II. HOSPITAL ADMINISTRATION A. Services

1. Administrative Service (pages 3-8) 1.1. Human Resource 1.2. Accounting 1.3. Budget and Finance 1.4. Billing and Claims 1.5. Procurement 1.6. Property and Supply Management 1.8 Linen and Laundry

1.9 Housekeeping 1.7. Nutrition and Dietary 1.8. Security Services 1.9. Ambulance Services 1.10. Central Information Management 1.11. Medical Records (Including Dental

Records) 1.12. Medical Social Services 1.13. Nutrition and Dietetics 1.14. Pharmacy

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

3. Patient Care (pages 10-13) 4. Implementation of Care (pages 13-15) 5. Evaluation of Care (page 16) 6. Leadership and Management (pages 16-17) 7. External Services (page 17)

8. Human Resource Management (page 18) 9. Data Collection, Management and Use (pages18-19) 10. Safe Practice and Environment including Patient and Staff Safety (pages 20-25) 11. Maintenance of Environment of Care (pages 26-27) 12. Infection Control (pages 28-32)) 13. Energy and Waste Management (page 33) 14. Improving Performance (page 34) III. PERSONNEL POSITION STAFFING REQUIREMENT(pages 35-43) 1. Top Management Personnel Qualification Standard 2. Administrative 3. Clinical 4. Nursing 5. Ancillary IV. EQUIPMENT AND INSTRUMENTS (pages44-52) List of Equipment and Instrument Requirement

1. Administrative 2. Clinical

2.1. Emergency Room 2.2. Outpatient Care 2.3. Operating Room 2.4. Recovery Room 2.5. High Risk Pregnancy Unit

2.6. Delivery Room 2.7. Neonatal Intensive care Unit 2.8. Intensive Care Unit

3. Nursing Unit/Ward 4. Isolation Room 5. Central Supply and Sterilization Unit/ Room 6. Physical Medicine and Rehabilitation Unit 7. Dialysis Clinic 8. Ambulatory Surgical Clinic 9. Dental Clinic

10. Dietary V. PHYSICAL PLANT REQUIREMENT(53-57) Required rooms/areas/offices VI.HOSPITAL PROGRAMS (pages 58-60)

1. Blood Services 2. Newborn Screening 3. Mother-Baby Friendly Hospital Initiative 4. Health Promotion and Disease Prevention 5. Generics Act 6. Health Emergency Management Services

VII. HOSPITAL COMMITTEES (page 61) VII. HOSPITAL OPERATIONS CRITERIA (page 62) VIII. SIGNATURE PAGE (page 63)

Department of Health

Bureau Of Health Facilities And Services (BHFS)

ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS

Assessment Tool for



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

sixty-three (63) pages and copies of the SOE,SOM and NOV Forms. 2. Assign sections of the tool to corresponding team members. 3. To properly fill-out this tool, the Regulatory Officer shall make use of:

INTERVIEWS, REVIEW OF DOCUMENTS, OBSERVATION and VALIDATION of findings.

4. If the corresponding items are present or available, place a on each

of the appropriate boxes alongside each corresponding item. If not, put an X instead.

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

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

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

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

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

10. The Team Leader shall ensure that all team members write down their printed names, designation and affix their signatures and indicate the date of inspection or monitoring,all at the last page of the Assessment Tool, on the SOE and SOMForms and if warranted, also on the NOV Form.

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

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

II. GENERAL INFORMATION: Name of Hospital: Address: (Number & Street) (Barangay/District)

(Municipality/City) (Province & Region) Telephone No../ Fax No.

E-mail Address:

License No (for renewal):

Date Issued Expiry Date:

Hospital Category: Level 1 Level 2 Level 3

Philhealth Accreditation:Center of: Safety Quality Excellence

Classification According to Ownership: Government Private

No. of: Authorized Bed Capacity Implementing Beds

Name of Owner or Governing Body (if corporation):

Name of Hospital Administrator, Medical Director or Chief of Hospital

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CODE STANDARDS CRITERIA INDICATOR

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EVIDENCE AREA REMARKS

HOSPITAL ADMINISTRATION: Goal- To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.

1.1.1 1.1.1.a 1.1.1.a.1

ADMINISTRATIVE AND FINANCE SERVICE: The

AFS shall ensure adequate and timely financial and direct support services to all hospital units. Administrative Group: Human Resource Management

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

Documented and implementable policies and procedures Approved documented policies, guidelines and procedures on: a) Staffing plan b) Recruitment and Selection c) Hiring/Appointment d) Orientation & Staff Development e) continuing education, and training Approved documented policies, guidelines and procedures on a) Staffing plan b) Recruitment and Selection c) Hiring/Appointment d) Orientation & Staff Development e) continuing education, and training

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

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1.1.1.b 1.1.1.b.1

1.1.1.b.2

Financial Management Group Accounting

There shall be a systematic recording of all financial transactions, preparation of financial statements and relevant reports, and maint-enance and safekeeping of Books of Accounts. Budget

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

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

: f) Performance Evaluation g) Rotation/Transfer h) Succession Plan i) Merit, Promotion, Awards & Incentives j) Resignation, Termination and Retirement k) Physical Examination record of schedule of duties appointment/employment contract, if valid updated health certificate (as required) orientation plan/program of new employees implemented record of schedule of duties appointment/employment contract, if valid updated health certificate (as required) orientation plan/program of new employees implemented documented and

implementable policies and procedures

documented and


documented and


Verifier: Documents review, Observe

Interview staff, Validate List of personnel check if Current Verifier: Documents review,

Interview staff, Validate

Verifier: Documents review,


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1.1.1.b.3 1.1.1.c 1.1.1.d 1.1.1.e 1.1.1.f

Billing and Claims

there shall be a system of billing of patients and processing of claims Procurement:

There shall be a comprehensive plan of systematic management of procurement and acquisition of supplies, materials, healthcare equipment, vehicles, services, infrastructure work and other required logistics for the effective and efficient delivery of quality services

Property and Supply Management:

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

Linen and Laundry There shall be adequate supply of clean linens for patients and other hospital units. Housekeeping There shall be provision and maintenance of clean, safe and sanitary facilities and environment for hospital personnel, patients and clients

documented and implementable policies and procedures Policies, guidelines and procedures on requisition, purchase, issuance and inventory; disposal of non-functional equipment, instruments, supplies, expired drugs and medicines and reagents are in place. documented and implementable policies and procedures Sorting of soiled and contaminated linens in designated areas Systematic washing of laundry with safeguard against spread of infection Disinfection of laundry Adequate housekeeping supplies.

Documents are readily available Look for approved Work and Financial Plan and its implementation Proof of transactions Documents are readily Available

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

evidence of continuous review of policies and procedures



Verifier: Documents review, Observe

Interview staff Validate Verifier: Documents review,

Interview staff, Validate Verifier: Documents review,



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1.1.1.g 1.1.1.h 1.1.1.i

. Security There shall be order within the hospital premises and protection of lives, properties and critical infrastructure from threats, harm and losses Ambulance Services (Compliance to A.O. 2010-0003- National Policy on Ambulance Use and Services) Central Information Management

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

Security check for internal and external customers including use of visitors pass Documented and approved policies and procedures on patient transport to and from the facility 24 hour availability of ambulance for ready use Available contract/ MOA, if contracted out Logbook on transport of patients/clients by ambulance to and from the facility documented and implementable policies and procedures

evidence of continuous review of policies and procedures With appropriate manpower, equipment and supplies during patient transport

If contracted out; note specifications in contract or MOA


Interview staff, Validate Verifier: Documents review, Observe, Interview staff&Validate Verifier: Documents review, Observe, Interview staff&Validate

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1.1.1.i.a 1.1.1.j

Medical Records (Including Dental Records)

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

There shall be policies and procedures in place pertaining to social case work, multisectoral networking and linkages in understanding the socio- behavioral and economic plight of patients and their families for the holistic approach in their management and treatment

Documented and implementable policies and procedures

ICD-10 reference books with additional ICD-10 modification Logbooks on: Admission OR DR ER OPD Approved documented policies and procedures and records on: a)Patient classification according to their capacity to pay b) Continuity of care c) Counselling of patients/clients and their families d) Records of pre-admission and pre- discharge assessment, and discharge plan Available contract or MOA with DSWD or the LGU whenever applicable (for private hospitals) Allocation of not less than 10% of its Authorized bed capacity as charity beds. Compliance to RA 9439, An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses, (IRR, AO No. 2008-0001)




Verifier: Observe, Interview staff, Validate

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1.1.1.c. 1.

1.1,1.k

1.1.1.b.

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

Actual implementation and evidence of continuous review of policies and procedures

If contracted out; note specifications in contract or MOA

documented and implementable policies and procedures


1.1.1.b. 1.1.1.l

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

Actual implementation and

evidence of continuous review of policies and procedures

documented and



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CODE

STANDARDS CRITERIA INDICATOR

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AREA REMARKS

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2.1

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

2.1.1 1.Organizational policies and procedures respect and support patients' right to quality care and their responsibilities in that care.

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

All patient charts have signed consent.

DOCUMENT

Patient charts sample charts of patients currently admitted. If hospital is department-alized, get samples during tour of the different departments. Note: *Informed consent - includes a patient-doctor discussion of the following issues: the nature of the decision or procedure; reasonable alternatives to the proposed intervention; the relative risks, benefits, and uncertainties related to each alternative; assessment to patient understanding; and patient's acceptance or refusal of the intervention.

Wards (sample

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

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2.1.2

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

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

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

DOCUMENT REVIEW

List of services available OBSERVATION:

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

ER OPD ICU OR RR PACU

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

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

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

OBSERVATION

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

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

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

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

Presence of directional signages to locate service areas. Directional signs are prominently posted. Check ER, OPD, wards and lobby.

ER OPD Wards Other Areas Lobby

2.2.1.c

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

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

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

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

ER OPD Wards

Other areas

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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

2.2.2.a

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

All patients are correctly identified by their patient charts.

All patients are correctly identified by their charts.

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

ER

OPD

Wards ICU

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

2.2.3.a

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

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

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

CHART REVIEW Wards

ER

DOCUMENT

Patient chart from wards or ER.

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

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2..2.3.b 8.Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.

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

All patient charts have progress notes by doctors.

CHART REVIEW Medical Records Office

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

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

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

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

CHART REVIEW

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

2.3 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients

2.3.1

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

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

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

DOCUMENT REVIEW

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

X-ray Laboratory

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

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

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

. For the timeliness of drug administration, check the hospital policy. If hospital does not have policy, frequency of drug administration in the chart should be checked and validate it thru patient interview Note: Surveyor may also check for administration of any of the following: antibiotics, anticonvulsants, MgSO4, KCl drip and other drips, calcium gluconate, sodium bicarbonate, etc. For oral medications, do direct observation

Chart Review

2.3.2.b

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

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

All doctors, dentists, nurses and pharmacists have updated licenses

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

Wards Pharmacy OPD ER

2.3.2.c

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

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

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

DOCUMENT Procedures on verification of orders. INTERVIEW Observe if staff verifies the prescriptions or orders for drugs with the doctor and the drug against the doctor's 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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2.3.2.d 2.3.2.e

14.Drugs are administered in a standardized and systematic manner in the provider organization 15.Drugs are administered in a standardized and systematic manner in the provider organization

Prescriptions or orders are verified and patients are identified before medications are administered. Drug administration is properly documented in the patient chart.

All charts have proper documentation of drug administration .

INTERVIEW

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

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

Medication sheet in patient chart from the medical records.

Medical Records Room

2. 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 part of the patient's care plan and is documented in the patient chart.

All charts have discharge plans

CHART REVIEW

Patient chart from medical records room, the discharge orders should contain the ff.: 1. May go home order 2.Home medications (if applicable) 3.Follow up visits/schedule 4. Home care/advise Note: Discharge plan is not synonymous with discharge summary.

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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.

2.5.1.a 2.5.1.b

17.The organization regularly reviews and updates its policies, guidelines and procedures 18.Terms of reference, membership and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved.

Strategically Posted Vision and Mission of all the Services Approved Manual of Operations and/ or Written Policies, Guidelines and Procedures on Clinical Services Offered Strategically Posted Functional and Organizational Chart with Photos Showing Names and Relationship by Positions Proof of the creation of all committees within the organization which includes the terms of reference for membership

OBSERVATION DOCUMENT REVIEW

2.5.1.c

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

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

INTERVIEW

1. Ask the management team about priorities for performance improvement that relate to hospital wide activities and patient outcomes 2. Ask management team how targets are set.

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2.6.1

20. Documented agreements and contracts cover external service providers and specify that the quality of services provided must be consistent with appropriate set standards.

Presence of MOA/ contract for all out-sourced services (e.g. dialysis unit, dietary, laboratory, radiology). (Outsourced are services/ facilities provided by third party but are inside the hospital)

DOCUMENT REVIEW 1.Contracts/MOA for outsourced services. 2. Valid licenses of all providers of the outsourced services.

Document review

OBSERVATION Actual presence of the outsourced services within the hospital if applicable Note: The contracts/MOA should be updated. MOA is sufficient for some hospitals where the outsourced services are not within the facility.

Imaging Laboratory Other areas

3.1 3.1.1

Human Resource Management Human Resource Planning

Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals.

3.1.1.a

21. Planning ensures that

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

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

Presence of policies and procedures for credentialing and privileging of staff

Policies and procedures for credentialing and privileging of staff

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3.1.1.b

22.Workload is monitored and appropriate guidelines consulted to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and

organizational outcomes.

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

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

DOCUMENT REVIEW

1. List of total number of licensed doctors and dentists, registered nurses and midwives/ nursing aides based on HR records and 2. The schedule of duties for the previous and current month 3. Number of beds applied for and the actual being used. OBSERVATION

Number of beds

4.1 DATA COLLECTION, AGGREGATION AND USE

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

RECORDS MANAGEMENT Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.

4.2

4.2.1 Medical Record

4.2.1.a

23.Clinical records are readily accessible to facilitate patient care, are kept confidential and safe, and comply with all relevant statutory requirements and codes of practice

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

Presence of policies and procedures on systematic filing, retrieval, retention, storage, disposal and management of medical records. Patients chart contents include the following: -Doctors 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

DOCUMENT REVIEW

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

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

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

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

-Doctors Progress Notes -Medication and Treatment Record -Laboratory and X-ray Reports -Dietary Assessment Nurses Progress Notes -Records of Transfer/Referral to another Physician or Health Facility -Inpatient Referral/Consultation Notes of Other Physicians -Final Diagnosis -Advance Directive, if any

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

DOCUMENT REVIEW

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

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

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

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6.1 6x1.1

SAFE PRACTICE AND ENVIRONMENT PATIENT AND STAFF SAFETY Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care.

6.1.1.a 6.1.1.b

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

The organizational environment complies with structural standards and safety codes as prescribed by law. There are management plans which address safety, security, disposal and control of hazardous materials and biological wastes Emergency and disaster preparedness, fire safety, radiation safety and utility systems.

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

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

Management plan which includes polices, procedures and programs, risk assessment, hazards surveillance among others that address the following: 1. Safety 2. Security 3. Disposal and control of hazardous materials/biologic wastes 4. Emergency and disaster preparedness 5. Fire safety 6. Radiation safety 7. Utility systems Note: The hospital must

have plans for all the elements enumerated in the criteria. Plans should have guiding policies and specific procedures.

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

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

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

Presence of operating manuals of the medical equipment.

DOCUMENT REVIEW

DOCUMENT

Operating manuals for the medical equipment

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

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

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

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

1. electrical safety 2. Fire and emergency preparedness - check for exit plans, plans for earthquake and other disasters. 3. Control of hazardous materials - MOA/Contract of outsourced services for waste management INTERVIEW 1. Ask staff from ER, Wards, OPD, Laboratory, Pharmacy, and facilities and maintenance on the manner of waste segregation and disposal (general waste, liquid & solid waste, infectious waste; non-infectious, hazardous and non-hazardous 2. Hospital safety program 3. Mechanical safety program of the hospital

2. medical device safety ER

3. chemical safety OPD

4. radiation safety Wards

5. mechanical safety Imaging

6. water safety Laboratory

7. combustible material safety

Pharmacy

8. waste management Facilities and maintenance

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

Other areas

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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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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 mercury)

ER

6.1.1.e

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

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

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

DOCUMENT 1. Operating manual 2. Preventive and corrective maintenance logbook

Wards OR/RR/DR

3. Qualifications of staff handling medical equipment INTERVIEW

1. Ask staff in the ER, ICU, wards, OR/RR/DR, facilities and maintenance, imaging and laboratory about the policies and procedures for use of medical equipment and their role in the implementation of such policies and procedures. 2. Ask staff in the ER, wards, ICU and OR/RR/DR for the hospital's program on the gradual phase-out of mercury.

Facilities and maintenance Imaging Laboratory Other areas

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6.1.1.f 31.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.

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

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

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

ER OPD Wards ICU OR/RR/DR Imaging Laboratory Pharmacy Other areas

6x1.1.g 32.The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.

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

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

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

Document review

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

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

Presence of an appointed personnel in charge of security.

Hospital order or Memo. DOCUMENT REVIEW Policies and procedures on risk identification, assessment and control, security risks, use of personal protective

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6x1.1.h

equipment, etc. or Appointment of person in charge of security INTERVIEW

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

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

7.1 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment.

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

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

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

DOCUMENT REVIEW Minutes of Leadership meeting Incident/sentinel event reports or com-munications/memoranda/orders or proceedings on sentinel events

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

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

Wards ER ICU OR

7.1.2 35. Emergency light and / or power supply, water and ventilation systems are provided for, in keeping with relevant statutory requirements

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

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

Facilities and maintenance

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and codes of practice. airconditioners . OBSERVATION

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

Other areas Facilities and maintenance

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

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

DOCUMENT REVIEW

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

Facilities and maintenance Imaging Laboratory Other areas

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

INTERVIEW Ask about how equipment (generator, airconditioner, medical devices and other equipment etc.) are maintained. Presence of operating manuals equipment DOCUMENT

Operating manual of generators, air con