Professional Documents
Culture Documents
OUTLINE OF CONTENTS
I.
GENERAL INFORMATION(page 2)
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.
9.
10.
11.
12.
13.
14.
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)
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.
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.
4.
(Barangay/District)
(Municipality/City)
Expiry Date:
Level 1 Level 2
Level 3
Private
Implementing Beds
INDICATOR
DOH MONITORING
CRITERIA
DOH INSPECTION
STANDARDS
SELF-ASSESSMENT
CODE
EVIDENCE
AREA
HOSPITAL ADMINISTRATION:
Goal- To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.
ADMINISTRATIVE AND
FINANCE SERVICE: The
AFS shall ensure adequate
Documented and
implementable policies and
1.1.1 and timely financial and
direct support services to all procedures
hospital units.
Approved documented policies,
guidelines and procedures on:
Administrative Group:
a) Staffing plan
Human Resource
b) Recruitment and
Complete, updated and
Management
Selection
easily retrievable
There shall be a
c) Hiring/Appointment
individual personnel file
comprehensive human
d) Orientation & Staff
Evidence of continuous
resource management plan
Development
improvement
1.1.1.a
which
includes
recruitment,
e)
continuing
education,
and
1.1.1.a.1
selection, promotion,
training
separation, welfare and
Approved documented policies,
benefits in accordance with
guidelines and procedures on
applicable laws.
a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training
REMARKS
:
f)
g)
h)
i)
Performance Evaluation
Rotation/Transfer
Succession Plan
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
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 maintenance and safekeeping of
Books of Accounts.
Budget
There shall be a
consolidation and
preparation of the Budget
Proposal, Work and
Financial/ Operational
Plans including its
implementation and
monitoring by the hospital
staff concerned.
documented and
implementable policies and
procedures
documented and
implementable policies and
procedures
Verifier:
Documents review,
Observe
Interview staff,
Validate
List of personnel
check if
Current
Verifier:
Documents review,
Interview staff,
Validate
Verifier:
Documents review,
Interview staff,
Validate
documented and
implementable policies and
1.1.1.b.3
1.1.1.c
1.1.1.d
1.1.1.e
1.1.1.f
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
Proof of transactions
Documents are readily
Available
Housekeeping
There shall be provision
and maintenance of clean,
safe and sanitary facilities
and environment for
hospital personnel, patients
and clients
Verifier:
Documents review,
Interview staff,
Validate
Documents are readily
available
Verifier:
Documents review,
Observe
Interview staff
Validate
Adequate
housekeeping
supplies.
evidence of continuous
review of policies and
procedures
Verifier:
Documents review,
Interview staff,
Validate
Verifier:
Documents review,
Interview staff,
Validate
Verifier:
Documents review,
Interview staff,
Validate
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. 20100003- 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.
evidence of continuous
review of policies and
procedures
Verifier:
Documents review,
Interview staff,
Validate
With appropriate
manpower, equipment and
supplies during patient
transport
Verifier:
Documents review,
Observe,
Interview
staff&Validate
documented and
implementable policies and
procedures
Verifier:
Documents review,
Observe,
Interview
staff&Validate
1.1.1.i.a
1.1.1.j
Medical Records
(Including Dental
Records)
Documented and
implementable policies and
procedures
Verifier:
Documents review,
Interview staff,
Validate
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
Verifier:
Observe, Interview
staff, Validate
Verifier:
Documents review,
Interview staff,
Validate
1.1,1.k
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.
documented and
implementable policies
and procedures
documented and
implementable policies
and procedures
Verifier:
Observe, Interview
staff, Validate
Verifier:
Observe, Interview
staff, Validate
2.1
INDICATOR
DOH MONITORING
CRITERIA
DOH
INSPECTION
STANDARDS
SELFASSESSMENT
CODE
EVIDENCE
AREA
2.1.1
1.Organizational policies
and procedures respect and
support patients' right to
quality care and their
responsibilities in that care.
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
departmentalized, get
two from
each department; when
a chart is
found to
have no
consent
before you
reach 10,
you do not
have to go
further.)
REMARKS
2.1.2
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
2.2
2.2.1
PATIENT CARE
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.
2.2.1.b
2.2.1.c
Presence of directional
signages to locate service
areas.
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
Other Areas
Lobby
.Presence of alternative
passageways (ramps and
elevators) that are
prominently marked and
free from obstruction for
patients with special needs.
ER
OPD
Wards
ICU
OR/RR/
DR/PACU
Imaging
Laboratory
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
2.2.2.
2.2.2.a
2.2.3
2.2.3.a
ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment
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
CHART REVIEW
Wards
OPD
Wards
ICU
ASSESSMENT
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.
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.
ER
DOCUMENT
Patient chart from wards
or ER.
NOTE: comprehensive
history includes present
illness, review of systems,
past medical, family and
personal history.
2..2.3.b
2.2.3.c
2.3
2.3.1
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.
9.Assessments are
performed regularly and
are determined by patient's
evolving response to care.
CHART REVIEW
Medical
Records
Office
IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients
10.Diagnostic examinations
appropriate to the provider
organization's service
capability and usual case
mix are available and are
performed by qualified
personnel.
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
2.3.2.a
2.3.2.b
2.3.2.c
Chart
Review
Wards
Pharmacy
OPD
ER
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
2.3.2.d
INTERVIEW
Verify from patients if they
were correctly identified
prior to drug
administration.
Medical
Records
Room
OBSERVATION
Observe if the staff
verifies the identity of
patient prior to
administration of
medications.
2.3.2.e
2.
2.4.1
Drug administration is
properly documented in the
patient chart.
CHART REVIEW
Medication sheet in
patient chart from the
medical records.
.
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.
CHART REVIEW
16. The discharge plan is
All charts have discharge
part of the patient's care
plans
Patient chart from medical
plan and is documented in
records room, the
the patient chart.
discharge orders should
contain the ff.:
1. May go home order
2.Home medications (if
applicable)
3.Follow up
visits/schedule
4. Home care/advise
Note: Discharge plan is not
synonymous with discharge
summary.
2.5
2.5.1.a
2.5.1.b
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.
2.5.1.c
19.The organization's
management team regularly
assesses its own
performance and the
performance of the
organization.
OBSERVATION
DOCUMENT REVIEW
INTERVIEW
1. Ask the management
team about priorities for
performance improvement
that relate to hospital wide
activities and patient
outcomes
2. Ask management team
how targets are set.
2.6.1
20. Documented
agreements and contracts
cover external service
providers and specify that the
quality of services provided
must be consistent with
appropriate set standards.
DOCUMENT REVIEW
1.Contracts/MOA for
outsourced services.
2. Valid licenses of all
providers of the
outsourced services.
OBSERVATION
Actual presence of the
outsourced services within
the hospital if applicable
Document
review
Imaging
Laboratory
Other areas
3.1.1.a
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.
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
4.2
4.2.1
4.2.1.a
of practice
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.
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 ICD10 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.
6.1
6x1.1
6.1.1.a
6.1.1.b
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.
ER
OPD
Wards ICU OR/
DR/RR
Facilities and
maintenance
Imaging
Laboratory
Others
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.
6.1.1.c
6.1.1.d
DOCUMENT REVIEW
Presence of operating
manuals of the medical
equipment.
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
DOCUMENT
Operating manuals for
the medical equipment
6. water safety
7. combustible material
safety
8. waste management
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 nonhazardous
2. Hospital safety program
3. Mechanical safety
program of the hospital
ER
OPD
Wards
Imaging
Laboratory
Pharmacy
Facilities and
maintenance
Other areas
OBSERVATION
1. Electrical safety - check
for exposed wires and
sockets, octopus
connections"
2. Emergency
preparedness - check for
evacuation plans, presence
of fire extinguishers
3. Control of hazardous
waste - waste disposal
system, segregation of
waste, proper labeling of
waste receptacles
4. Chemical safety - check
safe storage and disposal of
reagents
DOCUMENT
1. Quality control
programs and corrective
and preventive
maintenance programs
2. Record of disposal of
radiologic wastes
3. Preventive and
corrective maintenance
logbook
4. Film reject analysis
test results
INTERVIEW
Ask staff about their role
in the hospital waste
management program
particularly manner of
radiologic waste
disposal.
OBSERVATION
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)
6.1.1.e
DOCUMENT
1. Operating manual
2. Preventive and
corrective maintenance
logbook
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.
ER
Wards
OR/RR/DR
Facilities and
maintenance
Imaging
Laboratory
Other areas
6.1.1.f
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
DOCUMENT REVIEW
policies and procedures
on risk identification,
assessment and control,
security risks and use of
personal protective
equipment, etc.
Document
review
A coordinated security
arrangements in the
organization assures
protection of patients, staff
and visitors.
Presence of an appointed
personnel in charge of
security.
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.
6x1.1.h
7.1
7.1.1
7.1.2
DOCUMENT REVIEW
Minutes of Leadership
meeting
Incident/sentinel event
reports or communications/memoranda/o
rders or proceedings on
sentinel events
INTERVIEW
Ask readers and staff from
wards and ER how the
incident reporting system
works.
Wards
ER
ICU
OR
DOCUMENT
Preventive and corrective
maintenance logbooks
for generator/ emergency
light/ water tanks/
Facilities and
maintenance
airconditioners .
Other areas
OBSERVATION
1. Presence of
generator/emergency
light, water tanks,
adequate ventilation or
air conditioning
2. Test if faucets and
water closets are
working
7.1.3
Facilities and
maintenance
Facilities and
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).
maintenance
Imaging
Laboratory
Other
areas
7.1.4
INTERVIEW
Ask about how
equipment (generator,
airconditioner, medical
devices and other
equipment etc.) are
maintained.
Presence of operating
manuals equipment
DOCUMENT
Operating manual of
generators, air
conditioners and other
non-medical equipment.
8.1
INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel,
visitors and trainees are identified and
8.1.1.a
8.1.1.b
Presence of an Infection
Control
Committee (ICC) with
defined goals, objectives,
strategies and priorities or
for a primary hospital - a
designated doctor and nurse
in-charge of infection
control.
Presence of an infection
control program ensuring
prevention and control of
infections on all services.
DOCUMENT
REVIEW
DOCUMENT REVIEW
1. ICC composition (for a
primary hospital - proof of
designation of a doctor and
nurse in-charge of = in2.
ICC functions and activities
fection control)
3. Minutes of meeting, at
least quarterly activities
4. Statistics on nosocomial
infections
INTERVIEW
Ask a member of the ICC
regarding infection control
program of the hospital.
DOCUMENT REVIEW
1. Policies and procedures
on prevention and control
of nosocomial infection or
Infection control manual
2. Policies on rational antimicrobial use based on the
hospital antibiogram in
coordination with
Microbiology laboratory
and Pharmacy Therapeutics
Committee
3. Reports of infection
control activities e.g.
training,outbreak
investigation,
preventive programs
8.1.2.a
Presence of coordinated
system-wide procedure for
isolation of nosocomial
infections.
Document
review
DOCUMENT REVIEW
Procedures on isolation of
nosocomial infections
INTERVIEW
8.1.2.b
Presence of coordinated
system-wide procedure for
case containment of
nosocomial infections.
8.1.2.c
8.1.3.a
Presence of coordinated
system-wide procedure for
asepsis.
ER
Wards
ICU
DOCUMENT
REVIEW Procedures on
case containment of
nosocomial infections
Note: case containment
- means prevention of
spread of infection
examples: reverse isolation,
prophylaxis for exposed
personnel, vaccination,
immunization
Document
review
ER
Wards
ICU
INTERVIEW
Validate from staff in ER,
wards and ICU the
procedures on case
containment
DOCUMENT REVIEW
Procedures on asepsis
INTERVIEW
Ask staff from ER, wards,
laboratory and ICU about
the approaches for asepsis
during diagnostic and
treatment procedures.
DOCUMENT REVIEW
1. Policies and procedures
for prevention and
treatment of needle stick
injuries
ER
Wards
ICU
Laboratory
duties.
8.1.3.b
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 .
ER
Wards
ICU
Laboratory
ER
Wards
ICU
Laboratory
INTERVIEW
OR/DR
45.Cleaning, disinfecting,
drying, packaging and
sterilizing of equipment, and
maintenance of associated
environment, conform to
relevant statutory requirements
and codes of practice.
DOCUMENT REVIEW
1. Policies and procedures
on cleaning, disinfecting,
drying, packaging and
sterilizing of equipment,
instruments and supplies.
2. Policies on
decontamination,
disinfection, sterilization,
disinfectants for specific
medical equipment/items
and area.
3. Housekeeping
procedures in specific
patient areas.
8.1.5
DOCUMENT REVIEW
Ward
ER
OR/DR
Presence of policies,
procedures and guidelines
for safe reuse of items which
comply with relevant
statutory requirements.
9.1
DOCUMENT REVIEW
INTERVIEW
Ask heads and staff about
the following:
1. Policy on reuse of items
2. SOPs on reuse
3. Reporting
4. Personnel in charge
Goal: The organization demonstrates its commitment to environmental issues by considering and implementing
strategies to achieve environmental sustainability
9.1.1
47.The handling,
Presence of
9.1.2
10.1
licenses/permits/
clearances from
pertinent regulatory
agencies implementing
among others the
following: RA 9003, RA
6969, RA 275, PD 1586
DOH Hospital Waste
Management Manual,
RA 8749 (Clean Air Act
DOCUMENT
REVIEW
Pertinent
licenses/permits
from regulatory
agencies (LGU,
DENR, etc.)
48.The organization
implements a waste
disposal program which
involves reuse, reduction
and recycling.
Proof of implementation of
policies and procedures
on waste disposal.
DOCUMENT
REVIEW
1. Issuances - memos,
guidelines on waste
disposal
2. Contracts with waste
handlers or disposal
contractors, (if
applicable)
3. Hospital policy that
conforms to the joint
DOH-DENR circular on
waste management for
LGUs
1. Waste Segregation
2. Proper labeling of
waste receptacles
3. Recyclable waste
staging areas
4. Proper management
of temporary storage
areas prior to hauling for
disposal.
ER
Wards
ICU
Imaging
Laboratory
Facilities and
maintenance
IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and
meeting the needs of internal and external clients.
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 33 of 60
10.1.1
49.The organization has
a planned systematic
organization- wide
approach to process
design and performance
measurement,
assessment and
improvement
10.1.2
50.The organization
provides better care
service as a result of
continuous quality
improvement activities.
Presence of Quality
Improvement Program
Presence of patient
satisfaction survey
DOCUMENT REVIEW
1. Policy creating the QI
program
2. Proof of meetings or
similar documents of QA
Committee activities
3. Policies and
procedures on a
performance
measurement and
improvement
INTERVIEW
Validation of alI activities
thru interview of
pertinent staff including
frontliners and
Committee members.
DOCUMENT REVIEW
1. Patient satisfaction
survey results
2.Patient satisfaction
survey
questionnaire(may check
on the domains and
items)
10.1.1
Hospital Administrator
(Optional)
10.1.2
INDICATOR
DOH
MONITORING
CRITERIA
DOH
INSPECTION
POSITION STAFFING
REQUIREMENT I:
(Top Management
Positions)
SELFASSESSMENT
CODE
10.1
EVIDENCE
AREA
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/ Certificate
of units earned
Proof of
employment/appointment
REMARKS
Verifier:
10.1.3
10.1.4
Chief of Clinics/Chief
Medical Professional
Services
Department Head
Documents review,
Interview staff,
Validate:
Diploma
Proof of
employment/appointment
Verifier:
Documents review,
Interview staff,
Validate:
Diploma
Proof of
employment/appointment
10.1.5
10.1.6
Chief Nurse/Director
of Nursing/Deputy
Director for Nursing
3.5 Administrative
Officer
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/ Certificate of
units earned
Proof of
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/ Certificate of
units earned
Proof of
employment/appointment
employment/appointment
11.1
ADMINISTRATIVE
Chief of Hospital /Medical
Director/Medical Center Chief
Administrative Officer
Clerk:
- Pool
- Accounting
LEVEL 2
LEVEL 3
1
1:50 beds
1
1:50 beds
1
1:50 beds
1:50 beds
1:50 beds
1:50 beds
1
1
1
1(designate)
1(designate)
1
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11.1.13
11.1.14
11.1.15
11.1.16
11.1.17
1
1
1
1/Shift
1
1
1:50 beds
1:50 beds/shift
1
1
1:50 beds
1:50 beds/shift
11.1.18
Security Guard
1/shift
11.1.19
Engineer
1/entrance/exit
per shift
1
1/entrance/exit per
shift
1
11.1.20
Medical Equipment/Biomedical
Technician
Maintenance Personnel
1/shift
1/shift
11.1.1
11.1.2
11.1.3.a
11.1.3.b
11.1.4
11.1.5
11.1.6
11.1.7
11.1.8
11.1.9
11.1.10
11.1.11
11.1.12
11.1.1.21
DOH MONITORING
LEVEL 1
DOH INSPECTION
SELF ASSESSMENT
CODE
REMARKS
11.1.1.22
Mechanic
11.1.1.23
1:100 beds
1:100 beds
11.1.1.24
11.1.1.25
11.1.1.26
11.1
Cook
Food Service Worker
Food Service Supervisor
Medical Social Worker (For level 1, If
there is MOA with DSWD-LGU, the
Medical Social Worker should be
physically present in the hospital)
CLINICAL:
Chief of Clinics/Chief Medical
Professional Services
Department Head
1 (sharing is
allowed e.g.
hospital and
municipal/city
government)
1
0
0
1
11.2
11.2.1
11.2.2
11.2.3
11.2.4
1:100 beds
1:50 beds
1
1
1:100 beds
1:50 beds
1
1
1/
department
1/
department
50 beds = 6
Every additional
50 beds =
additional 2
100 beds = 8
Every additional
50 beds =
additional 3
( For
Departments with
accredited
residency training
program, number
will depend on
the requirement
of specialty board
concerned).
11.3
11.3.1
NURSING:
Chief Nurse/Director of Nursing
1
100 beds and
above=1
11.3.2
11.3.3
Supervising Nurse
1:50 beds
50 beds and
below = 1,
51-100 beds =
2,
101-150 beds =
3,
151 beds and
above = 4
11.3.4
11.3.5
11.3.6
11.3.7
11.3.8
11.3.9
11.3.10
1:15 RNs
1:12 beds at any
time
1/shift
1 per department
/special area
1 per critical
care unit
1:15 RNs
1:12 beds at
any time
1:15 RNs
1:12 beds at any
time
1:24 beds at
any time plus 1
reliever
1:15 beds at
any time
1/shift( may
increase
1/OR/shift( may
increase
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 40 of 60
11.3.11
1 per/shift
11.3.12
11.3.13
1/ shift
1
depending on
the average
number of OR
cases per day)
1/shift( may
increase
depending on
the average
number of
deliveries per
day)
1 shift
1
depending on the
average number
of OR cases per
day)
1/DR/shift( may
increase
depending on the
average number
of deliveries per
day)
Adequate
1/Dept/shift
1/Dept.
11.4
11.4.1
Pharmacist (full-time,registered);
Adequate
Adequate
11.4.2
Pathologist
11.4.3
Adequate
Adequate
Adequate
11.4.4
Adequate
Adequate
Adequate
11.4.5
Dentist
11.4.6
Dental Aide
11.4.7
Radiologist
11.4.8
Radiology Technologist
Adequate
11.4.9
1(designate)
11.4.10
Physical Therapist
11.4.11
Adequate
1(designate)
Adequate
1
1
12.1
12.1.1
12.1.1.1
Level 1
1.ADMINISTRATIVE
1
12.1.1.2
12.1.1.3
12.1.1.5
12.1.1.6
Level 3
FINDINGS
(Indicate actual
no.
equipment
& instruments)
EQUIPMENT/INSTRUMENT REQUIREMENT
12.1.1.4
Level 2
DOH
MONITORING
STANDARD REQUIREMENT
DOH
INSPECTION
CODE
SELF
ASSESSMENT
REQUIRED NUMBER
Fire Extinguisher
Overhead Projector/ LCD
DIETARY
Oven
Refrigerator/Freezer
Osterizer/Blender
Food Conveyor
Food Scale
Exhaust Fan
Utility Cart
Garbage Receptacle with Cover
1 or more
depending on the
need
1
1 or more
depending on
the need
1
1/station/
lobby/
stairways
1/room/unit
1
1/station/lobby/st
airways
1/station
/lobby/
stairways
1/room/unit
1
1/room/unit
1
REMARKS
13.1
13.1.1
13.1.1.1
13.1.1.1.a
13.1.1.1.b
13.1.1.2
CLINICAL
EMERGENCY ROOM
Ambu Bag
Adult
Pediatric
1
1
1
1
1
1
13.1.1.3
Defibrillator
13.1.1.4
ECG Machine
13.1.1.5
13.1.1.6
13.1.1.7
Examining Table
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
13.1.1.8
13.1.1.9
13.1.1.10
13.1.1.11
13.1.1.12
13.1.1.13
13.1.1.14
13.1.1.15
13.1.1.16
13.1.1.17
13.1.1.18
13.1.1.18a
13.1.1.18b
13.1.1.19
13.1.1.20
13.1.1.21
13.1.1.22
13.1.1.23
13.1.1.24
13.1.1.25
13.1.1.26
Adult Cuff
Pediatric Cuff
Stethoscope
Suction Apparatus
Suturing Set
Thermometer (non-mercurial)
Tracheostomy Set
Vaginal Speculum Set
wheelchair
Wheeled Stretchers with guard and wheel lock
Or anchor.
13.2.1
13.2.1.1
13.2.1.2
13.2.1.3
13.2.1.4
13.2.1 5
13.2.1.6
13.2.1.7
13.2.1.8
13.2.1.9
13.2.1.10
13.2.1.11
13.2.1.12
13.2.1.13
13.2.1.14
13.2.1.15
13.3.1
13.3.1.1
13.3.1.2
13.3.1.3
13.3.1.4
13.3.1.5
13.3.1.6
13.3.1.7
13.3.1.8
13.3.1.9
13.3.1.10
13.3.1.11
13.3.1.12
13.3.1.13
13.3.1.13a
13.3.1.1b
13.3.1.14
13.3.1.15
13.3.1.16
OUTPATIENT CARE
1. Clinical Weighing Scale
2. ECG Machine
3. EENT Diagnostic Set
4. Gooseneck Lamp/Examining Light
5. Examining Table with wheel lock or anchor
6. Instrument Table
7. Minor Surgery Instrument Set
8. Neurological Hammer
9. Oxygen Unit
10.Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
11. Stethoscope
12. Suture Removal Set
13. Thermometer, non-mercurial
13. Vaginal Speculum Set
14. Wheelchair
OPERATING ROOM
1. Air-conditioning Unit
2. Anesthesia Machine
3. Cardiac Monitor with pulse oximeter
4. C/S Set
5. Instrument Table
6. Laparotomy Set
7. Laryngoscope with Blades
8. Major Surgical Instrument Set
9. OR Light
10.OR Table
11. Ortho Instrument Set
12. Oxygen Unit (anchored)
13. Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
14. Spinal Set
15. Stethoscope
16. Suction Apparatus
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Pulse
Oximeter
1
1
1
1 set
1
1
1
1
1
1
1
1
1
1
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
1/OR
1/OR
1 set/OR
1/OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
1/OR
1/OR
1 set/OR
1OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 44 of 60
13.3.1.17
13.3.1.18
13.4.1
13.4.1.1
13.4.1.2
13.4.1.3
13.4.1.4
13.4.1.4a
13.4.1.4b
13.4.1.5
13.4.1.6
13.4.1.7
1.
2.
3.
4.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
13.5.1
Air-conditioning Unit
Bed with Guard Rail and wheel lock or anchor
Oxygen Unit (anchored)
Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
5. Pulse Oximeter
6. Stethoscope
7. Suction Apparatus
LABOR ROOM
13.5.1.1
13.5.1.2
13.5.1.3
13.5.1.4
1. CTG Machine
2. Amniotome
3. Sphygmomanometer (non-mercurial)
4. Stethoscope
13.6.1
13.6.1.1
13.6.1.2
13.6.1.3
13.6.1.4
13.6.1.5
13.6.1.6
13.6.1.7
13.6.1.8
13.6.1.9
13.6.1.10
13.6.1.11
13.6.1.12
1. Air-conditioning Unit
3. D/C Set
4. Delivery Set
5. DR Light
6. DR Table with Stirrup
7. Foetoscope (Doppler)
8. Instrument Table
9. Kelly Pad
10.Oxygen Unit, Anchored
11.Sphygmomanometer (non-mercurial)
12.Stethoscope
13.Suction Apparatus
1
1
1
1
1
1
1
1
1
1
1
1
1/DR
1/DR
1/DR
1/DR
1/DR
1
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
13.6.1.13
13.6.1.14
13.6.1.15
14.Wheeled Stretcher
15.Bassinet
16.Infant Weighing Scale
1
1
1
1
1
1
1
1
1
1
1
1
1
1.3.7.1
13.7.1.1
13.7.1.2
13.7.1.3
13.7.1.4
13..8.1
13..8.1.1
13..8.1.2
13..8.1.3
13..8.1.4
13..8.1.5
13..8.1.6
13..8.1.7
13..8.1.8
1 13..8.1.9
13..8.1.10
13..8.1.11
13..8.1.12
13..8.1.13
13..8.1.14
13..8.1.15
13..8.1.16
3. Suction Apparatus
4. Oxygen Unit, Anchored
NEONATAL INTENSIVE CARE UNIT
1. Bassinet
2. Bili Light
3. Cardiac Monitor
4. Emergency Cart
5. Umbilical Cannulation Set
6. Laryngoscope with Neonatal Blades
7. Examining Light
8. Incubator
9. Infant Ambu Bag
10. Infant Weighing Scale
Oxygen Unit
Respirator/Mechanical Ventilator
Radiant Warmer
Infusion Pump/Syringe Pump
Glucometer
Nebulizer
13..8.1.17
Pulse Oximeter
13..8.1.18
13..8.1.19
Neonatal Stethoscope
Suction Apparatus
INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1
Air-conditioning Unit
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Ambu Bag
Adult (in adult units)
Pediatric (in pediatric units)
Bed with Guard Rail
Cardiac Monitor
Defibrillator
ECG Machine
Emergency Cart with emergency
Medicines(Refer to annex for medicines and
supplies)
Laryngoscope with Blades
Endotracheal Tube
Oxygen Unit
Sphygmomanometer (non-mercurial
Adult Cuff (in adult units
Pediatric Cuff Set (in pediatric units)
Stethoscope
Suction Apparatus
Tracheostomy Set
Pulse Oximeter
Mechanical Ventilator
Infusion Pump
NURSING UNIT OR WARD
Ambu Bag
Adult (if Adult ward)
Pediatric ( if Pediatric ward)
Clinical Weighing Scale (per nursing unit)
ECG Machine
Emergency Cart or its equivalent (per
nursing unit)
Mechanical Bed/Patient Bed with Side Rails
(Patient beds in ER, Labor Room, and Critical
Areas are not included in the count)
Actual bed
count should
correspond to
ABC applied
for.
Actual bed
count should
correspond to
ABC applied
for.
1/Medical/
Pedia ward
1/Medical/
Pedia ward
Neurological Hammer
Oxygen Unit, Anchored
(may increase depending on the need)
Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
Stethoscope
Suction Apparatus
Thermometer (non- mercurial)
CENTRAL STERILIZING & SUPPLY ROOM
Autoclave ( may increase depending on
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 47 of 60
the need)
Steam Sterilizer ( may increase depending
on the need)
DENTAL CLINIC
Dental Chair
Operating Stool per Dental Chair
Autoclave
Air Compressor
Dental X-ray
Mouth Mirror Explorer
Explorer, double end
Scaler jacquettes set No. 1,2,3
Low speed hand piece (angled head)
Cotton pliers
High speed hand piece with bur remover
No.150 forceps (maxillary universal forceps)
No.151 forceps (lower universal)
No.150 S forceps (primary teeth)
No. 8L and No18R forceps(upper molar)
No.151A forceps (mandibular premolar)
No.17 forceps
No.15 S forceps (lower primary teeth)
Rongeur forceps
Surgical chisel and mallet
.. Bone file
Surgical Scissor
. Root elevator
. Periostal elevator No. 9 double end
Gum Separator double end
Cowhorn forceps
Bonefile Stainless end
DIALYSIS CLINIC- Not required for Levels 1 and 2.
(Refer to AO 2012-0001 New Rules and Regulations
Governing the Licensure and Regulation of Dialysis
Facilities in the Philippines
Use checklist for Dialysis facility
LEVEL 1
LEVEL 2
LEVEL 3
Lobby
Waiting Area
Information and Reception
Communication Booth (Area for level 1)
Toilet
Admitting Office ( Area for level 1)
Medical Records Office/Room
Business Office with the following sections
Billing
Cashier
Budget and Finance
Personnel Office (may be combined with
Administrative Office for level 1)
Office of the Admin. Officer
Office of Chief of Hospital
Office of the Chief of Clinics/Chief Medical
Professional Services
Library
Staff Toilet
Storage Area
Engineering /Maintenance Office for Level 2
Maintenance Area
not required
Waiting Area
Toilet (accessible)
Medicine
Pediatrics
OB-GYNE
Surgery
Anesthesia
Emergency Medicine
OPERATING ROOM (MAY BE
COMBINED IN ONE COMPLEX WITH DELIVERY
ROOM FOR LEVEL 1)
Major OR
Minor OR
Sub-Sterilizing/Work Areas
Scrub-up Area
Clean-up Area
Janitors Closet
RECOVERY ROOM
OBSTETRICS OPERATING ROOM
(MAY BE COMBINED WITH SURGICAL
OPERATING ROOM FOR LEVEL 1)
DELIVERY ROOM
Scrub-up Area
Clean-up Area
May be
combined
Janitors Closet
LABOR ROOM
Toilet
NEONATAL INTENSIVE CARE UNIT
Treatment Area
Viewing Area
Patient Area
Toilet
NURSING UNIT/WARD
Nurse Station
Toilet
Patient Area
Dressing Area
Utility Area
Linen Area
Toilet
Treatment Area
Janitors Closet
Toilet
ISOLATION ROOM
Toilet
Consultation room
Toilet
CENTRAL SUPPLY ROOM
Inspection Area
Packaging Area
Sterilizing Area
Releasing Area
PRAYER ROOM (AREA FOR LEVEL 1)
41
41x1
41x1.a
CRITERIA
B.DOH Programs
Implemented in the
Hospital>
1.Blood Services
Compliance to RA 7719
and its IRR, AO 20080008 Levels 1 and 2,
should be at least a
Blood Station Facility and
level 3, Blood Bank Facility
Documented policies:
To ensure adequate
supply of safe blood
and blood products.
blood and blood
products obtained from
blood service facilities
licensed by DOH
for BC, blood and
blood products
collected, obtained
from healthy voluntary
blood donors only
Documented policies:
To ensure adequate
supply of safe blood
and blood products
INDICATORS
MONITORING
STANDARDS
SELF
ASSESSMENT
DOH
INSPECTION
CODE
EVIDENCE
AREA
Verifier:
Documents review,
Observe
Interview staff
Validate
Verifier:
Documents review,
Observe
Interview staff
Validate
Blood
and
blood
products obtained from
blood service facilities
licensed by DOH
For BC, blood and blood
products
collected,
obtained
from
healthy
voluntary blood donors only
REMARKS
41x2
41x2,a
41x3
41x3.a
2.Health Promotion
and Disease
Prevention
2.1 Newborn Screening
- Compliance to
RA9288 and its
IRR
- Compliance to RA
7600 and its IRR
and R.A. 10028
and its IRR
- Milk Code (EO
No. 5
41x4
41x5
Documented policies
regarding NewbornScreening
Logbook of Newborns who
were tested and copies of
waiver for those who were not
screened
Documented policies
regarding Rooming-In and
practice of Breastfeeding
There should be no nursery
for normal newborns
Breastfeeding area should
be provided at the pathologic
nursery
Certification as Mother
Baby Friendly Hospital
Certification as Mother
Baby Friendly
Workplace
Verifier:
Documents review,
Observe
Interview staff
Validate
Verifier:
Documents review,
Observe
Interview staff
Validate
Verifier:
Documents review,
Observe
Interview staff
Validate
2.5. Immunization
(Republic Act No.
309)
2.6. Anti-Smoking
Program
(per RA 9211)
Verifier:
Documents review,
Observe
Interview staff
Validate
Documented policies
No smoking signages posted
at conspicuous areas
41x8
3.Generics Act of
1988
(R.A.6675)
41x8.a
1. e-EDPMSR.A.7581Price Act
of 1992; R.A.
9502Universally
Accessible Cheaper and
Quality
Medicines Act of 2008
41x9
4. Health Emergency
Management
Service(HEMS)
A.O. No. 2004-0168,
National
Policy on Health
Emergencies
and Disasters
Documented policies
implementing the EDPMS
in compliance with DOH
A.O. No.2008-0014Guidelines
on the
Pilot Implementation of the
e-EDPMS and A.O. No.
2011-0012 Implementing
Guidelines on Electronic
Drug Price Monitoring
System Version 2.0
Verifier:
Visit hospital pharmacy and
document review, Validate
Hospital/Office order
designating one
Conduct of drills/exercises
i.e, Fire,Earthquake, etc. (For
fire, it should be supervised by
the Bureau of Fire Protection).
Documentation of
drills/exercises conducted.
Proof of implementation of
the plan.
Verifier:
Documents review,
Observe
Interview staff
Validate
Verifier:
Documents review,
Observe
Interview staff
Validate
41X9.a
Evacuation Plan/Route
posted in every room/area
CODE
42
C.HOSPITAL COMMITTEES:
Written
Designation of
Members and
their
roles/functions
Written Policies
and Procedure
Updated and
Relevant Minutes
of Meeting
Reports/ Records
of Implementation
REMARKS
1.Credentials
42x1
2.Blood transfusion
42x2
3.HIV/AIDS Core Team
42x3
4.Waste Management
42x4
42x5
40x6
40x7
5.Patient Safety
6.Infection Control
7.Pharmacologic/Therapeutics
428
8.Health Emergency/
Crisis Management
42x9
42x10
9.CQI
10.Tissue
(for levels 2 and 3 only)
42x11
11.Ethics
(for levels 2,and 3 only)
12.Grievance
42x12
42x13
Rehab
Anesthesia
Surgery
OR
Pediatrics
OB/ Gyne
(Delivery
Room)
Medicine
Emergency
43
D.HOSPITAL OPERATIONS:
(The following Criteria
Requirements are applicable
only to level 3 ).
OPD
REMARKS
43x4
3.Inter/Intra Departmental
Referrals
4.Disaster
Management/Crisis
Management
5.Infection Control
43x5
43x6
43x7
43x8
43x9
43x10
11.Others, please specify
43x11
ASSESSED BY:
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
________________________________
Signature over Printed Name
_______________________________
Position
_______________________________
Position
_______________________________
Position
________________________________
Position
_______________________________
Date
_______________________________
Date
_______________________________
Date
________________________________
Date
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
________________________________
Signature over Printed Name
_______________________________
Position
_______________________________
Position
________________________________
Position
_______________________________
Date
_______________________________
Date
________________________________
Date
CONCURRED BY:
_______________________________
Signature over Printed Name
_______________________________
Position/Designation
_______________________________
Date