Benchbook SelfAssessment

Orientation of Hospitals on Benchbook Self-Assessment and Accreditation Process
MANUAL II
PHILIPPINE HEALTH INSURANCE CORPORATION
Manual 2 Table of Contents

SECTION 1 DOCUMENT REVIEW... 2 SECTION 2 LEADERSHIP INTERVIEW ... 45 SECTION 3 CHART REVIEW . 59 SECTION 4 WARDS . 64 SECTION 5 EMERGENCY ROOM.. 89 SECTION 6 OUT-PATIENT DEPARTMENT 108 SECTION 7 INTENSIVE CARE UNIT 120 SECTION 8 OPERATING ROOM.. 142 SECTION 9 IMAGING . 120 SECTION 10 LABORATORY .... 152 SECTION 11 HUMAN RESOURCE... 164 SECTION 12 MEDICAL RECORDS.. 170 SECTION 13 PHARMACY . 173 SECTION 14 FACILITIES MAINTENANCE. 178 SECTION 15 OTHERS ... 185
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BENCHBOOK for HOSPITALS
SECTION 1 - DOCUMENT REVIEW
Self Assessment and Survey Tool

CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE REMARKS
1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations Presence of policies and 1.1.b.1 Organizational policies and Policies and procedures DOCUMENT REVIEW __ __ 1. Policies and procedures on patients' rights: procedures respect and support which identify and address procedures to identify and __ __ 2. Policies and procedures on patients' rights: address patients' rights: patients' right to quality care and patients rights and __ __ 3. Policies and procedures on patients' rights: right to care, right to consent, their responsibilities in that care. responsibilities are __ 4. Policies and procedures on patients' rights: __ freedom of choice, rights of documented and incompetent patient (ex. monitored. patients (minors) minors) 1.1.d.1 Organizational policies and procedures respect and support patients' right to quality care and their responsibilities in that care. The hospital protects patients and respects their rights during research involving human subjects Presence of policies and procedures to protect patients and respect their rights during research involving human subjects __ __
right to care right to consent freedom of choice rights of incompetent
DOCUMENT REVIEW Policies and procedures on conduct of research involving patients: benefits and risks, informed consent, etc. INTERVIEW If hospital has done or has an ongoing research study involving patients: Ask leaders/researcher during leadership meeting regarding recruitment of participants, informed consent, confidentiality, etc DOCUMENT REVIEW 1. Policies on patient education 2. Policies on family education 3. Policies on patient involvement in care decision-making 4. Policies on family involvement in care decision-making
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1.2.a.1
The organization encourages and promotes opportunities to involve patients and their families in their care.
Policies and programs to educate patients and families on how to take a more pro-active role in health care decision making are documented, monitored and evaluated for their effectiveness. Policies and programs to educate patients and families on how to take a more pro-active role in health care decision making are documented, monitored and evaluated for their effectiveness.
Presence of policies regarding active participation of patients and families in health care decisions
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1.2.a.3
The organization encourages and promotes opportunities to involve patients and their families in their care.
Proof of ongoing policy review to monitor and evaluate the effectiveness of the program on patient education
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DOCUMENT REVIEW Monitoring reports related to patient or family education program/policy
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CODE 1.2.b.1 STANDARDS The organization encourages and promotes opportunities to involve patients and their families in their care. CRITERIA Patients and their families are involved in making care decisions with ethical issues, such as withholding resuscitation, foregoing life-sustaining treatment, end-of-life care, etc. INDICATOR Presence of policies and procedures on involvement of patients and families in making care decisions on ethical issues such as withholding resuscitation, foregoing lifesustaining treatment, end-oflife care, etc. HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures on involvement of patients and families in making care decisions on ethical issues to include the ff: Right of unconscious patients Right to dignity Right to appropriate care based on religious and personal beliefs etc. INTERVIEW 1. Ask the doctors and nurses in the ER, wards or ICU on how they involve the patients' families on making care decisions with ethical issues 2. Ask the patient or patient's family (ER, wards or ICU) if the doctor/hospital staff involves them in making care decisions with ethical issues e.g. In medicine ward, you may ask about advance directives, truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy consent. In surgery and OB wards - procedures involving reproductive tract (BTL, hysterectomy, oophorectomy, sexual reassignment) DOCUMENT REVIEW 1. Policies and procedures that address patients' needs for confidentiality 2. Policies and procedures that address patients' needs for privacy 3. Policies and procedures that address patients' needs for security 4. Policies and procedures that address patients' needs for religious counseling 5. Policies and procedures that address patients' needs for communication Note : Take note of the provisions of the policies for use in interview during survey of wards, ER, imaging and laboratory 1.3.b.1 The organization documents and follows policies and procedures for addressing patients' needs for confidentiality, privacy, security, religious counseling and communication. The hospital systematically determines, monitors and improves the extent to which patients' needs for confidentiality, privacy, security, counseling and communication are addressed. Presence of patient feedback mechanism on addressing patients' needs for confidentiality, privacy, security, religious counseling and communication __ __ DOCUMENT REVIEW Any reports on patient feedback monitoring e.g. analysis of patients' suggestions, complaints and other feedback or patient satisfaction survey result INTERVIEW Ask leaders about their patient feedback mechanism and/or their patient satisfaction survey REMARKS
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1.3.a.1
The organization documents and follows policies and procedures for addressing patients' needs for confidentiality, privacy, security, religious counseling and communication.
Hospital staff is aware of and follows policies and procedures in addressing patients needs for confidentiality, privacy, security, counseling, and communication.
Presence of policies and procedures that address patients' needs for confidentiality, privacy, security, religious counseling and communication
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CODE 1.4.a.1 STANDARDS The organization systematically elicits, monitors and acts upon feedback from patients, their families, visitors and communities. CRITERIA Policies and procedures for routinely determining and improving the level of patient satisfaction with all relevant aspects of care are documented and monitored. Policies and procedures for addressing and resolving patients complaints are documented and monitored. The organization identifies relevant codes of professional conduct and other statutory standards and informs its personnel about these codes and standards. INDICATOR Presence of policies for routinely determining and improving the level of patient satisfaction HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies for routinely determining and improving the level of patient satisfaction 2. Patient satisfaction questionnaire/survey or patient satisfaction survey results or documentation of actions to address the identified gaps REMARKS
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1.4.b.1
The organization systematically elicits, monitors and acts upon feedback from patients, their families, visitors and communities. The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards.
Presence of policies and procedures for addressing and resolving patients' complaints
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DOCUMENT REVIEW 1. Policies and procedures on addressing and resolving patients complaints 2. Minutes of meetings that address/resolve patients' complaints or patient satisfaction survey results DOCUMENT REVIEW Policies and procedures on codes of professional conduct Policies and procedures on codes of professional conduct are consistent with relevant statutory standards such as, but not limited to: 1. Codes of professional standards (PRC, PMA, PNA, PAMET, CSC, DOLE, etc) 2. Patient detention (RA 9434) and 3. Anti-deposit law (RA 8344) 4. Sexual harassment law (RA 7877).
1.5.a.1
Presence of policies and procedures on codes of professional conduct consistent with relevant statutory standards
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1.5.a.2
The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards.
The organization identifies relevant codes of professional conduct and other statutory standards and informs its personnel about these codes and standards.
Presence of programs on improving staff awareness on codes of professional conduct and other statutory standards
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DOCUMENT REVIEW Documents related to implementation of the program e.g. copy of lectures on professional conduct and related topics INTERVIEW Ask staff (HR) about the programs on awareness on codes of professional conduct and other statutory standards
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CODE 1.5.b.1 STANDARDS The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. CRITERIA The organization identifies and monitors personnel compliance with the code of ethics relevant to their respective disciplines. INDICATOR Presence of policies and procedures on monitoring compliance of personnel with codes of professional conduct relevant to their respective disciplines HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures 1.5.c.1 The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. Procedures for resolving ethical issues related to professional practice or to conflicts of interest are based on the relevant code of ethics and other professional and legal standards. Presence of policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest that are based on the relevant code of ethics and other professional and legal standards __ __ __ __ DOCUMENT REVIEW 1. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest 2. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest are based on relevant codes of ethics and other professional and legal standards 3. Proof of compliance to the policies and procedures, which may include the establishment of an Ethics Committee that will resolve issues related to professional practice or to conflicts of interest or minutes of meeting of the committee INTERVIEW Ask leaders how they handle ethical issues related to professional practice or conflicts of interest DOCUMENT REVIEW Policies and procedures for resolving ethical issues arising from patient care or reports or records of resolution of ethical dilemmas arising in the course of providing care e.g. disclosure of treatment-related injuries or adverse events REMARKS
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1.6.a.1
The organization documents and follows procedures for resolving ethical issues as they arise from patient care.
Procedures for resolving ethical issues that arise in the course of providing care are monitored for their effectiveness.
Presence of policies and procedures for resolving ethical issues arising from patient care
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CODE 1.6.a.2 STANDARDS The organization documents and follows procedures for resolving ethical issues as they arise from patient care. CRITERIA Procedures for resolving ethical issues that arise in the course of providing care are monitored for their effectiveness. INDICATOR Proof of monitoring of policies/procedures for resolving ethical issues arising from patient care HOSP PHIC EVIDENCE DOCUMENT REVIEW Annual reports of the Ethics Committee (if present) or any similar reports on ethical issues by any hospital committee or body REMARKS
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2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of facilities 2.1.1.b.1 The organization informs the Clinical services are consistent with clinical service core community about the services it appropriate to patients' capability based on DOH provides and the hours of their needs and the former's license in accordance with availability. availability is consistent the hospitals level (e.g. level with the organization's service capability and role 2 surgical capability, level 3 ICU, level 4 teaching and in the community. training hospital) CORE 2.1.1.b.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 services addressing the endemic and most common diseases in the community DOCUMENT REVIEW 1. List of services available 2. DOH License 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
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DOCUMENT REVIEW 1. Inpatient census 2. Outpatient census. 3. The hospital should have services that address the top ten diseases in their census. 4. The hospital should have services in accordance to the 'Mother-Baby Friendly Hospital Initiative" 5. The hospital should have services for newborn screening INTERVIEW Interview leaders regarding availability of services for endemic and most common diseases in the community based on their census
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CODE STANDARDS CRITERIA The organization documents, follows policies and procedures, and provides resources for the safe and efficient direction of patients, their families and visitors and staff traffic. INDICATOR Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic are followed HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual REMARKS
2.1.2.e.1 Physical access to the organization and its services is facilitated and is appropriate to patients' needs.
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.1.a.1 Patients receive prompt and Patient waiting times are Presence of policies and DOCUMENT REVIEW procedures on patient waiting __ __ Policies and procedures on patient waiting time timely attention by qualified routinely monitored, time professionals upon entry. evaluated and improved based on standards and procedures developed by the organization. Depending on their needs, patients are seen within the planned waiting period. 2.2.1.a.2 Patients receive prompt and timely attention by qualified professionals upon entry. Patient waiting times are Presence of monitoring system for patient waiting routinely monitored, times evaluated and improved based on standards and procedures developed by the organization. Depending on their needs, patients are seen within the planned waiting period. DOCUMENT REVIEW Monitoring and evaluation reports on patient waiting time Note: Hospitals should set the patient waiting time.
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CODE STANDARDS CRITERIA INDICATOR Presence of policies on informing patients for any cause of delay in the delivery of services HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures on informing patients for any cause of delay in the delivery of services DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing patients' clinical needs 2. Policies and procedures in identifying clinical services that will best address patient's clinical needs REMARKS
2.2.1.b.1 Patient receive prompt and timely Patients are informed of attention by qualified the cause of any delay in professionals upon entry. the delivery of services. 2.2.2.a.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging.
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The staff follows policies Presence of policies and procedures in determining and procedures in determining and prioritizing and prioritizing patients patients' clinical needs and clinical needs and in identifying clinical services in identifying clinical that will best address them services that will best address them. The staff follows policies Presence of policies and procedures in determining and procedures in determining admissibility of and prioritizing admissibility of patients or the need for patients or the need for referral to other organizations referral to other organizations.
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2.2.2.b.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging.
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DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing admissibility of patients or the need for referral to other organizations 2. Policies and procedures in determining and prioritizing the need for referral to other organizations 3. ER/OPD logbook of admissions and referrals INTERVIEW Ask ER/OPD staff on procedures of admission and referrals Note : identify personnel to be interviewed. May obtain chart from wards and look for the chief complaint, determine admissibility and need for referral.
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2.2.2.c.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging.
Patients are correctly and efficiently assigned to the clinical services appropriate to their needs
Percentage of patients correctly assigned to the clinical services appropriate to their needs
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DOCUMENT Patient chart from ward and ICU Note: Determine if the service the patient is admitted to coincides with the patient's chief complaint and working diagnosis. Formula: Number of patients correctly assigned to the clinical services appropriate to their needs / total number of patients interviewed x 100 Sample Size: Rule of 10
2.2.3.a.1 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
Presence of policies and procedures for correctly identifying patients by their chart
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DOCUMENT REVIEW Policies and procedures for correctly identifying patients by their chart Footnote: to uniquely identify a patient may mean making the patient number a lifetime number.
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2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. 2.3.2.a.1 Appropriate professionals Based on collaboratively Presence of policies and procedures on conducting __ developed policies and perform coordinated and initial assessments in an sequenced patient assessment to procedures, qualified efficient and systematic reduce waste and unnecessary personnel conduct initial manner repetition. assessments in an efficient and systematic manner to avoid repetition. 2.3.3.d.1 Assessments are performed regularly and are determined by patient's evolving response to care. 2.3.5.a.1 Diagnostic examinations appropriate to the provider organization's service capability and usual case mix are available and are performed by qualified personnel. 2.3.5.a.2 Diagnostic examinations core appropriate to the provider organization's service capability and usual case mix are available and are performed by qualified personnel. 2.3.5.b.1 Diagnostic examinations appropriate to the provider organization's service capability and usual case mix are available and are performed by qualified personnel. Qualified personnel give Presence of policies and patients for surgery preprocedures regarding preoperative physical and pre- operative and pre-anesthetic anesthetic assessment. assessment Policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations are documented and monitored Policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations are documented and monitored Policies and procedures for accessing and referring patients to approved external providers when diagnostic services are not available within the provider organization are documented and monitored Presence of policies and procedures for the standard performance, monitoring and quality control of diagnostic examinations
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DOCUMENT REVIEW Policies and procedures on conducting initial assessments in an efficient and systematic manner
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DOCUMENT REVIEW 1. Policies and procedures regarding pre-operative assessment e.g.. cardio-pulmonary clearance 2. Policies and procedures regarding pre-anesthetic assessment DOCUMENT REVIEW 1. Policies and procedures for the standard performance of diagnostic examinations 2. Policies and procedures for the monitoring of diagnostic examinations 3. Policies and procedures for the 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.)
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Proof of monitoring of the implementation of the policies and procedures on quality control of diagnostic examinations CORE Presence of policies and procedures for accessing and referring patients to approved external providers
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DOCUMENT REVIEW Policies and procedures on accessing and referring patients to approved external providers (outside laboratories, imaging, etc)
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CODE STANDARDS CRITERIA Policies and procedures for accessing and referring patients to approved external providers when diagnostic services are not available within the provider organization are documented and monitored Policies and procedures identify patients with special needs and the specific types of assessment appropriate to their needs INDICATOR Presence of monitoring system on the implementation of referral to approved external providers HOSP PHIC EVIDENCE DOCUMENT REVIEW Logbooks for monitoring referral to approved external providers, monitoring reports or documented actions or Monitoring reports on documented actions e.g. memos Note : Hospitals without policies on referral get an automatic score of 1. REMARKS
2.3.5.b.2 Diagnostic examinations appropriate to the provider organization's service capability and usual case mix are available and are performed by qualified personnel.
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2.3.6.a.1 Assessments of patients with special needs are determined by policies and procedures that are consistent with legal and ethical requirements.
Presence of policies and procedures that identify patients with special needs and the specific type of assessment appropriate to their needs
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DOCUMENT REVIEW 1. Policies and procedures that identify patients with special needs 2. Policies and procedures that identify the specific type of assessment appropriate to the needs of patients with special needs Note : For hospitals not handling patients with special needs, their policies should clearly indicate this. Footnote: Patients with special needs include infants, school-aged children, adolescents, the elderly and the disabled, victims of alleged sexual abuse or violence, patients with emotional or behavioral disorder, patients with drug dependencies or alcoholism
2.4 CARE PLANNING Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. 2.4.2.a.1 The care plan is consistent with The care plan is Proof of involvement of a scientific evidence, professional developed by a multimultidisciplinary team in the __ __ standards, cultural values, disciplinary team of health formulation of medico-legal and statutory professionals within the adapted/developed protocols, requirements. organization CPGs or pathways 2.4.2.b.1 The care plan is consistent with scientific evidence, professional standards, cultural values, medico-legal and statutory requirements. The care plan is developed following search and appraisal of published scientific literature Proof that evidence-based approach was used in developing/adopting the protocols, CPGs or pathways
DOCUMENT REVIEW Documents (memos, issuances, orders) stating the involvement of a multidisciplinary team (doctors, nurses, dietitians, social worker and other medical and paramedical staff) in the development of protocols, guidelines or pathways DOCUMENT REVIEW 1. Documents (memos, issuances, orders) stating that evidence based approaches (systematic literature search and appraisal using accepted tools) were used in adopting/developing the protocols, CPGs and pathways. 2. Minutes of meetings on development/adoption of the protocols, guidelines or pathways
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.1.a.1 Care is delivered in a timely, safe, In the management of Presence of policies and appropriate and coordinated clinical pathway-covered procedures on manner, according to care plans. conditions, the order and implementation/ compliance timing of treatments follow to pathways the pathway 2.5.1.b.1 Care is delivered in a timely, safe, Orders for treatments are appropriate and coordinated implemented within time manner, according to care plans. intervals established by the organization 2.5.1.b.2 Care is delivered in a timely, safe, Orders for treatments are appropriate and coordinated implemented within time manner, according to care plans. intervals established by the organization Presence of policies and procedures on time intervals to act on orders for treatment Proof that orders for treatment are implemented within time intervals established by the organization
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DOCUMENT REVIEW Policies and procedures on implementation/compliance to clinical pathways
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DOCUMENT REVIEW Policies and procedures on time intervals to act on orders for treatment e.g. doctors orders must be carried out within 30 minutes; time intervals for IV medications DOCUMENT REVIEW Monitoring reports, if none, ask for patient charts and look at the doctors orders and medication sheet INTERVIEW 1. Ask nurses regarding time intervals established by the hospital and how they are implemented 2. Ask patients regarding time intervals of treatment e.g. what time usually are medications given, etc. Note : If hospital has no policy on time intervals to act on orders of treatment, automatic score of 1.
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2.5.2.b.1 Rights and needs of patients are Patients wish to decline considered and respected by all tests or treatments is the staff. respected 2.5.3.a.1 Care is coordinated to ensure continuity and to avoid duplication. Policies and procedures that determine the extent of duplicate assessments and treatments performed by trainees respect patients rights, and are documented and monitored.
Presence of policy on test or treatment refusal
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DOCUMENT REVIEW Policy on refusal of test or treatment
Presence of policies and procedures on duplicate assessments and treatments performed by trainees
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DOCUMENT REVIEW 1. Policies and procedures indicating extent of duplicate assessments and treatments performed by trainees 2. Policies and procedures indicating the extent of duplicate assessments and treatments performed by trainees respect patients' rights
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CODE STANDARDS CRITERIA Policies and procedures that determine the extent of duplicate assessments and treatments performed by trainees respect patients rights, and are documented and monitored. The organization documents and implements policies and procedures, and provides resources to promote interactive, appropriate and relevant educational programs for patients. The organization documents and implements policies and procedures, and provides resources to promote interactive, appropriate and relevant educational programs for patients. INDICATOR Proof that the policies and procedures on duplicate assessments and treatments are monitored HOSP PHIC EVIDENCE DOCUMENT REVIEW Monitoring reports in compliance to policies and procedures on duplicate assessments and treatments INTERVIEW Interview management or QA team on how they monitor compliance to the policies REMARKS
2.5.3.a.2 Care is coordinated to ensure continuity and to avoid duplication.
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2.5.4.a.1 Appropriate personnel educate patients and/or their families to help them understand patients' diagnosis, prognosis, treatment options, health promotion and illness prevention strategies.
Presence of policies and procedures on promoting interactive, appropriate and relevant educational programs for patients
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DOCUMENT REVIEW Policies and procedures promoting interactive, appropriate and relevant educational programs for patients
Proof of provision of resources for patient educational programs
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DOCUMENT REVIEW Approved budget to support patient educational programs OBSERVATION Presence of materials, equipment, structures to support the patient educational programs e.g.. LCD, posters, venue
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2.5.5.a.1 Drugs are administered in a standardized and systematic manner in the provider organization. 2.5.5.b.1 Drugs are administered in a standardized and systematic manner in the provider organization.
Drugs are administered in Presence of policies and a timely, safe, appropriate procedures on drug and controlled manner administration The provider organization documents and follows policies and procedures and allocates resources for the training, supervision, and evaluation of professionals who administer drugs Presence of policies and procedures for training, supervision and evaluation of professionals who administer drugs
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DOCUMENT REVIEW Policies and procedures on drug administration
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DOCUMENT REVIEW 1. Policies and procedures for training of professionals who administer drugs 2. Policies and procedures for supervision of professionals who administer drugs 3. Policies and procedures for evaluation of professionals who administer drugs
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CODE STANDARDS CRITERIA The provider organization documents and follows policies and procedures and allocates resources for the training, supervision, and evaluation of professionals who administer drugs INDICATOR Presence of resources allocated for training, supervision and evaluation of professionals who administer drugs HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who administer drugs 2. Training plan, training modules/materials, evaluation forms Note : Use organizational chart as guide/reference. OBSERVATION Observe presence of related structures present, e.g.. training room, conference room, libraries DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who administer drugs 2. Evaluation reports of professionals who administer drugs 3. Proof of training, e.g.. certificates of training INTERVIEW Ask leaders how the supervision of professionals who administer drugs are conducted DOCUMENT REVIEW 1. Policy on regular review of prescription orders 2. Evaluation reports by nurses/doctors in the floors, clinical pharmacist or therapeutics committee or minutes of meeting of the therapeutics committee INTERVIEW Ask leaders about utilization review activities, audit/peer review, other activities where appropriateness and safety of drug use are discussed Footnote: This is to ensure that prescriptions are written correctly (e.g.. in generic form), and that precautions for drug-drug and drug-food interactions have been adequately addressed. 2.5.5.f.1 Drugs are administered in a standardized and systematic manner in the provider organization. Presence of policies and Telephone orders are procedures regarding countersigned by the ordering physician not later telephone orders than standards set by the organization and based on statutory requirements DOCUMENT REVIEW Policies and procedures regarding telephone orders REMARKS
2.5.5.b.2 Drugs are administered in a standardized and systematic manner in the provider organization.
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2.5.5.d.1 Drugs are administered in a standardized and systematic manner in the provider organization.
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CODE STANDARDS CRITERIA Discontinued or recalled drugs are retrieved and safely disposed of according to established policies and procedures Drugs are selected and procured based on the organization's usual case mix and according to policies and procedures that are consistent with scientific evidence and government policies. INDICATOR Presence of policies and procedures on retrieval and safety disposal of drugs HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures on retrieval of drugs 2. Policies and procedures on safety disposal of drugs REMARKS
2.5.5.g.1 Drugs are administered in a standardized and systematic manner in the provider organization. 2.5.5.h.1 Drugs are administered in a standardized and systematic manner in the provider organization.
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Presence of policies and procedures on selection and procurement of drugs, consistent with scientific evidence and government policies
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DOCUMENT REVIEW 1. Policies and procedures on drug selection and procurement 2. Policies and procedures on drug selection and procurement are consistent with scientific evidence 3. Policies and procedures on drug selection and procurement are consistent with government policies e.g.. National Drug Policy INTERVIEW Ask the members of therapeutics committee regarding manner of selection and procurement of drugs OBSERVATION Observe actual supply of drugs in the pharmacy in accordance with the organization's policies DOCUMENT REVIEW 1. Policies and procedures for detecting adverse effects 2. Policies and procedures for reporting adverse effects 3. Policies and procedures for monitoring adverse effects DOCUMENT REVIEW 1. Forms for reporting incidents, adverse drug events, sentinel events or adverse events 2. Regular monitoring reports on adverse events DOCUMENT REVIEW 1. Policies on treatment procedures, clinical pathways, CPGs, flowcharts or algorithms 2. For hospitals with operating rooms: WHO surgical safety checklist is included in the policies on treatment procedures
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2.5.5.j.1
Drugs are administered in a standardized and systematic manner in the provider organization. Drugs are administered in a standardized and systematic manner in the provider organization.
Policies and procedures for detecting, reporting and monitoring adverse effects are documented and monitored Policies and procedures for detecting, reporting and monitoring adverse effects are documented and monitored
Presence of policies and procedures for detecting, reporting and monitoring adverse effects Proof of compliance to policies and procedures for detecting, reporting and monitoring adverse effects
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2.5.5.j.2
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2.5.6.a.1 Treatment procedures are Treatment procedures are Presence of policies on performed in a standardized and performed in a timely, treatment procedures systematic manner in the provider safe, appropriate and organization. controlled manner
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CODE STANDARDS CRITERIA INDICATOR Presence of policies and procedures for training, supervision and evaluation of professionals who perform the procedures HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures for training of professionals who perform the procedures 2. Policies and procedures for supervision of professionals who perform the procedures 3. Policies and procedures for evaluation of professionals who perform the procedures REMARKS
2.5.6.b.1 Treatment procedures are The provider organization performed in a standardized and documents and reviews systematic manner in the provider policies and procedures organization. and allocates resources for the training, supervision, and evaluation of professionals who perform procedures. 2.5.6.b.2 Treatment procedures are The provider organization performed in a standardized and documents and reviews systematic manner in the provider policies and procedures organization. and allocates resources for the training, supervision, and evaluation of professionals who perform procedures. 2.5.6.b.3 Treatment procedures are The provider organization performed in a standardized and documents and reviews systematic manner in the provider policies and procedures organization. and allocates resources for the training, supervision, and evaluation of professionals who perform procedures. 2.5.6.f.1 Medical devices and Treatment procedures are performed in a standardized and equipment are used, systematic manner in the provider maintained, stored and organization. disposed based on technical specifications.
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Presence of resources allocated for training, supervision and evaluation of professionals who perform procedures
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DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who perform procedures 2. Training plan, training modules/materials, organizational chart, evaluation forms OBSERVATION Observe related structures present, e.g.. training room, conference room, libraries DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who perform the procedure or evaluation reports 2. Proof of training, e.g.. certificates of training INTERVIEW Validate with leaders regarding supervision of performance of procedures and training. DOCUMENT 1. Policies and procedures on use and maintenance of medical devices 2. Policies and procedures on storage and disposal of medical devices 3. Schedule of equipments maintenance check, calibration of equipment 4. Logbook on preventive maintenance INTERVIEW Ask personnel how they use, maintain, store and dispose medical devices
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Proof that medical devices and equipment are used maintained, stored and disposed based on technical specifications.
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CODE STANDARDS CRITERIA INDICATOR Presence of policies and procedures regarding selection and procurement of medical devices and equipment based on organizations case mix, staff expertise, service capability, scientific evidence and government policies HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures on selection and procurement of medical devices and equipment 2. Policies and procedures on selection and procurement of medical devices and equipment are based on organization's case mix, staff expertise, and service capability 3. Policies and procedures on selection and procurement of medical devices and equipment are consistent with scientific evidence 4. Policies and procedures on selection and procurement of medical devices and equipment are consistent with government policies DOCUMENT REVIEW List of equipment procured the previous year/s. Check if procured according to policies and procedures. INTERVIEW Ask management team regarding basis for procurement of the listed equipment REMARKS
2.5.6.g.1 Treatment procedures are Medical devices and performed in a standardized and equipment are selected systematic manner in the provider and procured based on organization. organizations case mix, staff expertise, service capability and according to policies and procedures that are consistent with scientific evidence and government policies 2.5.6.g.2 Treatment procedures are Medical devices and performed in a standardized and equipment are selected systematic manner in the provider and procured based on organization. organizations case mix, staff expertise, service capability and according to policies and procedures that are consistent with scientific evidence and government policies 2.5.7.a.1 The care of patients with special needs is governed by policies and procedures that are consistent with legal and ethical requirements
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Proof that medical devices and equipment are selected and procured based on organization's case mix, staff expertise, service capability and according to policies and procedures that are consistent with scientific evidence and government policies
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The care of patients with Presence of policies and special needs is governed procedures that govern care by policies and procedures of patients with special needs that are consistent with legal and ethical requirements
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DOCUMENT Policies and procedures that govern care of patients with special needs Examples: care of pregnant patients in radiology department, care of victims of sexual or child abuse in the ER Footnote: Patients with special needs include infants, school-age children, adolescents, the elderly and the disabled, victims of alleged or suspected sexual abuse or violence, patients with emotional or behavioral disorders, patients with drug dependencies or alcoholism.
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2.6 EVALUATION OF CARE Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. 2.6.1.a.1 Data relating to processes and The organization routinely Proof of data collection DOCUMENT REVIEW collects process and related to processes and outcomes of patient care are Process and outcomes data reports such as but not limited to: __ 1. medical audit reports outcomes of care __ analyzed to provide information outcomes data from its __ 2. morbidity and mortality reports for care improvement. provision of patient care __ __ 3. hospital infection data __ __ 4. adverse event reports __ __ 5. evaluation reports of diagnostics, procedures and treatment __ __ 6. other reports: disposition data, variance reports, etc __ 2.6.1.b.1 Data relating to processes and outcomes of patient care are analyzed to provide information for care improvement. The organization provides resources for the formal and collaborative evaluation of care using analysis of process and outcomes data Presence of budget or resource allocation for CQI activities that makes use of analysis of process and outcomes data __ __ DOCUMENT REVIEW 1. Budget or resource allocation for collection of data related to process and outcomes of care such as the following: medical audit, morbidity and mortality reports, adverse event and hospital infection data, etc 2. Budget or resource allocation for analysis of data related to process and outcomes of care such as: medical audit, mortality and morbidity conferences, etc INTERVIEW Ask QA committee what are the resources provided by the organization for CQI activities DOCUMENT REVIEW Documents showing that results of evaluation of care are fed back to concerned health care providers such as issuances, memos or reports INTERVIEW Verify with health care providers if they were given the results of the evaluation of care DOCUMENT REVIEW Documents showing that results of evaluation of care were presented and discussed in meetings of top management such as issuances, memos, directives, excerpts/minutes/agenda of meetings INTERVIEW Ask management team if the QA committee presents and discusses the results of evaluation
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__ 2.6.1.c.1 Data relating to processes and outcomes of patient care are analyzed to provide information for care improvement. Results of evaluation of care are fed back to the health care providers concerned Proof that results of evaluation of care are fed back to health care providers concerned
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__ 2.6.1.d.1 Data relating to processes and outcomes of patient care are analyzed to provide information for care improvement. Results of evaluation of care are routinely presented and discussed in meetings of top management Proof that results of evaluation of care are routinely presented and discussed in meetings of top management
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CODE STANDARDS CRITERIA Evaluation of care leads to formal and collaborative performance improvement activities that harness the resources of appropriate services INDICATOR Presence of collaborative performance improvement activities that harness the resources of appropriate services HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies /memo/ letters regarding any collaborative performance improvement activities as a result of evaluation of care INTERVIEW Verify with health care team if there are performance improvement activities as a stemming from results of evaluation of care. DOCUMENT REVIEW Minutes of QA committee meetings, reports, memoranda/ orders/policies emanating from resolution of cases INTERVIEW Ask leaders on QI activities, specific cases brought to the attention of the QC/QT REMARKS
2.6.2.a.1 The health care team takes action to address any improvements required.
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2.6.3.x.1 Quality improvement activities are documented, enable continuous quality improvement and incorporate the following elements: * Monitoring, assessment, analysis and evaluation of activities * Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results 2.6.3.x.2 Quality improvement activities are documented, enable continuous quality improvement and incorporate the following elements: * Monitoring, assessment, analysis and evaluation of activities * Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results
Proof of documentation of QI activities
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Proof that QI activities incorporate the following elements: *Monitoring, assessment, analysis and evaluation of activities *Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results
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DOCUMENT REVIEW Reports of CQI activities INTERVIEW Validate with QA committee members regarding the (4) elements of CQI activities
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Presence of organizational 3.1.1.x.1 The provider organization's DOCUMENT REVIEW structure __ __ Organizational structure/chart or manual of operations management team provides leadership, acts according to the organization's policies and has OBSERVATION __ __ Observe if the organizational structure/chart is posted conspicuously in overall responsibility for the organization's operation, and the appropriate areas (Lobby) quality of its services and its resources 3.1.2.x.1 The organization's management ensures the presence of effective working relationships within the organization, with the community, and with other relevant organizations and individuals. 3.1.2.x.2 The organization's management ensures the presence of effective working relationships within the organization, with the community, and with other relevant organizations and individuals. 3.1.3.x.1 Terms of reference, membership core and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved. Presence of staff satisfaction survey which includes interpersonal relationships __ __ DOCUMENT REVIEW Reports on the results of staff satisfaction survey, and should include the following: analysis, conclusion and recommendation
Presence of activities that promote team building/good working relationship
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DOCUMENT REVIEW 1. Documentation of team building activities Examples: christmas party, sports activities, outing, etc. 2. Community outreach program Examples : medical mission, charity service, special clinic, community service DOCUMENT REVIEW Proof of the creation of all committees which includes the terms of reference for membership e.g. memo, office order, etc INTERVIEW Ask leaders what the committees in their hospital are and ask for the order that created these committees
Proof of the creation of all committees within the organization which includes the terms of reference for membership CORE
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CODE STANDARDS CRITERIA INDICATOR Presence of recorded minutes of the meetings for all committees within the organization HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Minutes of meetings for Quality Assurance Committee (level 1, 2, 3 and 4) 2. Minutes of meetings for Therapeutics Committee (level 2, 3 and 4) 3. Minutes of meetings for Infection Control Committee (level 3 and 4) 4. Minutes of meetings for other committees Note: Level I hospitals may not necessarily have TC or infection committee, but there should at least be 2 persons looking at the use of therapeutic drugs & infection control INTERVIEW Committee members to validate the above activities 3.1.4.x.1 The organization's management core team regularly assesses its own performance and the performance of the organization. Presence of evaluation and monitoring activities to assess management and organizational performance CORE __ __ DOCUMENT REVIEW Documentation of evaluation activities to assess management and organizational performance such as monthly, quarterly, semestral or annual reports as applicable 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 DOCUMENT REVIEW 1. Written vision 2. Written mission 3. Written goals Note: Content of the Vision, Mission & Goals should include addressing the health needs of the community. REMARKS
3.1.3.x.2 Terms of reference, membership and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved.
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__ 3.1.5.a.1 The organization develops and The organization develops Presence of written mission, implements policies and its mission, vision and vision, and goals procedures which cover the major corporate goals based on services and aspects of agreed-upon values. operations. __ __ __
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CODE STANDARDS CRITERIA INDICATOR Presence of written by-laws, policies and procedures, which are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Written by-laws 2. Policies and procedures 3. Written by-laws are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities 4. Policies and procedures are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities INTERVIEW Ask leaders how their by-laws, policies and procedures were developed DOCUMENT REVIEW 1. Memos or issuances on review and/or revision of policies 2. Minutes of meetings on the review and/or revision of policies INTERVIEW Ask leaders how they review and revise policies and procedures DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures DOCUMENT REVIEW Proof of designation of a person responsible for information dissemination INTERVIEW Ask leaders who the responsible person for information dissemination is REMARKS
3.1.5.b.1 The organization develops and The organization's byimplements policies and laws, policies and procedures which cover the major procedures support care services and aspects of delivery and are consistent operations. with its goals, statutory requirements, accepted standards and its community and regional responsibilities.
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__ 3.1.5.c.1 The organization develops and Policies and procedures, Proof that policies and implements policies and aside from being complied procedures are reviewed and procedures which cover the major with, are reviewed and revised as necessary services and aspects of revised as necessary. operations. 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all procedures which cover the major and procedures to all levels of the workforce services and aspects of levels of the workforce. operations.
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__ __ __ __ 3.1.5.d.2 The organization develops and The organization Presence of a responsible implements policies and communicates its policies person for information procedures which cover the major and procedures to all dissemination services and aspects of levels of the workforce. operations.
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3.2 EXTERNAL SERVICES Goal: The organization ensures that services provided by external contractors meet appropriate standards. Presence of MOA/contract for 3.2.1.x.1 Documented agreements and __ __ all outsourced services (e.g. core contracts cover external service dialysis unit, dietary, __ __ providers and specify that the laboratory, radiology) quality of services provided must CORE 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 Note: The contracts/MOA should be updated. MOA is sufficient for some hospitals where the outsourced services are not within the facility
4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. The organization defines Presence of job descriptions 4.1.1.a.1 Planning ensures that DOCUMENT REVIEW the qualifications and indicating the qualifications appropriately trained and Job descriptions of personnel specifying the following: competencies of its staff. and competencies __ __ 1. functions qualified (and where relevant, appropriate to the personnel's __ __ 2. duties and responsibilities and the credentialed) staff are available job functions, duties and __ __ 3. required qualifications and competencies to undertake the type and level of responsibilities activity performed by the organization. This includes those who are consulted when suitable expertise is not available within the organization. 4.1.1.b.1 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 on hiring of staff DOCUMENT REVIEW Policies and procedures for hiring of staff INTERVIEW Ask appropriate personnel a certain procedure for hiring of staff. Note: The surveyor can randomly pick out a doctor, a nurse, an admin staff, both newly hired or old, and ask them the process of selection, hiring and screening and performance appraisal; when was it last conducted and by whom.
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CODE STANDARDS CRITERIA The organization documents and follows policies and procedures for hiring, credentialing, and privileging of its staff. INDICATOR Presence of policies and procedures for credentialing and privileging of staff CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures for credentialing and privileging of staff REMARKS
4.1.1.b.2 Planning ensures that core 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.
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Staff numbers and skill mix Presence of human resource 4.1.2.a.1 Workload is monitored and inventory system appropriate guidelines consulted are based on actual clinical needs. to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and organizational outcomes.
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DOCUMENT REVIEW List of personnel, staffing pattern, or documents related to the HR inventory system Note: The hospital may document and analyze information like daily patient loads, utilization rates and services, turn-around times to determine staff size and mix. INTERVIEW Ask appropriate personnel (e.g. HR manager) how the right number and mix of competent staff are maintained to meet the needs of internal and external clients. DOCUMENT REVIEW Employee report card or its equivalent (e.g.. DTR, logbook)
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Staff numbers and skill mix Presence of performance 4.1.2.a.2 Workload is monitored and monitoring on attendance, appropriate guidelines consulted are based on actual clinical needs. tardiness and absenteeism to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and organizational outcomes. Staff numbers and skill mix 4.1.2.a.3 Workload is monitored and core appropriate guidelines consulted are based on actual clinical needs. to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and organizational outcomes. Staff to bed ratio for licensed doctors, registered nurses and midwives/nursing aides follow the DOH prescribed ratio. CORE
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DOCUMENT REVIEW 1. List of total number of licensed doctors, 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 registered with DOH and actually being used. OBSERVATION Number of beds.
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CODE STANDARDS CRITERIA Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise. INDICATOR Presence of HR contingency plan e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load. HOSP PHIC EVIDENCE DOCUMENT REVIEW HR contingency plan e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load INTERVIEW Ask HR, Wards and ER staff: 1. What happens when one staff is absent? 2. When one staff goes AWOL? 3. When there are too many patients? 4. What is the back up system to maintain appropriate number of staff? DOCUMENT REVIEW 1. Mandatory Monthly Hospital Report (take note of Maximum Bed Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate exceeding 100% to identify occasions of increased patient load); 2. Actual plan and monitoring report showing how the increased patient load was addressed. INTERVIEW Ask HR, doctors, nurses and staff how the appropriate number of staff was maintained and what monitoring procedure was made? REMARKS
4.1.2.b.1 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.
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__ __ __ __ Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise. Proof of implementation and monitoring of HR contingency plan (e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load).
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4.2 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. The organization defines, Proof that the organization 4.2.1.a.1 Recruitment, selection, DOCUMENT REVIEW __ __ 1. Policies and procedures governing personnel recruitment, selection appointment and reappointment disseminates and ensures defines, disseminates and ensures compliance with compliance with policies procedures ensure appropriate and appointments. __ __ 2. Memos/endorsements reflecting the dissemination of policies and competence, training, experience, and procedures governing policies and procedures governing personnel licensing and credentialing of all personnel recruitment, procedures governing personnel recruitment, selection and recruitment, selection and selection and appointees. appointments. __ __ 3. Actions of the board/owner e.g. those reflected in its minutes, appointments. appointments resolutions, etc. showing that the organization ensures compliance to policies and procedures on personnel recruitment, selection and appointments. INTERVIEW Interview HR and wards staff for validation if the organization's policies and procedures on personnel recruitment, selection and appointments are actually being implemented.
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CODE STANDARDS CRITERIA INDICATOR Proof that recruitment and selection are consistent with the policies of the CSC (for government) or the organization. HOSP PHIC EVIDENCE DOCUMENT REVIEW Corporate policy on recruitment, selection and appointment of staff INTERVIEW 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It should be known to all staff and managers. 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities and maintenance and other areas for what conditions will lead to their firing 3. Ask staff regarding the process of their selection DOCUMENT REVIEW 1. Special/Office Orders or similar issuances defining the membership of the body/committee/group tasked to develop and implement personnel recruitment, selection and appointment; 2. Proof/minutes of meetings 3. Attendance of members INTERVIEW Ask leaders which team screens and appoints people and how members of the team are selected. DOCUMENT REVIEW Committee reports on selection and appointment REMARKS
The recruitment and 4.2.1.b.1 Recruitment, selection, appointment and reappointment selection process is open & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and licensing and credentialing of all ethical requirements, and allows a fair and unbiased appointees. evaluation of the qualifications and competencies of all applicants Relevant staff members 4.2.1.c.1 Recruitment, selection, appointment and reappointment participate in the development and procedures ensure appropriate competence, training, experience, implementation of licensing and credentialing of all personnel recruitment, selection and appointment. appointees.
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__ Selection and appointment 4.2.1.d.1 Recruitment, selection, appointment and reappointment and evidence of staff compliance with selection procedures ensure appropriate competence, training, experience, or appointment standards licensing and credentialing of all are documented appointees. 4.2.1.f.1 Evidence of continuing Recruitment, selection, appointment and reappointment staff education and training is routinely procedures ensure appropriate competence, training, experience, monitored and assessed. licensing and credentialing of all appointees. Proof of documentation reflecting staff compliance with selection and appointment standards.
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Presence of system to monitor and assess continuing education and training of staff
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DOCUMENT REVIEW 1. Certificates of attendance to trainings and formal continuing education for personnel; 2. Monitoring reports on CME and training of staff
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CODE STANDARDS CRITERIA The organization ensures that staff accountabilities and responsibilities are consistent with their qualifications, training, experience, registration and licensure. INDICATOR Percentage of doctor(s), nurse(s) and staff with job functions, accountabilities and responsibilities matching their credentials, training and experience. HOSP PHIC EVIDENCE DOCUMENT REVIEW Written job description and/or relevant document defining the job functions, accountabilities and responsibilities of personnel and the corresponding credentials, training and experience required and match this with the credentials of the doctor/nurse/staff chosen for the job. Formula: Number of staff with job description matching their credentials, training and experience/number of staff interviewed x 100 Sample size : Rule of 10 REMARKS
4.2.3.a.1 Staff members are accountable for the care and services they give and for the discharge of their delineated responsibilities.
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4.3 STAFF TRAINING AND DEVELOPMENT Goal: A comprehensive program of staff training and development meets individual and organizational needs. 4.3.1.a.1 There are relevant orientation, The organization assesses Presence of Training Needs DOCUMENT REVIEW __ __ TNA report or its equivalent training and development the educational needs of Assessment (TNA) System programs to meet the educational management and staff needs of management and staff. and identifies and/or provides resources to meet those needs 4.3.1.a.2 There are relevant orientation, training and development programs to meet the educational needs of management and staff. The organization assesses Presence of annual plan on the educational needs of training activities management and staff and identifies and/or provides resources to meet those needs Policies and procedures for orientation of new management and staff are documented and monitored Presence of policies and procedures for the orientation of new employees on general hospital policies
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DOCUMENT REVIEW Annual plan (including resource/budgetary allocation) on training activities
4.3.1.b.1 There are relevant orientation, training and development programs to meet the educational needs of management and staff.
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DOCUMENT REVIEW Policies and procedures on orientation of new employees to general hospital policies INTERVIEW Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented.
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CODE STANDARDS CRITERIA The organization evaluates the effectiveness of training and development programs to ensure that they meet organizational, community and individual needs. The organization evaluates the effectiveness of training and development programs to ensure that they meet organizational, community and individual needs. INDICATOR Presence of an evaluation system of the training and development program. HOSP PHIC EVIDENCE DOCUMENT REVIEW Evaluation reports on the training and development program REMARKS
4.3.1.c.1 There are relevant orientation, training and development programs to meet the educational needs of management and staff.
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4.3.1.c.2 There are relevant orientation, training and development programs to meet the educational needs of management and staff.
Presence of end-of-training assessment report
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DOCUMENT REVIEW End of training assessment report or its equivalent
4.3.2.b.1 The organization clearly defines The staff are provided with and ensures compliance with the a documented job lines of authority and supervision. description outlining accountabilities and responsibilities.
Percentage of staff provided with job description outlining their accountabilities and responsibilities
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DOCUMENT REVIEW Written job descriptions with conforme Formula: Number of written job descriptions with conforme/number of written job descriptions reviewed Sample size: Rule of 10
5. INFORMATION MANAGEMENT 5.1 DATA COLLECTION, AGGREGATION AND USE Goal: Collection and aggregation of data are done for patient care, management of services, education and research. 5.1.1.a.1 Relevant, accurate, quantitative The organization defines Presence of policies and DOCUMENT REVIEW __ Policies and procedures on data collection relevant to delivery of patient and qualitative data are collected the relevant aspects of its procedures on data collection __ and used in a timely and efficient operations from which data relevant to delivery of patient care and management of services will be collected care and management of manner for delivery of patient services care and management of services. 5.1.1.b.1 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services. 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 __ __ __ __ __ __ __ __ DOCUMENT REVIEW 1. Annual Hospital Statistical Reports 2. Annual reports submitted to the DOH 3. MMHR submitted to PhilHealth 4. Other additional statistics as determined by the management or hospital forms that serve as data aggregation instruments or data sets and methods in preparation for statistical reports
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CODE STANDARDS CRITERIA The organization defines data sets, data generation, collection and aggregation methods and the qualified staff who are involved in each stage INDICATOR Presence of qualified staff involved in data definition, generation, collection and aggregation HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Proof of training/seminar or certificate on records management of staff involved in data definition 2. Document (memo or issuance) designating a staff for data definition, generation, collection and aggragation INTERVIEW Interview staff regarding their qualifications and functions DOCUMENT REVIEW 1. Policies and procedures to monitor the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations 2. Policies and procedures to improve the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations REMARKS
5.1.1.b.2 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.
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__ 5.1.1.c.1 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services. The organization defines policies and procedures to monitor and improve the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations. The organization provides resources and opportunities to enable management and staff to use data in their decision and policymaking activities. Presence of policies and procedures to monitor and improve the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations
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5.1.1.d.1 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.
Presence of budget or resources needed to collect, maintain, process and analyze data
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DOCUMENT REVIEW Plans, which include the budget for procurement of computers, software and other resources (including training for data management), research outputs, reports or budget execution report showing that such budget has been disbursed INTERVIEW Ask leaders the content of plans and actual activities pertaining to collection, maintenance, processing and analysis of data OBSERVATION Presence of computers, software, personnel, storage area for hard copies of records DOCUMENT REVIEW Policies and procedures on record storage, safekeeping and maintenance, retention and disposal Note: Policies and procedures on records management are updated every 5 years
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5.1.1.e.1 Relevant, accurate, quantitative core and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.
Policies and procedures on record storage, retention and disposal are documented and monitored
Policy on record storage, safekeeping, retention and disposal CORE
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CODE STANDARDS CRITERIA The organization collects and submits reports required by DOH and PhilHealth INDICATOR Compilation of DOH and PhilHealth reports HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. MMHR - Submitted every 10th day of the succeeding month 2. DOH reports - annual statistical reports Note: For annual reports, look for the reports of the previous year, for quarterly reports, previous quarter REMARKS
5.1.2.a.1 The collection of data and reporting of information comply with professional standards, statutory and PhilHealth requirements.
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5.1.3.b.1 Every patient has a sufficiently detailed patient chart to facilitate continuity of care, and meet education, research, evaluation and medico-legal and statutory requirements. 5.1.4.a.1 Data in the patient charts are coded and indexed to ensure the timely production of quality patient care information and reports to PhilHealth.
Patient charts are routinely Proof that charts are checked checked for completeness for completeness and and accuracy, and action accuracy is taken to improve their quality Data from the patient charts are routinely collected, aggregated and reported for use in quality improvement activities, for administrative purposes and for mandatory reporting to the Department of Health and PhilHealth Data from the patient charts are routinely collected, aggregated and reported for use in quality improvement activities, for administrative purposes and for mandatory reporting to the Department of Health and PhilHealth Presence of policies & procedures on routine collection, aggregation and reporting of data from patient charts for use in quality improvement, administrative purposes and for mandatory reporting to Department of Health and PhilHealth
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DOCUMENT REVIEW Checklist for the completeness of the chart accomplished by the records officer or other proof that charts are routinely checked for completeness and accuracy.
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DOCUMENT REVIEW 1. Policies & procedures on routine collection and aggregation of data from patient charts for use in quality improvement, administrative purposes and for mandatory reporting to Department of Health and PhilHealth 2. Policies & procedures on routine reporting of data from patient charts for use in quality improvement, administrative purposes and for mandatory reporting to Department of Health and PhilHealth
5.1.4.a.2 Data in the patient charts are coded and indexed to ensure the timely production of quality patient care information and reports to PhilHealth.
Proof that data collected and aggregated from patient charts are used for quality improvement activities, administrative purposes and for mandatory reporting to the Department of Health and PhilHealth
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DOCUMENT REVIEW Minutes of Quality Circle Meetings or Report/s on status of routine data collection and aggregation from patient charts INTERVIEW Ask leaders on procedures on collection and aggregation of data from patient charts for purposes of quality improvement activities, administrative and mandatory reporting to DOH and PhilHealth
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5.2 RECORDS MANAGEMENT Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met. Presence of policies and When patients are 5.2.1.a.1 Clinical records are readily procedures on filing and __ __ admitted or are seen for core accessible to facilitate patient ambulatory or emergency retrieval of charts care, are kept confidential and CORE safe, and comply with all relevant care, patient charts statutory requirements and codes documenting any previous care can be quickly of practice. retrieved for review, updating and concurrent use 5.2.1.b.1 Clinical records are readily core accessible to facilitate patient care, are kept confidential and safe, and comply with all relevant statutory requirements and codes of practice. 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 Presence of procedures to protect records and patient charts against loss, destruction, tampering and unauthorized access or use CORE __ __
DOCUMENT REVIEW Policies and procedures on systematic filing, retrieval and management of medical records
DOCUMENT REVIEW Policies and procedures on records management for the entire hospital to maintain privacy, accuracy and prevent loss and destruction OBSERVATION Observe nurses in the wards and records personnel on how they protect patient chart against loss, tampering and unauthorized use
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6. SAFE PRACTICE AND ENVIRONMENT 6.1 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.1 The organization plans a safe The organizational Presence of updated DOH DOCUMENT REVIEW core and effective environment of care environment complies with license to operate __ __ 1. Updated DOH license consistent with its mission, structural standards and CORE __ __ 2. If facility has nuclear medicine, ask for the certificate issued by the services, and with laws and safety codes as prescribed Philippine Nuclear Research Institute (PNRI) regulations. by law
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CODE STANDARDS CRITERIA 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. INDICATOR 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 CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW Management plan which includes policies, procedures and programs, risk assessment, hazard 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.1 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 written plans on the safe and efficient use of medical equipment according to specifications DOCUMENT Management plan which includes policies / procedures and programs such as equipment maintenance programs for safe and efficient use of medical equipment REMARKS
6.1.1.b.1 The organization plans a safe core and effective environment of care consistent with its mission, services, and with laws and regulations.
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CODE STANDARDS CRITERIA 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 INDICATOR Presence of 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 and existence of safety programs on: 1. electrical safety 2. medical device safety 3. chemical safety 4. radiation safety 5. mechanical safety 6. water safety 7. combustible material safety 8. waste management 9. hospital safety program (fire,emergency and disaster preparedness) HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures that address the following: 1. Safety 2. Security 3. Control of hazardous material and biological wastes (including the implementation of the gradual phase-out of mercury) 4. Emergency and disaster preparedness 5. Fire safety 6. Radiation safety 7. Utility systems safety Existence of safety programs such as: 1. Electrical safety 2. Medical device safety 3. Chemical safety 4. Radiation safety 5. Mechanical safety 6. Water safety 7. Combustible material safety 8. Waste management 9. Hospital safety program (fire, emergency and disaster preparedness) 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 REMARKS
6.1.2.a.1 The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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CODE STANDARDS CRITERIA 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 INDICATOR Proof of implementation of the policies, procedures and safety programs on 1. electrical safety 2. medical device safety 3. chemical safety 4. radiation safety 5. mechanical safety 6. water safety 7. combustible material safety 8. waste management 9. hospital safety program (fire, emergency and disaster preparedness) CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Water safety - water analysis results for the past 6 months 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 & non-infectious, hazardous & non hazardous) 2. Hospital safety programs 3. Mechanical safety program of the hospital 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 REMARKS
6.1.2.a.2 The organization provides a safe core and effective environment of care consistent with its mission and services, and with laws and regulations.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.b.1 The organization provides a safe core 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 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 for the safe and efficient use of medical equipment CORE __ __ DOCUMENT REVIEW Policies and procedures on the safe and efficient use of medical equipment (including the implementation of DOH AO# 2008-0021on the gradual phase-out of mercury) REMARKS
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6.1.2.e.1 The organization provides a safe core and effective environment of care consistent with its mission and services, and with laws and regulations.
Presence of policies and procedures on risk identification, assessment and control CORE
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DOCUMENT REVIEW Policies and procedures on risk identification, assessment and control, security risks, use of personal protective equipment, etc.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW Policy on facility security measures EVIDENCE REMARKS
6.1.2.e.2 The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used. A coordinated security Presence of policy regarding arrangements in the facility security measures organization assures protection of patients, staff and visitors A coordinated security arrangements in the organization assures protection of patients, staff and visitors Presence of an appointed personnel in charge of security CORE
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The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations. The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations.
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6.1.2.f.2 core
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DOCUMENT REVIEW Contract of security agency or appointment of in-house security 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 DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems
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__ 6.1.3.a.1 The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care. The effectiveness of safety procedures and devices are routinely tested, monitored and improved Proof of monitoring and action to improve the effectiveness of safety procedures and devices __ __ __ __ __ __
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CODE STANDARDS CRITERIA An incident reporting system identifies potential harms, evaluates causal and contributing factors for the necessary corrective and preventive action INDICATOR Presence of incident reporting system/sentinel event monitoring system (which may include nosocomial infections, unexpected deaths, adverse drug reactions, blood transfusion reactions, falls, etc) CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge. __ __ __ __ DOCUMENT REVIEW 1. Incident/sentinel event reports 2. Written documents showing corrective and/or preventive actions addressing the reported incidents e.g. memos, office orders, root cause analysis etc. INTERVIEW Ask leaders how incidents/ adverse events/ sentinel events are handled REMARKS
6.1.3.b.1 The organization routinely core collects and evaluates information to improve the safety and adequacy of the environment of care.
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6.1.3.b.2 The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care.
Proof that reported potential An incident reporting system identifies potential harm are acted upon harms, evaluates causal and contributing factors for the necessary corrective and preventive action
__ 6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. Presence of written cleaning 6.2.2.x.1 Regular maintenance of grounds, schedules, logbooks and facilities and equipment in checklists for grounds, keeping with relevant statutory facilities and equipment requirements, codes of practice, corrective and preventive or manufacturers' specifications maintenance are done to ensure a clean and safe environment.
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DOCUMENT REVIEW MOA/Contract for outsourced services for maintenance of equipment, janitorial services, etc. DOCUMENT 1. Cleaning schedule and checklist of facilities and equipment 2. Preventive and corrective maintenance logbook for equipment OBSERVATION Cleanliness of surroundings especially comfort rooms
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CODE STANDARDS CRITERIA INDICATOR Proof of training of the staff who is in charge of the maintenance of the equipment CORE HOSP PHIC EVIDENCE 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) INTERVIEW Ask about how equipment (generator, airconditioner, medical devices and other equipment etc.) are maintained DOCUMENT REVIEW 1. Preventive and corrective maintenance logbook for equipment 2. Operating manual 3. Equipment management plan which includes: - who will maintain - qualifications of those who maintain and - schedule of maintenance REMARKS
6.2.3.x.1 Equipment is serviced only by core people trained in the maintenance of that equipment. Registers and records of equipment and related maintenance are kept.
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__ 6.2.3.x.2 Equipment is serviced only by people trained in the maintenance of that equipment. Registers and records of equipment and related maintenance are kept. Presence of registers and records of equipment and related maintenance
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. 6.3.1.x.1 An interdisciplinary infection Presence of an Infection DOCUMENT REVIEW __ 1. ICC composition (for a primary hospital - proof of designation of a core control program ensures the Control Committee (ICC) with __ prevention and control of defined goals, objectives, doctor and nurse in-charge of infection control) __ 2. ICC functions and activities __ infection in all services. strategies and priorities or for __ 3. Minutes of meeting, at least quarterly __ a primary hospital - a designated doctor and nurse activities __ 4. Statistics on nosocomial infections __ in-charge of infection control CORE INTERVIEW __ Ask a member of the ICC regarding infection control program of the __ hospital 6.3.1.x.2 An interdisciplinary infection core control program ensures the prevention and control of infection in all services. Presence of an infection control program ensuring prevention and control of infections on all services CORE __ __ __ __ 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
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CODE STANDARDS CRITERIA The organization undertakes case finding and identification of nosocomial infections The organization takes steps to prevent and control outbreaks of nosocomial infections INDICATOR Presence of program for case finding and identification of nosocomial infections HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Surveillance forms for nosocomial infection 2. Nosocomial Infection Case Reports 3. Hospital Acquired Infection Reports: semi annual infection rates, antibiotic resistance pattern DOCUMENT REVIEW Procedures on isolation of nosocomial infections INTERVIEW Ask staff in ER, wards and ICU the procedures on isolation isolation - physical isolation of a patient with infection 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 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 2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks INTERVIEW Interview hospital staff on how they handle and dispose needles OBSERVATION Presence of receptacles for proper disposal of sharps REMARKS
6.3.2.a.1 The organization uses a coordinated system-wide approach to reduce the risks of nosocomial infections. 6.3.2.b.1 The organization uses a core coordinated system-wide approach to reduce the risks of nosocomial infections.
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Presence of a coordinated system-wide procedure for isolation of nosocomial infections CORE
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6.3.2.b.2 The organization uses a core coordinated system-wide approach to reduce the risks of nosocomial infections.
The organization takes steps to prevent and control outbreaks of nosocomial infections
Presence of a coordinated system-wide procedure for case containment of nosocomial infections CORE
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__ 6.3.2.b.3 The organization uses a core coordinated system-wide approach to reduce the risks of nosocomial infections. The organization takes steps to prevent and control outbreaks of nosocomial infections Presence of a coordinated system-wide procedure for asepsis CORE
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__ 6.3.3.a.1 The organization uses a core coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties. There are programs for prevention and treatment of needle stick injuries, and policies and procedures for the safe disposal of used needles are documented and monitored Presence of policies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles CORE
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CODE STANDARDS CRITERIA 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 INDICATOR 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 CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Infection control procedures on isolation and universal precaution 2. Program for the protection of healthcare workers e.g. personal protective equipment (PPEs) 3. Policies on all patient admission/referral, isolation and timely case reporting of highly transmissible and notifiable infectious disease e.g. meningococcemia, SARS, avian flu, etc 4. Hand hygiene procedures 5. Environmental care and healthcare waste management 6. Procedures on recycling & reuse of equipment i.e. personal protective equipment INTERVIEW Validate hospital policies on infection control such as use of PPEs, isolation precautions and hand washing OBSERVATION 1. Observe for use of gloves, surgical masks 2. Look for sinks or lavatories or designated areas for hand washing or dispenser for sanitizers 3. Look for separate holding area/room for highly infectious cases 4. Ask a hospital staff to demonstrate hand washing technique REMARKS
6.3.3.b.1 The organization uses a core coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties.
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6.3.4.x.1 Cleaning, disinfecting, drying, core packaging and sterilizing of equipment, and maintenance of associated environment, conform to relevant statutory requirements and codes of practice. 6.3.5.x.1 When needed, the organization core reports information about infections to personnel and public health agencies.
Presence of policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments and supplies CORE Presence of policies and procedures on reporting of infections to personnel and public health agencies CORE
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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 DOCUMENT REVIEW Policies and procedures on reporting of infections to personnel and public health agencies
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6.4 EQUIPMENT AND SUPPLIES Goal: The provision of equipment and supplies supports the organization's role. Presence of policies and Appropriate equipment 6.4.1.a.1 Planning of facilities and and supplies that support procedures regarding selection and acquisition of equipment and supplies involve the organizations role and acquisition of equipment and supplies, considering the input from relevant staff and are level of service are provided. Consideration is intended use, safety, cost undertaken by appropriatelybenefit, storage, infection given to at least: qualified personnel. control, waste creation and *the intended use disposal *cost benefits *infection control *safety *waste creation and disposal *storage
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DOCUMENT REVIEW Procurement policy and plan which considers the following: 1. intended use 2. cost benefits 3. infection control 4. safety 5. waste creation and disposal 6. storage Note : all elements must be present in the policies, if not - score is partial INTERVIEW Ask about the processes in selecting and acquiring equipment and supplies (especially for LGU hospitals because procurement is centralized at the provincial/municipal/ city level) DOCUMENT REVIEW 1. License if applicable 2. List of specialized equipment 3. Certificates of training, certificates of attendance, or equivalent experience (at least 1 year) under a trained personnel OBSERVATION Identify specialized equipment that need only trained staff to operate Example of specialized equipment : MRI, CT scan, ECG, 2d echo, x-ray, respirator, ultrasound, anesthesia machine, endoscopes, etc
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6.4.2.x.1 Specialized equipment is operated according to specifications and only by appropriately -trained staff.
Proof that specialized equipment is operated only by a trained staff
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6.4.3.x.1 Items designated by the core manufacturer for single use are not reused unless the organization has specific policies and guidelines for safe reuse which take into consideration relevant statutory requirements and codes of practice.
Presence of policies, procedures and guidelines for safe reuse of items which comply with relevant statutory requirements CORE
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DOCUMENT REVIEW Policies and procedures on safe reuse of items INTERVIEW Ask heads and staff about the following: 1. Policy on reuse of items 2. SOPs on reuse 3. Reporting 4. Personnel in charge
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6.5 ENERGY AND WASTE MANAGEMENT Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. 6.5.1.x.1 The handling, collection, and Presence of licenses/permits/ DOCUMENT REVIEW __ __ Pertinent licenses/permits from regulatory agencies (LGU, DENR, etc.) clearances from pertinent core disposal of waste conform to relevant statutory requirements regulatory agencies implementing among others and codes of practice. the following: RA 9003, RA 6969, RA 9275, PD 1586 DOH Hospital waste management manual, RA 8749 (Clean Air Act) CORE
6.5.2.x.1 The organization implements a waste disposal program which involves reuse, reduction an recycling. 6.5.2.x.2 The organization implements a core waste disposal program which involves reuse, reduction an recycling.
Presence of policies and procedures on waste disposal which involve reuse, reduction and recycling Proof of implementation of policies and procedures on waste disposal CORE
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DOCUMENT REVIEW 1. Policies and procedures which involves reuse, reduction and recycling in compliance with RA 9003 and DOH guidelines 2. Waste management program 3. MOA/contract of outsourced services for waste management 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 INTERVIEW Ask staff regarding SOPs on actual procedure waste disposal
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7. 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 7.1.x.1 The organization has a planned Presence of Quality DOCUMENT REVIEW __ 1. Policy creating the QI program Improvement Program __ core systematic organization- wide __ 2. Proof of meetings or similar documents of QA Committee activities approach to process design and CORE __ __ 3. Policies and procedures on performance measurement and __ performance measurement, assessment and improvement. improvement INTERVIEW Validation of QI activities thru interview of pertinent staff including frontliners and Committee members DOCUMENT REVIEW Annual plan and budget showing funds allotted to CPG development or adoption and implementation INTERVIEW Ask staff for presence of person knowledgeable of CPG appraisal DOCUMENT REVIEW Documentation of dissemination of PhilHealth-adopted CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and other issuances OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics DOCUMENT REVIEW Documentation of dissemination and monitoring of CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and other issuances OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics
__ 7.2.a.1 New process of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. There are resources Proof that there are available for developing or resources available for adopting clinical practice developing or adopting CPG guidelines
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__ 7.2.b.1 Clinical practice guidelines for the top 10 causes of admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Clinical practice guidelines for the top 10 causes of admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Proof of dissemination of PhilHealth-adopted CPGs for the 10 conditions as contained in HTA Forum (if CPG is applicable in the hospital) __
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__ Proof of dissemination of CPGs for the top 10 causes of admission and/or consultation
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7.2.b.2
New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences.
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CODE 7.2.b.3 STANDARDS New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. CRITERIA INDICATOR HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Conduct of utilization review of drugs, procedures or diagnostic tests based on CPG 2. Use of clinical pathways based on CPG 3. Conduct of medical audits using CPG as standard REMARKS
Clinical practice guidelines Proof of monitoring of CPG dissemination for the top 10 causes of admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Proof that the 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 implementation Proof that all service units and staff are responsible for, and demonstrate involvement in performance improvement that results in better services for internal and external clients
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7.3.x.1
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 dayto-day implementation.
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DOCUMENT REVIEW 1. Memoranda/orders creating the QI team/Quality circle 2. Minutes of meetings/extracts of minutes relating to concerned topic, documentation of activities 3. Monitoring reports on CPG use or similar QI activities 4. Designation of a point person for the QA program INTERVIEW Validate the activities by asking the management team or officer involved in QA program DOCUMENT REVIEW 1. Policies or issuances on CQI Program 2. QA/CQI manual 3. Patient satisfaction survey results/ratings 4. Staff satisfaction survey INTERVIEW Validate the activities thru interview of any staff including the frontliners, patients, external clients DOCUMENT REVIEW 1. Minutes or extracts of minutes of the management or Executive Committee meetings 2. Memoranda, policies, orders emanating from the evaluation of QI programs/activities 3. Monitoring and evaluation reports DOCUMENT REVIEW 1. Patient satisfaction survey results 2. Patient satisfaction survey questionnaire (may check on the domains and items)
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7.4.x.1
All service units and staff are responsible for, and demonstrate involvement in, performance improvement that results in better services in internal and external clients.
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__ 7.5.x.1 Managers and staff evaluate the effectiveness of the quality improvement program and take action to address any improvements required. Proof of evaluation of the quality improvement program
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7.6.x.1 core
The organization provides better care service as a result of continuous quality improvement activities.
Presence of patient satisfaction survey CORE
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CODE 7.6.x.2 STANDARDS The organization provides better care service as a result of continuous quality improvement activities. The organization provides better care service as a result of continuous quality improvement activities. Quality improvement activities respect the confidentiality of data regarding patients, staff and other care providers. CRITERIA INDICATOR Proof of better patient outcomes HOSP PHIC EVIDENCE DOCUMENT REVIEW Documentation of better outcomes for patients as a result of CQI activities e.g. declining trends of nosocomial infection, increase in patient satisfaction ratings, in OB - increase in trend of trial labor vs. CS, increase use of component blood vs. fresh whole blood, etc. DOCUMENT REVIEW Documentation of better services e.g. reduction of turn-around-time for diagnostic tests, OPD and ER services; increase in patient satisfaction ratings, higher Benchbook assessment ratings for renewal application, etc. DOCUMENT REVIEW 1. Policies and procedures on confidentiality of records 2. QA/CQI manual 3. Reports related to QI activities INTERVIEW Ask also 1. How the staff protect /ensure confidentiality of patient's data especially in relation to audit or peer review and how they prevent staff from leaking data or information. 2. How they present a picture of a patient like in IEC materials. Note : The surveyor should look for any data that can be attributed to specific individuals REMARKS
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Proof of better services whether inpatient or outpatient
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7.7.x.1
Proof that QI activities respect the confidentiality of data regarding patients, staff and other care providers.
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SECTION 2 - LEADERSHIP INTERVIEW

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations Presence of policies and 1.1.d.1 Organizational policies and The hospital protects DOCUMENT REVIEW __ Policies and procedures on conduct of research involving patients: procedures respect and support patients and respects their procedures to protect patients __ and respect their rights during patients' right to quality care and rights during research benefits and risks, informed consent, etc. their responsibilities in that care. involving human subjects research involving human subjects INTERVIEW __ __ If hospital has done or has an ongoing research study involving patients: Ask leaders/researcher during leadership meeting regarding recruitment of participants, informed consent, confidentiality, etc 1.3.b.1 The organization documents and follows policies and procedures for addressing patients' needs for confidentiality, privacy, security, religious counseling and communication. The hospital systematically determines, monitors and improves the extent to which patients' needs for confidentiality, privacy, security, counseling and communication are addressed. The organization identifies and monitors personnel compliance with the code of ethics relevant to their respective disciplines. Presence of patient feedback mechanism on addressing patients' needs for confidentiality, privacy, security, religious counseling and communication __ __ DOCUMENT REVIEW Any reports on patient feedback monitoring e.g. analysis of patients' suggestions, complaints and other feedback or patient satisfaction survey result INTERVIEW Ask leaders about their patient feedback mechanism and/or their patient satisfaction survey DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures
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1.5.b.1
The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards.
Presence of policies and procedures on monitoring compliance of personnel with codes of professional conduct relevant to their respective disciplines
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CODE 1.5.c.1 STANDARDS The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. CRITERIA Procedures for resolving ethical issues related to professional practice or to conflicts of interest are based on the relevant code of ethics and other professional and legal standards. INDICATOR Presence of policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest that are based on the relevant code of ethics and other professional and legal standards HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest 2. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest are based on relevant codes of ethics and other professional and legal standards 3. Proof of compliance to the policies and procedures, which may include the establishment of an Ethics Committee that will resolve issues related to professional practice or to conflicts of interest or minutes of meeting of the committee INTERVIEW Ask leaders how they handle ethical issues related to professional practice or conflicts of interest REMARKS
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2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of services 2.1.1.b.2 The organization informs the Clinical services are addressing the endemic and community about the services it appropriate to patients' most common diseases in the provides and the hours of their needs and the former's community availability. availability is consistent with the organization's service capability and role in the community. DOCUMENT REVIEW 1. Inpatient census 2. Outpatient census. 3. The hospital should have services that address the top ten diseases in their census. 4. The hospital should have services in accordance to the 'Mother-Baby Friendly Hospital Initiative" 5. The hospital should have services for newborn screening INTERVIEW Interview leaders regarding availability of services for endemic and most common diseases in the community based on their census
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. Proof that the policies and 2.5.3.a.2 Care is coordinated to ensure Policies and procedures continuity and to avoid that determine the extent procedures on duplicate duplication. of duplicate assessments assessments and treatments and treatments performed are monitored by trainees respect patients rights, and are documented and monitored. 2.5.5.b.3 Drugs are administered in a standardized and systematic manner in the provider organization. The provider organization documents and follows policies and procedures and allocates resources for the training, supervision, and evaluation of professionals who administer drugs Regular review of prescription orders is undertaken by appropriately trained staff to ensure safe and appropriate use of drugs Proof of training, supervision, and evaluation of professionals who administer drugs
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DOCUMENT REVIEW Monitoring reports in compliance to policies and procedures on duplicate assessments and treatments INTERVIEW Interview management or QA team on how they monitor compliance to the policies
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DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who administer drugs 2. Evaluation reports of professionals who administer drugs 3. Proof of training, e.g.. certificates of training INTERVIEW Ask leaders how the supervision of professionals who administer drugs are conducted DOCUMENT REVIEW 1. Policy on regular review of prescription orders 2. Evaluation reports by nurses/doctors in the floors, clinical pharmacist or therapeutics committee or minutes of meeting of the therapeutics committee INTERVIEW Ask leaders about utilization review activities, audit/peer review, other activities where appropriateness and safety of drug use are discussed Footnote: This is to ensure that prescriptions are written correctly (e.g.. in generic form), and that precautions for drug-drug and drug-food interactions have been adequately addressed.
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2.5.5.d.1 Drugs are administered in a standardized and systematic manner in the provider organization.
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CODE STANDARDS CRITERIA Drugs are selected and procured based on the organization's usual case mix and according to policies and procedures that are consistent with scientific evidence and government policies. INDICATOR Presence of policies and procedures on selection and procurement of drugs, consistent with scientific evidence and government policies HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures on drug selection and procurement 2. Policies and procedures on drug selection and procurement are consistent with scientific evidence 3. Policies and procedures on drug selection and procurement are consistent with government policies e.g.. National Drug Policy INTERVIEW Ask the members of therapeutics committee regarding manner of selection and procurement of drugs OBSERVATION Observe actual supply of drugs in the pharmacy in accordance with the organization's policies DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who perform the procedure or evaluation reports 2. Proof of training, e.g.. certificates of training INTERVIEW Validate with leaders regarding supervision of performance of procedures and training. DOCUMENT REVIEW List of equipment procured the previous year/s. Check if procured according to policies and procedures. INTERVIEW Ask management team regarding basis for procurement of the listed equipment REMARKS
2.5.5.h.1 Drugs are administered in a standardized and systematic manner in the provider organization.
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2.5.6.b.3 Treatment procedures are The provider organization performed in a standardized and documents and reviews systematic manner in the provider policies and procedures organization. and allocates resources for the training, supervision, and evaluation of professionals who perform procedures. 2.5.6.g.2 Treatment procedures are Medical devices and performed in a standardized and equipment are selected systematic manner in the provider and procured based on organization. organizations case mix, staff expertise, service capability and according to policies and procedures that are consistent with scientific evidence and government policies
Proof of training, supervision, and evaluation of professionals who perform the procedures
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Proof that medical devices and equipment are selected and procured based on organization's case mix, staff expertise, service capability and according to policies and procedures that are consistent with scientific evidence and government policies
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2.6 EVALUATION OF CARE Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. 2.6.1.b.1 Data relating to processes and The organization provides Presence of budget or DOCUMENT REVIEW __ __ 1. Budget or resource allocation for collection of data related to process resource allocation for CQI resources for the formal outcomes of patient care are activities that makes use of analyzed to provide information and collaborative and outcomes of care such as the following: medical audit, morbidity and analysis of process and for care improvement. evaluation of care using mortality reports, adverse event and hospital infection data, etc outcomes data analysis of process and 2. Budget or resource allocation for analysis of data related to process __ and outcomes of care such as: medical audit, mortality and morbidity __ outcomes data conferences, etc INTERVIEW Ask QA committee what are the resources provided by the organization for CQI activities DOCUMENT REVIEW Documents showing that results of evaluation of care were presented and discussed in meetings of top management such as issuances, memos, directives, excerpts/minutes/agenda of meetings INTERVIEW Ask management team if the QA committee presents and discusses the results of evaluation DOCUMENT REVIEW Policies /memo/ letters regarding any collaborative performance improvement activities as a result of evaluation of care INTERVIEW Verify with health care team if there are performance improvement activities as a stemming from results of evaluation of care.
__ 2.6.1.d.1 Data relating to processes and outcomes of patient care are analyzed to provide information for care improvement. Results of evaluation of care are routinely presented and discussed in meetings of top management Proof that results of evaluation of care are routinely presented and discussed in meetings of top management
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__ 2.6.2.a.1 The health care team takes action to address any improvements required. Evaluation of care leads to formal and collaborative performance improvement activities that harness the resources of appropriate services Presence of collaborative performance improvement activities that harness the resources of appropriate services
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CODE STANDARDS CRITERIA INDICATOR Proof of documentation of QI activities HOSP PHIC EVIDENCE DOCUMENT REVIEW Minutes of QA committee meetings, reports, memoranda/ orders/policies emanating from resolution of cases INTERVIEW Ask leaders on QI activities, specific cases brought to the attention of the QC/QT REMARKS
2.6.3.x.1 Quality improvement activities are documented, enable continuous quality improvement and incorporate the following elements: * Monitoring, assessment, analysis and evaluation of activities * Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results 2.6.3.x.2 Quality improvement activities are documented, enable continuous quality improvement and incorporate the following elements: * Monitoring, assessment, analysis and evaluation of activities * Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results
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Proof that QI activities incorporate the following elements: *Monitoring, assessment, analysis and evaluation of activities *Appropriate and timely action *Evaluation of the effectiveness of any action taken *Feedback of evaluation results
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DOCUMENT REVIEW Reports of CQI activities INTERVIEW Validate with QA committee members regarding the (4) elements of CQI activities
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Proof of the creation of all 3.1.3.x.1 Terms of reference, membership DOCUMENT REVIEW committees within the __ __ Proof of the creation of all committees which includes the terms of core and procedures are defined for organization which includes the meetings of all committees reference for membership e.g. memo, office order, etc the terms of reference for within the organization. Minutes membership of meetings are recorded and INTERVIEW CORE __ __ Ask leaders what the committees in their hospital are and ask for the approved. order that created these committees
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CODE STANDARDS CRITERIA INDICATOR Presence of recorded minutes of the meetings for all committees within the organization HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Minutes of meetings for Quality Assurance Committee (level 1, 2, 3 and 4) 2. Minutes of meetings for Therapeutics Committee (level 2, 3 and 4) 3. Minutes of meetings for Infection Control Committee (level 3 and 4) 4. Minutes of meetings for other committees Note: Level I hospitals may not necessarily have TC or infection committee, but there should at least be 2 persons looking at the use of therapeutic drugs & infection control INTERVIEW Committee members to validate the above activities 3.1.4.x.1 The organization's management core team regularly assesses its own performance and the performance of the organization. Presence of evaluation and monitoring activities to assess management and organizational performance CORE __ __ DOCUMENT REVIEW Documentation of evaluation activities to assess management and organizational performance such as monthly, quarterly, semestral or annual reports as applicable 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 INTERVIEW Ask the management team about how the vision and mission were developed. Note: Content of the Vision, Mission & Goals should include addressing the health needs of the community. REMARKS
3.1.3.x.2 Terms of reference, membership and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved.
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__ 3.1.5.a.2 The organization develops and The organization develops Proof that the mission and implements policies and its mission, vision and vision were developed based procedures which cover the major corporate goals based on on agreed upon values services and aspects of agreed-upon values. operations. __
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CODE STANDARDS CRITERIA INDICATOR Presence of written by-laws, policies and procedures, which are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Written by-laws 2. Policies and procedures 3. Written by-laws are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities 4. Policies and procedures are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities INTERVIEW Ask leaders how their by-laws, policies and procedures were developed DOCUMENT REVIEW 1. Memos or issuances on review and/or revision of policies 2. Minutes of meetings on the review and/or revision of policies INTERVIEW Ask leaders how they review and revise policies and procedures DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures DOCUMENT REVIEW Proof of designation of a person responsible for information dissemination INTERVIEW Ask leaders who the responsible person for information dissemination is REMARKS
3.1.5.b.1 The organization develops and The organization's byimplements policies and laws, policies and procedures which cover the major procedures support care services and aspects of delivery and are consistent operations. with its goals, statutory requirements, accepted standards and its community and regional responsibilities.
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__ 3.1.5.c.1 The organization develops and Policies and procedures, Proof that policies and implements policies and aside from being complied procedures are reviewed and procedures which cover the major with, are reviewed and revised as necessary services and aspects of revised as necessary. operations. 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all procedures which cover the major and procedures to all levels of the workforce services and aspects of levels of the workforce. operations.
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__ __ __ __ 3.1.5.d.2 The organization develops and The organization Presence of a responsible implements policies and communicates its policies person for information procedures which cover the major and procedures to all dissemination services and aspects of levels of the workforce. operations.
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Staff numbers and skill mix Presence of human resource 4.1.2.a.1 Workload is monitored and DOCUMENT REVIEW __ List of personnel, staffing pattern, or documents related to the HR inventory system __ appropriate guidelines consulted are based on actual clinical needs. to ensure that appropriate staff inventory system numbers and skill mix are available to achieve desired Note: The hospital may document and analyze information like daily patient and organizational patient loads, utilization rates and services, turn-around times to outcomes. determine staff size and mix. INTERVIEW Ask appropriate personnel (e.g. HR manager) how the right number and mix of competent staff are maintained to meet the needs of internal and external clients.
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4.2 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. Presence of representation of Relevant staff members 4.2.1.c.1 Recruitment, selection, DOCUMENT REVIEW __ 1. Special/Office Orders or similar issuances defining the membership relevant staff in the __ appointment and reappointment participate in the development and development and procedures ensure appropriate of the body/committee/group tasked to develop and implement implementation of personnel competence, training, experience, implementation of personnel recruitment, selection and appointment; __ 2. Proof/minutes of meetings recruitment, selection and __ licensing and credentialing of all personnel recruitment, __ 3. Attendance of members __ selection and appointment. appointment policies appointees. INTERVIEW Ask leaders which team screens and appoints people and how members of the team are selected.
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5. INFORMATION MANAGEMENT 5.1 DATA COLLECTION, AGGREGATION AND USE Goal: Collection and aggregation of data are done for patient care, management of services, education and research. 5.1.1.d.1 Relevant, accurate, quantitative The organization provides Presence of budget or DOCUMENT REVIEW __ Plans, which include the budget for procurement of computers, software resources needed to collect, __ and qualitative data are collected resources and maintain, process and and used in a timely and efficient opportunities to enable and other resources (including training for data management), research management and staff to analyze data manner for delivery of patient outputs, reports or budget execution report showing that such budget use data in their decision care and management of has been disbursed and policymaking services. activities. INTERVIEW __ Ask leaders the content of plans and actual activities pertaining to __ collection, maintenance, processing and analysis of data OBSERVATION Presence of computers, software, personnel, storage area for hard copies of records DOCUMENT REVIEW Minutes of Quality Circle Meetings or Report/s on status of routine data collection and aggregation from patient charts INTERVIEW Ask leaders on procedures on collection and aggregation of data from patient charts for purposes of quality improvement activities, administrative and mandatory reporting to DOH and PhilHealth
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5.1.4.a.2 Data in the patient charts are coded and indexed to ensure the timely production of quality patient care information and reports to PhilHealth.
Data from the patient charts are routinely collected, aggregated and reported for use in quality improvement activities, for administrative purposes and for mandatory reporting to the Department of Health and PhilHealth
Proof that data collected and aggregated from patient charts are used for quality improvement activities, administrative purposes and for mandatory reporting to the Department of Health and PhilHealth
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6. SAFE PRACTICE AND ENVIRONMENT 6.1 PATIENT AND STAFF SAFETY Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. Presence of policies and 6.1.2.a.1 The organization provides a safe Policies and procedures DOCUMENT REVIEW procedures that address and effective environment of care that address safety, Policies and procedures that address the following: __ 1. Safety __ safety, security, control of consistent with its mission and security, control of __ 2. Security __ services, and with laws and hazardous materials and hazardous materials and __ 3. Control of hazardous material and biological wastes (including the biological wastes, emergency __ regulations. biological wastes, and disaster preparedness, emergency and disaster implementation of the gradual phase-out of mercury) __ 4. Emergency and disaster preparedness __ preparedness, fire safety, fire safety, radiation safety __ 5. Fire safety __ radiation safety and utility and utility systems and __ 6. Radiation safety __ systems are documented existence of safety programs __ 7. Utility systems safety __ on: and implemented 1. electrical safety 2. medical device safety Existence of safety programs such as: __ 1. Electrical safety __ 3. chemical safety __ 2. Medical device safety __ 4. radiation safety __ 3. Chemical safety __ 5. mechanical safety __ 4. Radiation safety __ 6. water safety __ 5. Mechanical safety 7. combustible material safety __ __ 6. Water safety __ 8. waste management __ 7. Combustible material safety __ 9. hospital safety program __ 8. Waste management __ (fire,emergency and disaster __ 9. Hospital safety program (fire, emergency and disaster preparedness) __ preparedness) 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
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CODE STANDARDS CRITERIA An incident reporting system identifies potential harms, evaluates causal and contributing factors for the necessary corrective and preventive action INDICATOR Presence of incident reporting system/sentinel event monitoring system (which may include nosocomial infections, unexpected deaths, adverse drug reactions, blood transfusion reactions, falls, etc) CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge. __ __ __ __ DOCUMENT REVIEW 1. Incident/sentinel event reports 2. Written documents showing corrective and/or preventive actions addressing the reported incidents e.g. memos, office orders, root cause analysis etc. INTERVIEW Ask leaders how incidents/ adverse events/ sentinel events are handled REMARKS
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6.1.3.b.2 The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care.
Proof that reported potential An incident reporting system identifies potential harm are acted upon harms, evaluates causal and contributing factors for the necessary corrective and preventive action
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. 6.3.1.x.1 An interdisciplinary infection Presence of an Infection DOCUMENT REVIEW __ 1. ICC composition (for a primary hospital - proof of designation of a core control program ensures the Control Committee (ICC) with __ prevention and control of defined goals, objectives, doctor and nurse in-charge of infection control) __ 2. ICC functions and activities __ infection in all services. strategies and priorities or for __ 3. Minutes of meeting, at least quarterly __ a primary hospital - a designated doctor and nurse activities __ 4. Statistics on nosocomial infections __ in-charge of infection control CORE INTERVIEW __ Ask a member of the ICC regarding infection control program of the __ hospital
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6.4 EQUIPMENT AND SUPPLIES Goal: The provision of equipment and supplies supports the organization's role. Presence of policies and Appropriate equipment 6.4.1.a.1 Planning of facilities and and supplies that support procedures regarding selection and acquisition of equipment and supplies involve the organizations role and acquisition of equipment and supplies, considering the input from relevant staff and are level of service are provided. Consideration is intended use, safety, cost undertaken by appropriatelybenefit, storage, infection given to at least: qualified personnel. control, waste creation and *the intended use disposal *cost benefits *infection control *safety *waste creation and disposal *storage
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DOCUMENT REVIEW Procurement policy and plan which considers the following: 1. intended use 2. cost benefits 3. infection control 4. safety 5. waste creation and disposal 6. storage Note : all elements must be present in the policies, if not - score is partial INTERVIEW Ask about the processes in selecting and acquiring equipment and supplies (especially for LGU hospitals because procurement is centralized at the provincial/municipal/ city level)
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7. 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 7.1.x.1 The organization has a planned Presence of Quality DOCUMENT REVIEW __ 1. Policy creating the QI program core systematic organization- wide Improvement Program __ __ 2. Proof of meetings or similar documents of QA Committee activities approach to process design and CORE __ __ 3. Policies and procedures on performance measurement and performance measurement, __ assessment and improvement. improvement INTERVIEW Validation of QI activities thru interview of pertinent staff including frontliners and Committee members DOCUMENT REVIEW Annual plan and budget showing funds allotted to CPG development or adoption and implementation INTERVIEW Ask staff for presence of person knowledgeable of CPG appraisal
__ 7.2.a.1 New process of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. There are resources Proof that there are available for developing or resources available for adopting clinical practice developing or adopting CPG guidelines
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CODE 7.3.x.1 STANDARDS 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 dayto-day implementation. CRITERIA INDICATOR Proof that the 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 implementation Proof that QI activities respect the confidentiality of data regarding patients, staff and other care providers. HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Memoranda/orders creating the QI team/Quality circle 2. Minutes of meetings/extracts of minutes relating to concerned topic, documentation of activities 3. Monitoring reports on CPG use or similar QI activities 4. Designation of a point person for the QA program INTERVIEW Validate the activities by asking the management team or officer involved in QA program DOCUMENT REVIEW 1. Policies and procedures on confidentiality of records 2. QA/CQI manual 3. Reports related to QI activities INTERVIEW Ask also 1. How the staff protect /ensure confidentiality of patient's data especially in relation to audit or peer review and how they prevent staff from leaking data or information. 2. How they present a picture of a patient like in IEC materials. Note : The surveyor should look for any data that can be attributed to specific individuals REMARKS
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Quality improvement activities respect the confidentiality of data regarding patients, staff and other care providers.
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SECTION 3 - CHART REVIEW

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.2.a.2 The organization encourages and Policies and programs to Percentage of charts with CHART REVIEW health education, advice and __ __ Patient charts from medical records - check the nurses' notes/doctor's promotes opportunities to involve educate patients and patients and their families in their families on how to take a home instructions orders for health education, advice and home instructions care. more pro-active role in health care decision Formula: Number of charts with health education, advice and home making are documented, instructions/ Number of charts reviewed monitored and evaluated Sample size : 10 charts from the medical records or 10% whichever is for their effectiveness. lower 2. PATIENT CARE 2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. Percentage of charts that 2.3.1.b.1 Each patient's physical, Whenever appropriate, __ have mental status psychological and social status is mental status examinations, psychological assessed. examinations, psychological evaluations evaluations, nutritional or functional assessments and nutritional and performed among patients functional assessments who need such evaluations are performed on the patient.
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CHART REVIEW Patient charts from medical records Note: Review charts and look for records of mental status examination, psychological evaluations, nutritional and functional assessments, as applicable Formula : Number of patients who underwent mental status examination, psychological evaluation, nutritional and functional assessment/Number of patients who should have undergone such examinations or assessments x 100 Sample size : Rule of 10
2.3.2.c.1 Appropriate professionals core perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.
Previously obtained All patient charts have information is reviewed at progress notes by doctors every stage of the CORE assessment to guide future assessments
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CHART REVIEW Patient chart from medical records Note: The progress notes should be done regularly and documented in the patient chart either as separate 'progress notes' sheets or side notes in the doctor's order sheets. Formula: Number of charts with progress notes by attending health care professional/total number of charts reviewed x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE CHART REVIEW Patient chart from medical records Note: Look for nurses' progress notes Formula: Number of charts with progress notes by attending health care professional/total number of charts reviewed x 100 Sample size: Rule of 10 2.3.3.a.1 Assessments are performed regularly and are determined by patient's evolving response to care. During the course of management, qualified personnel re-assess the patients' physical and psychological conditions according to the patient's needs. Re-assessment is done whenever the patients' condition take an unexpected turn. Proof that re-assessment is conducted by qualified personnel according to the patient's needs __ __ CHART REVIEW Patient chart from medical records Note: Check if the health professional doing the re-assessment is licensed and qualified. REMARKS
2.3.2.c.2 Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition.
Previously obtained Percentage of charts with information is reviewed at progress notes by nurses every stage of the assessment to guide future assessments
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2.3.3.b.1 Assessments are performed regularly and are determined by patient's evolving response to care.
Percentage of charts with progress notes during instances when patient needs reassessment
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CHART REVIEW Patient chart from medical records Note: Ask for charts with unexpected outcomes/turn of events, e.g. adverse events, morbidities, mortalities. Formula: Number of charts with progress notes/total number of charts reviewed x 100 Sample size: Rule of 10
2.3.3.c.1 Assessments are performed regularly and are determined by patient's evolving response to care.
Re-assessment results in a review of the patients' management.
Proof that re-assessment results in a review of the patients' management
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CHART REVIEW Patient chart from medical records Note : Look at the progress notes and doctor's orders. Look for the reassessments done. These should be followed correspondingly by doctor's orders pertaining to the management of the patient (e.g. continue present management, an order for an additional medication, diagnostic or referral)
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE CHART REVIEW Patient chart from medical records (surgery patients) Note : Look for pre-operative assessment, e.g.. Cardio-pulmonary clearance Formula : Number of patients with pre-operative assessments performed by qualified personnel / Number of patients for surgery reviewed x 100 Sample size : Rule of 10 2.3.3.d.3 Assessments are performed core regularly and are determined by patient's evolving response to care. All patients for surgery have Qualified personnel give patients for surgery preundergone pre-operative operative physical and pre- anesthetic assessment anesthetic assessment. CORE __ __ CHART REVIEW Patient chart from medical records (surgery patients) Note: Look for pre-operative anesthetic evaluation in the patient chart. Pre-operative assessment should be done for patients requiring more than local anesthesia. Formula: Number of patients with pre-operative assessments performed by qualified personnel / Number of patients for surgery reviewed x 100 Sample size: Rule of 10 2.3.3.e.1 Assessments are performed regularly and are determined by patient's evolving response to care. The status of postoperative patients is assessed upon admission into, during confinement and upon discharge from the recovery area Legible written records of the initial and ongoing assessments are accomplished for each patient and kept in the patient chart Percentage of patients who have undergone postoperative assessment upon admission into, during confinement and upon discharge from the recovery area Percentage of charts with legibly written entries of the initial and ongoing assessments __ __ CHART REVIEW Patient chart from medical records (surgery patients) Formula: Number of patients with post-operative assessments / Number of patients for surgery reviewed x 100 Sample size: Rule of 10 CHART REVIEW Patient chart from medical records Note: Look at progress notes, side notes or doctor's orders. To test for legibility, ask the staff nurses to read the entries of the doctors. Formula : Number of charts with legibly written entries of the initial and ongoing assessments/total number of charts reviewed x 100 Sample size : Rule of 10 REMARKS
2.3.3.d.2 Assessments are performed regularly and are determined by patient's evolving response to care.
Qualified personnel give Percentage of patients for patients for surgery presurgery who have undergone operative physical and pre- pre-operative anesthetic assessment. physical/medical assessment
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2.3.4.a.1 Assessments are documented and used by the health care team to ensure effective communication and continuity of care.
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.1.c.1 Care is delivered in a timely, safe, Referrals to other Percentage of charts with referrals made according to appropriate and coordinated specialties are made manner, according to care plans. according to established pathways or guidelines pathways or guidelines
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CHART REVIEW Patient charts - Verify if orders for referrals (or nonreferrals) are consistent with related CPGs and clinical pathways Formula: Number of charts with referral made according to pathway/ number of charts with referrals x 100 Sample size: Rule of 10
2.5.1.d.1 Care is delivered in a timely, safe, Results of referrals are appropriate and coordinated communicated to relevant manner, according to care plans. members of the health care team and are considered in the management.
Percentage of charts with results of referral communicated to relevant health care team and are considered in the management
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CHART REVIEW Patient charts - Check charts if results of referrals are communicated to relevant members of the health care team and if these are considered in the management Formula: Number of charts with referral communicated to relevant health care team and considered in the management/ number of charts with referrals x 100 Sample size: Rule of 10
2.5.5.a.2 Drugs are administered in a core standardized and systematic manner in the provider organization.
Drugs are administered in All drugs are administered in a timely, safe, appropriate a timely, safe, appropriate and controlled manner and controlled manner to the right patient CORE
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CHART REVIEW Patient chart from the medical records 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 Formula: Number of drugs administered to the right patient at the correct time, manner, and route/number of drugs x 100. Sample size: 10 drugs (may come from different charts) Note: Surveyor may also check for administration of any of the following: antibiotics, anticonvulsants, MgSO4, KCl drip and other drips, calcium gluconate, sodium bicarbonate, etc. For oral medications, do direct observation
2.5.5.c.2 Drugs are administered in a standardized and systematic manner in the provider organization.
Only qualified personnel order, prescribe, prepare, dispense and administer drugs
Percentage of charts with orders for drug administration that were made by licensed doctors
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CHART REVIEW Doctor's orders in patient chart from the medical records Orders that were made by interns should be countersigned by licensed residents or consultants Formula: Number of charts with orders for drug administration made by licensed doctors/number of charts reviewed x 100 Sample size: Rule of 10
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CODE 2.5.5.i.1 core STANDARDS Drugs are administered in a standardized and systematic manner in the provider organization. CRITERIA Drug administration is properly documented in the patient chart INDICATOR All charts have proper documentation of drug administration CORE HOSP PHIC EVIDENCE CHART REVIEW Medication sheet in patient chart from medical records Formula: Number of charts with proper documentation of drug administration/total charts reviewed x 100 Sample size: rule of 10 REMARKS
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2.7. DISCHARGE 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. 2.7.1.x.1 The discharge plan is part of the All charts have discharge CHART REVIEW core patient's care plan and is plans __ __ Patient chart from medical records, look at the discharge orders. It documented in the patient chart. CORE 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 Formula: Number of charts with discharge plans/number of charts reviewed x 100 Sample size: Rule of 10 Note : Discharge plan is not synonymous with discharge summary 5. INFORMATION MANAGEMENT 5.1 DATA COLLECTION, AGGREGATION AND USE Goal: Collection and aggregation of data are done for patient care, management of services, education and research. Care providers document Percentage of properly 5.1.3.a.1 Every patient has a sufficiently CHART REVIEW __ __ Patient charts from medical records (surgical and medical cases) detailed patient chart to facilitate management details in the accomplished patient records patient chart. All entries continuity of care, and meet education, research, evaluation are promptly Formula: Number of properly accomplished patient records/Number of accomplished, accurate, and medico-legal and statutory records retrieved legible, dated and duly requirements. Sample size: 10 charts or 10%, whichever is lower signed by the care Scoring for properly accomplished charts providers whose 1. legibility 2. date, time & signature designations are clearly 3. completeness of entries (SOAP, review of systems, medication indicated treatment) Note: Documentation in patient charts should be sufficiently detailed to enable any member of the health care team to understand care plans and care provision. Clinical pathways are excellent means to achieve this.
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1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.1.a.1 Organizational policies and Informed consent is All patient charts have signed DOCUMENT consent __ __ Patient charts - sample charts of patients currently admitted. If hospital core procedures respect and support obtained from patients patients' right to quality care and prior to initiation of care. CORE is departmentalized, get samples during tour of the different their responsibilities in that care. departments. Formula: No. of patient charts with signed consent / no. of patient charts reviewed x 100 Sample size: 10% or 10 charts whichever is lower Note: *Informed consent - includes a patient-doctor discussion of the ff 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. 1.1.c.1 Organizational policies and Patients receive written procedures respect and support statements of their rights patients' right to quality care and and responsibilities. their responsibilities in that care. Proof that patients are informed of their rights and responsibilities through IEC materials; e.g., posters, flyers, pamphlets, audiovisual presentation, etc. DOCUMENT or OBSERVATION Written statements of patient rights and responsibilities given to patients or Information Education Campaign (IEC) materials on patient rights and responsibilities such as posters, flyers, pamphlets, audio-visual presentation, etc. Check the following areas: admitting section, ER, wards and OPD. INTERVIEW Ask patients from ER, wards or OPD what their rights and responsibilities are
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CODE 1.2.b.1 STANDARDS The organization encourages and promotes opportunities to involve patients and their families in their care. CRITERIA Patients and their families are involved in making care decisions with ethical issues, such as withholding resuscitation, foregoing life-sustaining treatment, end-of-life care, etc. INDICATOR Presence of policies and procedures on involvement of patients and families in making care decisions on ethical issues such as withholding resuscitation, foregoing lifesustaining treatment, end-oflife care, etc. HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures on involvement of patients and families in making care decisions on ethical issues to include the ff: Right of unconscious patients Right to dignity Right to appropriate care based on religious and personal beliefs etc. INTERVIEW 1. Ask the doctors and nurses in the ER, wards or ICU on how they involve the patients' families on making care decisions with ethical issues 2. Ask the patient or patient's family (ER, wards or ICU) if the doctor/hospital staff involves them in making care decisions with ethical issues e.g. In medicine ward, you may ask about advance directives, truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy consent. In surgery and OB wards - procedures involving reproductive tract (BTL, hysterectomy, oophorectomy, sexual reassignment) DOCUMENT Security logs (ER, entrance) INTERVIEW 1. Ask patients from the wards, ER and imaging if they feel secured 2. Ask patients from the wards, ER and imaging if their privacy is respected 3. Ask staff regarding provisions of the policy addressing needs for privacy, confidentiality, religious counseling and communication OBSERVATION 1. Observe if patients privacy is respected in all areas of the hospital e.g.. partitioning in patients room for those who will undergo procedures and examination that require privacy. 2. The structures of emergency room and OPD allow for auditory and visual privacy. 3. Observe if all areas in which patients receive care are secured. Observe the vicinity (outside the building). REMARKS
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1.3.a.2
The organization documents and follows policies and procedures for addressing patients' needs for confidentiality, privacy, security, religious counseling and communication.
Hospital staff is aware of and follows policies and procedures in addressing patients needs for confidentiality, privacy, security, counseling, and communication.
Proof of hospital staff awareness and compliance with the policy in addressing patients needs for confidentiality, privacy, security, religious counseling, and communication.
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CODE 1.5.b.1 STANDARDS The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. CRITERIA The organization identifies and monitors personnel compliance with the code of ethics relevant to their respective disciplines. INDICATOR Presence of policies and procedures on monitoring compliance of personnel with codes of professional conduct relevant to their respective disciplines HOSP PHIC EVIDENCE DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. 2.1.2.a.1 Physical access to the Entrances and exits are Presence of entrances and core organization and its services is clearly and prominently exits that are readily facilitated and is appropriate to marked, free of any accessible and free from patients' needs. obstruction and readily obstruction accessible. CORE OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 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) 2.1.2.b.1 Physical access to the core 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 CORE __ __ OBSERVATION Directional signs are prominently posted. Check ER, OPD, wards and lobby. NOTE: For smaller hospitals, look for labels/signages in major areas including comfort rooms. REMARKS
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CODE STANDARDS CRITERIA Alternative passageways for patients with special needs (e.g. ramps) are available, clearly and prominently marked and free of any obstruction The organization documents, follows policies and procedures, and provides resources for the safe and efficient direction of patients, their families and visitors and staff traffic. INDICATOR Presence of alternative passageways (ramps, elevators) that are prominently marked and free from obstruction for patients with special needs CORE Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic are followed HOSP PHIC EVIDENCE 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. REMARKS
2.1.2.c.1 Physical access to the core organization and its services is facilitated and is appropriate to patients' needs.
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DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.)
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2.1.2.f.1
Physical access to the organization and its services is facilitated and is appropriate to patients' needs.
Patients, their visitors and Presence of safe and staff can efficiently and spacious hallways/ safely move within the passageways confines of the organization.
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.1.b.2 Patient receive prompt and timely Patients are informed of Percentage of patients INTERVIEW attention by qualified the cause of any delay in informed of the cause of any __ __ Ask patients from ER, OPD, wards, imaging or laboratory if they were professionals upon entry. the delivery of services. delay informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA Patients are correctly and efficiently assigned to the clinical services appropriate to their needs INDICATOR Percentage of patients correctly assigned to the clinical services appropriate to their needs HOSP PHIC EVIDENCE DOCUMENT Patient chart from ward and ICU Note: Determine if the service the patient is admitted to coincides with the patient's chief complaint and working diagnosis. Formula: Number of patients correctly assigned to the clinical services appropriate to their needs / total number of patients interviewed x 100 Sample Size: Rule of 10 2.2.3.a.2 The organization uniquely core identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel. 2.2.3.b.1 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 CORE 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 Formula: Number of charts correctly identified with patient / total number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower The patient charts contain Percentage of charts with identifiers unique to each unique identifiers for each patient patient __ __ DOCUMENT Patient chart from ER, OPD, wards and ICU Note: Review patients charts and look for patients complete name, address, birthday, demographic data (sex, age, civil status), hospital number. For newborns, look for parents' names and footprint of the baby, attending physician, room number Formula: Number of charts with unique identifiers/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower 2.2.3.c.1 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. Patient charts are appropriately and systematically indexed to facilitate retrieval and storage and to avoid duplication or loss Percentage of charts properly indexed __ __ OBSERVATION Look at how the charts in the OPD, wards and medical records are indexed and arranged in the chart tray Formula: Number of charts properly indexed/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower REMARKS
2.2.2.c.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging.
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CODE STANDARDS CRITERIA Prior to admission, patients and/or their families are appropriately informed by authorized qualified personnel of their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options, and the likely costs of treatment. Patient and/or their families demonstrate knowledge of their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options, and the likely costs of treatment. Patients and/or their families are informed of the expected (barring any complications) approximate duration of treatment, the extent or frequency of reassessment, the likely outcomes and their need for follow-up care after discharge INDICATOR Percentage of patients admitted who are appropriately informed by authorized qualified personnel of their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely costs of treatment HOSP PHIC EVIDENCE INTERVIEW Ask patient/family from the wards/ICU if they were appropriately informed by authorized qualified personnel (doctor, nurse or other allied medical staff) about the following: their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely cost of treatment Formula: Number of patients/families who were appropriately informed by authorized qualified personnel/Total number of patients/families interviewed x 100 Sample size: 10 charts or 10% whichever is lower REMARKS
2.2.4.a.1 The health professional responsible for the care of the patient obtains informed consent for treatment.
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2.2.4.b.1 The health professional responsible for the care of the patient obtains informed consent for treatment.
Percentage of patients/relatives who have knowledge about their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options and the likely costs of treatment
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INTERVIEW Ask the patients/relatives from wards or ICU about the following: their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options and the likely costs of treatment Formula: Number of patients/relatives who have knowledge about their disease/total number of patients /relatives interviewed x 100 Sample size: 10 patients or 10% whichever is lower
2.2.5.a.1 Planning for discharge begins upon entry into the organization and ensures a coordinated approach to discharge and continuing management.
Percentage of patients/relatives who were informed of the approximate duration of treatment, the extent or frequency of reassessment, the likely outcomes and their need for follow up care after discharge
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INTERVIEW Ask patients/relatives if any member of the health care team has informed them of the following: approximate duration of treatment, extent or frequency of reassessment, likely outcomes and need for follow up care after discharge. Note : The surveyor should look for patients who are admitted within the last 48h and are not yet for discharge Formula: Number of patients or their relatives who were informed of approximate duration of treatment , etc/total number of patients or relatives interviewed x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA Patients and/or their families are informed of the need for and availability of resources to continue care after discharge INDICATOR Percentage of patients and/or their families informed of the need and availability of resources to continue care after discharge HOSP PHIC EVIDENCE INTERVIEW Ask patients and/or relatives if they were informed of the need and availability of resources to continue care after discharge Formula: Number of patients and/or relatives informed of the need and availability of resources to continue care after discharge/total number of patients and/or relatives interviewed Sample size: Rule of 10 REMARKS
2.2.5.b.1 Planning for discharge begins upon entry into the organization and ensures a coordinated approach to discharge and continuing management.
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2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. All patients have 2.3.1.a.1 Each patient's physical, An appropriately __ core psychological and social status is comprehensive history and comprehensive history and PE within 24 hours from assessed. physical examination is performed on every patient admission CORE within 24 hours from admission. The history includes present illness, past medical, family, social and personal history. 2.3.2.a.2 Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition. Based on collaboratively developed policies and procedures, qualified personnel conduct initial assessments in an efficient and systematic manner to avoid repetition. Proof that health professionals who conduct initial assessmenst are qualified
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DOCUMENT Patient chart from wards or ER NOTE: comprehensive history includes present illness, review of systems, past medical, family and personal history Formula: Number of charts with comprehensive history and PE within 24 hours from admission/number of charts reviewed x 100 Sample size: Rule of 10 INTERVIEW 1. Ask the staff from the ER and wards who did the initial assessments. Verify if the identified staff is qualified. 2. Ask the patient from the ER and wards who did the initial assessments. Verify if the identified staff is qualified.
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2.3.2.b.1 Appropriate professionals The order of assessment perform coordinated and is determined by the sequenced patient assessment to patient's prioritized needs reduce waste and unnecessary repetition.
Proof that order of assessment was determined by the patient's prioritized needs
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INTERVIEW Ask health care professional, e.g.. physician, nurse, PT, etc. how he/she assessed the patient and relate it to the needs of the patient Note: The patient's prioritized needs are based on the priority medical needs as determined by the health care professional.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE OBSERVATION Safe and accessible area for keeping of medical records in the wards, ER, OPD and ICU. Records should be safe from unauthorized access. REMARKS
2.3.4.b.1 Assessment are documented and used by the health care team to ensure effective communication and continuity of care.
Medical records are stored Presence of safe and in an area that is safe and accessible area for keeping accessible to all members of medical records of the health care team, and whenever appropriate, to external providers
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2.4 CARE PLANNING Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. Presence of 2.4.1.a.1 The care plan addresses patient's The plan, aside from __ relevant clinical, social, emotional delineating responsibilities, adopted/developed protocols, __ __ CPGs or pathways containing __ and religious needs. includes goals to be __ __ goals to be achieved, achieved, services to be __ __ services to be provided, provided, patient __ __ education strategies to be patient education strategies __ __ implemented, time frames to be implemented, time to be met, resources to be frames to be met and resources to be used used.
DOCUMENT Adopted/developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education strategies to be implemented time frames to be met resources to be used Footnote : Clinical pathways derived from clinical practice guidelines and other types of clinical evidence should be developed or implemented for the top 10 cases of admissions and/or consultations DOCUMENT Patient chart from wards or ICU - doctor's orders Review management if based on practice standards or if expert judgment (specialists) and patient values were considered as needed INTERVIEW Ask doctors their basis for their management, whether they use practice guidelines, protocols, journal articles or books. DOCUMENT Documentation of care plan in patient chart (from wards, ICU, ER or OPD) - Look at the following: 1. Detailed clinical history 2. SOAP format 3. Admitting orders 4. Doctor's orders 5. Nurses notes 6. Medication sheet 7. TPR sheet 8. Laboratories
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2.4.2.c.1 The care plan is consistent with scientific evidence, professional standards, cultural values, medico-legal and statutory requirements.
Expert judgment, practice standards and patients values are considered in developing care plans.
Proof that practice standards and when necessary, expert judgment and patient's values are considered in the care plan
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__ Care planning is Presence of documentation 2.4.3.a.1 The organization ensures that documented in the patient of care plan in the patient information about the patient's chart proposed care is clear and readily chart. accessible to designated multidisciplinary health care providers and other relevant persons.
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CODE STANDARDS CRITERIA INDICATOR Presence of clinical pathways, algorithms or problem-oriented notes in SOAP format in the medical record HOSP PHIC EVIDENCE DOCUMENT Clinical pathways, algorithms or problem-oriented notes in SOAP format should be incorporated in the chart/medical record REMARKS
Clinical pathways, 2.4.3.b.1 The organization ensures that algorithms and probleminformation about the patient's proposed care is clear and readily oriented notes in SOAP format are incorporated in accessible to designated the medical record multidisciplinary health care providers and other relevant persons.
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.1.a.2 Care is delivered in a timely, safe, In the management of Percentage of charts with appropriate and coordinated clinical pathway-covered clinical pathway-based manner, according to care plans. conditions, the order and management timing of treatments follow the pathway
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DOCUMENT Ask for charts with clinical pathway-covered conditions. Formula: Number of charts managed according to clinical pathways/total number of charts reviewed Sample size: Rule of 10
2.5.2.a.1 Rights and needs of patients are Patients receive considered and respected by all explanations on the nature the staff. of a test or treatment, the need for it prior to administration, its likely effects and side effects, and what patients can do to cope with them 2.5.2.b.2 Rights and needs of patients are Patients wish to decline considered and respected by all tests or treatments is the staff. respected
Percentage of patients who received explanation on the nature, necessity, effects, and side effects and how to cope with them
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INTERVIEW Ask patient if he/she received explanations on the nature of a test or treatment, the need for it prior to admission, its likely effects and side effects, and what patients can do to cope with them Formula: Number of patients who received explanation on the nature, necessity, effects, and side effects and coping with side effects of a test or treatment/ number of patients interviewed x 100 Sample size: Rule of 10
Percentage of patients whose wish to decline tests or treatments was respected
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INTERVIEW Ask patients who wish to decline tests if their wish was respected. Formula: Number of patients whose wish to decline tests or treatments were respected/ number of patients interviewed who declined tests or treatments x 100 Sample size: Rule of 10 Note : If there are no patients (who wish to decline test) around, ask for charts from the medical records section and look for HAMA, DNR, refuse IV, refuse BT, unnecessary drugs or procedures. The signed waiver could be in the doctors orders, progress notes or waiver forms.
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CODE STANDARDS CRITERIA The organization documents and implements policies and procedures, and provides resources to promote interactive, appropriate and relevant educational programs for patients. INDICATOR Proof of individual patient education by appropriate health care professional HOSP PHIC EVIDENCE DOCUMENT Look at the doctor's orders in the patient chart for the documentation of patient education (wards). Note : The word 'advised' is sufficient proof of compliance. INTERVIEW Ask patient if they were advised/educated by any of the health care team. Cross refer to patient's chart if relevant and appropriate Note : Health care professionals are not limited to doctors only. It also includes nurses, physical therapists, dentists, etc. 2.5.4.a.3 Appropriate personnel educate patients and/or their families to help them understand patients' diagnosis, prognosis, treatment options, health promotion and illness prevention strategies. The organization documents and implements policies and procedures, and provides resources to promote interactive, appropriate and relevant educational programs for patients. Proof of provision of resources for patient educational programs DOCUMENT REVIEW Approved budget to support patient educational programs OBSERVATION Presence of materials, equipment, structures to support the patient educational programs e.g.. LCD, posters, venue REMARKS
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2.5.4.b.1 Appropriate personnel educate patients and/or their families to help them understand patients' diagnosis, prognosis, treatment options, health promotion and illness prevention strategies. 2.5.5.c.1 Drugs are administered in a core standardized and systematic manner in the provider organization.
Patients are aware of their Percentage of patients who roles and responsibilities in are aware of their roles and their health care responsibilities in their care
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INTERVIEW Ask patients their role and responsibilities in their health Formula: Number of patients aware of their roles and responsibilities in their care/number of patients interviewed x 100 Sample size: Rule of 10
Only qualified personnel order, prescribe, prepare, dispense and administer drugs
All doctors, nurses and pharmacists have updated licenses CORE
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INTERVIEW Randomly check the licenses of doctors, nurses and pharmacists if they are updated Formula: Number of doctors, nurses and pharmacists with updated licenses/number of doctors, nurses and pharmacists interviewed x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA 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 CORE HOSP PHIC EVIDENCE DOCUMENT Procedures on verification of prescriptios and orders INTERVIEW Ask staff how they verify orders from doctors prior to drug administration OBSERVATION 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 REMARKS
2.5.5.e.1 Drugs are administered in a core standardized and systematic manner in the provider organization.
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Prescriptions or orders are verified and patients are identified before medications are administered
Proof that patients are correctly identified prior to administration of medications CORE
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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 DOCUMENT Look at the telephone orders in the charts. Take note of the time of receipt of order and time of countersigning; validate with hospital standard/policy Note : All telephone orders should be countersigned within 24 hours or within the time set by the hospital Formula: Number of countersigned telephone orders/number of telephone orders x 100 (should be applied per chart; overall rating for the indicator will be the mean of ratings) Sample size: Rule of 10
__ 2.5.5.f.2 Drugs are administered in a standardized and systematic manner in the provider organization. Percentage of telephone Telephone orders are orders countersigned by countersigned by the ordering physician not later ordering doctor within the than standards set by the standard time interval organization and based on statutory requirements
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CODE STANDARDS CRITERIA Discontinued or recalled drugs are retrieved and safely disposed of according to established policies and procedures INDICATOR Proof that policies and procedures on retrieval and safety disposal of drugs are followed HOSP PHIC EVIDENCE DOCUMENT Look for documents such as memos, issuances or receipts showing that recalled or discontinued drugs are either returned to manufacturers/distributors or disposed of properly. INTERVIEW Ask staff the actual practice of retrieval and safe disposal of recalled or discontinued drugs. OBSERVATION Ask staff to show where they dispose recalled, discontinued or expired drugs. DOCUMENT 1. Review patient chart and verify appropriateness of treatment procedures. 2. For hospitals with operating rooms: WHO surgical safety checklist is incorporated in the charts of surgery patients INTERVIEW 1. Ask staff how they ensure performing treatment procedures in a timely manner. 2. Ask staff how they ensure performing procedures in a safe and controlled manner 3. Ask patients/caregivers how certain procedures such as IV insertion, catheterization were done? Note : Treatment procedures include but are not limited to appendectomy, CS, hydration for AGE, suturing, excision, incision and drainage, thoracotomy, chest tube insertion, IV insertion 2.5.6.c.1 Treatment procedures are Only qualified personnel performed in a standardized and order, plan, perform and systematic manner in the provider assist in performing organization. procedures Percentage of charts with orders for treatment procedures performed by qualified personnel DOCUMENT Verify from patient chart if the orders for treatment procedures were performed by qualified personnel Formula: Number of charts with orders for treatment procedures performed by qualified personnel/number of charts reviewed x 100 Sample size: rule of 10 REMARKS
2.5.5.g.2 Drugs are administered in a standardized and systematic manner in the provider organization.
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__ 2.5.6.a.2 Treatment procedures are Treatment procedures are performed in a standardized and performed in a timely, systematic manner in the provider safe, appropriate and controlled manner organization. Proof that treatment procedures are performed in a timely, safe, appropriate and controlled manner
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CODE STANDARDS CRITERIA INDICATOR Proof that orders are verified and patients are identified before procedures are performed HOSP PHIC EVIDENCE INTERVIEW Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly identified prior to performance of procedures OBSERVATION Observe if staff verifies the orders for procedures with the doctor and how the staff identify the patients e.g.., arm banding DOCUMENT Verify from doctor's orders in patient chart the legibility and accuracy of documentation of treatment procedures. Ask the nurse/hospital staff to read the orders from the chart. Formula: Number of charts with legibly and accurately documented treatment procedures / total number of charts reviewed with procedures x 100 Sample size: rule of 10 2.6 EVALUATION OF CARE Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. 2.6.1.c.1 Data relating to processes and Results of evaluation of Proof that results of DOCUMENT REVIEW outcomes of patient care are care are fed back to the evaluation of care are fed __ __ Documents showing that results of evaluation of care are fed back to analyzed to provide information health care providers back to health care providers concerned health care providers such as issuances, memos or reports for care improvement. concerned concerned INTERVIEW Verify with health care providers if they were given the results of the __ __ evaluation of care 2.7. DISCHARGE 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. Proof that the patients are 2.7.2.x.1 The organization provides INTERVIEW informed of the continuing __ __ Ask patients how they were informed of the continuing management information about continuing management plan while management plan to the patient plan, may ask about home medications (if applicable), follow up maintaining confidentiality and relevant health care visits/schedule and other home care/advise. Use chart of the patient as and privacy providers in a manner that reference during interview. maintains patient confidentiality and privacy. REMARKS
2.5.6.d.1 Treatment procedures are Orders are verified and performed in a standardized and patients are identified systematic manner in the provider before treatment organization. procedures are performed.
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__ 2.5.6.e.1 Treatment procedures are Treatment procedures are performed in a standardized and legibly and accurately systematic manner in the provider documented in the patient organization. chart by qualified personnel. Percentage of charts with legible and accurate documentation of treatment procedures by qualified personnel
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CODE STANDARDS CRITERIA INDICATOR Proof that the relevant health care providers are informed of the continuing management plan while maintaining confidentiality and privacy Proof that the organization arranges access to other relevant community health services in a timely manner HOSP PHIC EVIDENCE INTERVIEW Ask staff how they inform other health care providers regarding continuing management plans for referred patients. Use chart of patient as reference during interview. REMARKS
2.7.2.x.2 The organization provides information about continuing management plan to the patient and relevant health care providers in a manner that maintains patient confidentiality and privacy. 2.7.3.x.1 The organization arranges access to other relevant community health services in a timely manner, and ensures that patients are aware of appropriate services before discharge.
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DOCUMENT Patient chart - check for discharge orders and arrangements, referral forms to community health services (e.g. RHU, CHO) Footnote: Examples of other relevant community health services include, but are not limited to, RHUs, Botika sa Barangay, etc. INTERVIEW Ask staff how such arrangements are made, who is in charge, what facilities they make arrangements with for provision of health care services; validate answers to such with the patients INTERVIEW Ask patients if they are aware of the appropriate services in the community before discharge
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2.7.3.x.2 The organizations arranges access to other relevant community health services in a timely manner, and ensures that patient are aware of appropriate services before discharge. 2.7.4.x.1 Patients understand the discharge plans and their responsibilities for continuing management.
Proof that the organization ensures that patients are aware of the appropriate services in the community before discharge.
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Percentage of patients who understand their discharge plans
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INTERVIEW Ask patients about their knowledge and understanding of the care plan and their responsibilities for continuing management Formula: Number of patients who understand their discharge plans and responsibilities for continuing management / total number of patients for discharge interviewed x 100 Sample size: rule of 10 Note : Interview patients for discharge. If there are no in-patients for discharge, interview patients from the OPD or ER.
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Percentage of staff aware of 3.1.1.x.2 The provider organization's INTERVIEW their leadership team __ __ Ask 10 staff to identify the management team (hospital director or chief management team provides leadership, acts according to the of hospital or chief health officer together with the administrative officer organization's policies and has or administrator and service/department heads) overall responsibility for the organization's operation, and the Formula: Number of staff aware of their leadership/total number of staff quality of its services and its interview x 100 resources Sample size : Rule of 10 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all procedures which cover the major and procedures to all levels of the workforce services and aspects of levels of the workforce. operations. DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. The organization Presence of policies and 4.1.1.b.1 Planning ensures that DOCUMENT REVIEW documents and follows procedures on hiring of staff __ __ Policies and procedures for hiring of staff appropriately trained and policies and procedures qualified (and where relevant, credentialed) staff are available for hiring, credentialing, INTERVIEW __ __ Ask appropriate personnel a certain procedure for hiring of staff. to undertake the type and level of and privileging of its staff. activity performed by the organization. This includes those Note: The surveyor can randomly pick out a doctor, a nurse, an admin who are consulted when suitable staff, both newly hired or old, and ask them the process of selection, expertise is not available within hiring and screening and performance appraisal; when was it last the organization. conducted and by whom.
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CODE STANDARDS CRITERIA INDICATOR Staff to bed ratio for licensed doctors, registered nurses and midwives/nursing aides follow the DOH prescribed ratio. CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. List of total number of licensed doctors, 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 registered with DOH and actually being used. OBSERVATION Number of beds. DOCUMENT REVIEW HR contingency plan e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load INTERVIEW Ask HR, Wards and ER staff: 1. What happens when one staff is absent? 2. When one staff goes AWOL? 3. When there are too many patients? 4. What is the back up system to maintain appropriate number of staff? DOCUMENT REVIEW 1. Mandatory Monthly Hospital Report (take note of Maximum Bed Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate exceeding 100% to identify occasions of increased patient load); 2. Actual plan and monitoring report showing how the increased patient load was addressed. INTERVIEW Ask HR, doctors, nurses and staff how the appropriate number of staff was maintained and what monitoring procedure was made? REMARKS
Staff numbers and skill mix 4.1.2.a.3 Workload is monitored and core appropriate guidelines consulted are based on actual clinical needs. to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and organizational outcomes. 4.1.2.b.1 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. Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise.
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4.2 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. The organization defines, Proof that the organization 4.2.1.a.1 Recruitment, selection, DOCUMENT REVIEW __ 1. Policies and procedures governing personnel recruitment, selection __ appointment and reappointment disseminates and ensures defines, disseminates and ensures compliance with compliance with policies procedures ensure appropriate and appointments. __ 2. Memos/endorsements reflecting the dissemination of policies and __ competence, training, experience, and procedures governing policies and procedures governing personnel licensing and credentialing of all personnel recruitment, procedures governing personnel recruitment, selection and recruitment, selection and selection and appointees. appointments. __ 3. Actions of the board/owner e.g. those reflected in its minutes, __ appointments. appointments resolutions, etc. showing that the organization ensures compliance to policies and procedures on personnel recruitment, selection and appointments. INTERVIEW Interview HR and wards staff for validation if the organization's policies and procedures on personnel recruitment, selection and appointments are actually being implemented. DOCUMENT REVIEW Corporate policy on recruitment, selection and appointment of staff INTERVIEW 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It should be known to all staff and managers. 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities and maintenance and other areas for what conditions will lead to their firing 3. Ask staff regarding the process of their selection OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff
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The recruitment and 4.2.1.b.1 Recruitment, selection, appointment and reappointment selection process is open & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and licensing and credentialing of all ethical requirements, and allows a fair and unbiased appointees. evaluation of the qualifications and competencies of all applicants Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees.
Proof that recruitment and selection are consistent with the policies of the CSC (for government) or the organization.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10 REMARKS
4.2.4.a.1 All services are provided by staff members with appropriate qualifications, experience or training.
Percentage of doctors, All doctors, nurses and midwives providing clinical nurses and midwives with care have current licenses valid licenses and documented evidence of appropriate training and experience.
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4.3 STAFF TRAINING AND DEVELOPMENT Goal: A comprehensive program of staff training and development meets individual and organizational needs. 4.3.1.b.1 There are relevant orientation, Policies and procedures Presence of policies and DOCUMENT REVIEW training and development for orientation of new procedures for the orientation __ __ Policies and procedures on orientation of new employees to general programs to meet the educational management and staff are of new employees on general hospital policies needs of management and staff. documented and hospital policies monitored INTERVIEW __ __ Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented.
6. SAFE PRACTICE AND ENVIRONMENT 6.1 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.c.2 The organization plans a safe There are management Presence of operating DOCUMENT core and effective environment of care plans for the safe and manuals of the medical __ __ Operating manuals for the medical equipment consistent with its mission, efficient use of medical equipment services, and with laws and equipment according to CORE regulations. specifications
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.b.2 The organization provides a safe core 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 CORE __ __ __ __ __ __ 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 OBSERVATION 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 REMARKS
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6.1.2.c.1 The organization provides a safe core 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) CORE
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE INTERVIEW Ask personnel to describe their roles in safe practice Examples: identify safety issues and ask personnel how he/she will address this issue Formula: Number of personnel who understands role in safe practice/number of personnel interviewed x 100 Sample size: Rule of 10 REMARKS
6.1.2.d.1 The organization provides a safe All personnel understand Percentage of personnel who and effective environment of care and fulfill their role in safe understand and fulfill their consistent with its mission and practice role in safe practice services, and with laws and regulations.
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used. 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, blood transfusion reactions, falls, etc) CORE
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DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge.
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. 6.3.2.b.1 The organization uses a The organization takes Presence of a coordinated DOCUMENT REVIEW core coordinated system-wide steps to prevent and system-wide procedure for __ __ Procedures on isolation of nosocomial infections approach to reduce the risks of control outbreaks of isolation of nosocomial nosocomial infections. nosocomial infections infections INTERVIEW CORE __ __ Ask staff in ER, wards and ICU the procedures on isolation isolation - physical isolation of a patient with infection
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CODE STANDARDS CRITERIA The organization takes steps to prevent and control outbreaks of nosocomial infections INDICATOR Presence of a coordinated system-wide procedure for case containment of nosocomial infections CORE HOSP PHIC EVIDENCE 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 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 2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks INTERVIEW Interview hospital staff on how they handle and dispose needles OBSERVATION Presence of receptacles for proper disposal of sharps REMARKS
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6.4 EQUIPMENT AND SUPPLIES Goal: The provision of equipment and supplies supports the organization's role. 6.4.2.x.1 Specialized equipment is Proof that specialized equipment is operated only operated according to specifications and only by by a trained staff appropriately -trained staff.
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DOCUMENT REVIEW 1. License if applicable 2. List of specialized equipment 3. Certificates of training, certificates of attendance, or equivalent experience (at least 1 year) under a trained personnel OBSERVATION Identify specialized equipment that need only trained staff to operate Example of specialized equipment : MRI, CT scan, ECG, 2d echo, x-ray, respirator, ultrasound, anesthesia machine, endoscopes, etc
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6.5 ENERGY AND WASTE MANAGEMENT Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. 6.5.2.x.2 The organization implements a Proof of implementation of DOCUMENT REVIEW __ 1. Issuances - memos, guidelines on waste disposal core waste disposal program which policies and procedures on __ __ 2. Contracts with waste handlers or disposal contractors, (if applicable) involves reuse, reduction an waste disposal __ recycling. CORE 3. Hospital policy that conforms to the joint DOH-DENR circular on __ waste management for LGUs __ INTERVIEW Ask staff regarding SOPs on actual procedure waste disposal __ __ OBSERVATION 1. Segregation of waste 2. Proper labeling of waste receptacles 3. Recyclable waste staging areas 4. Proper management of temporary storage areas prior to hauling for disposal
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7. 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 7.2.b.1 New processes of care are Clinical practice guidelines Proof of dissemination of DOCUMENT REVIEW PhilHealth-adopted CPGs for __ __ Documentation of dissemination of PhilHealth-adopted CPGs e.g. for the top 10 causes of designed collaboratively based the 10 conditions as on scientific evidence, clinical admissions and/or Conferences- topics, meetings - look at the minutes, agenda, memos contained in HTA Forum (if consultations and standards, cultural values and and other issuances CPG is applicable in the patient preferences. PhilHealth-adopted hospital) guidelines are OBSERVATION disseminated and __ __ CPGs or IEC materials available in the wards, nurses station, and monitored emergency room, doctors' offices/clinics 7.2.b.2 New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. Clinical practice guidelines for the top 10 causes of admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Proof of dissemination of CPGs for the top 10 causes of admission and/or consultation __ __ DOCUMENT REVIEW Documentation of dissemination and monitoring of CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and other issuances OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics DOCUMENT REVIEW 1. Policies or issuances on CQI Program 2. QA/CQI manual 3. Patient satisfaction survey results/ratings 4. Staff satisfaction survey INTERVIEW Validate the activities thru interview of any staff including the frontliners, patients, external clients
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Proof that all service units and staff are responsible for, and demonstrate involvement in performance improvement that results in better services for internal and external clients
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1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations Proof that patients are Patients receive written 1.1.c.1 Organizational policies and DOCUMENT or OBSERVATION __ __ Written statements of patient rights and responsibilities given to patients informed of their rights and procedures respect and support statements of their rights responsibilities through IEC patients' right to quality care and and responsibilities. or Information Education Campaign (IEC) materials on patient rights and materials; e.g., posters, flyers, their responsibilities in that care. responsibilities such as posters, flyers, pamphlets, audio-visual pamphlets, audio-visual presentation, etc. Check the following areas: admitting section, ER, presentation, etc. wards and OPD. INTERVIEW Ask patients from ER, wards or OPD what their rights and responsibilities are DOCUMENT REVIEW Policies and procedures on involvement of patients and families in making care decisions on ethical issues to include the ff: Right of unconscious patients Right to dignity Right to appropriate care based on religious and personal beliefs etc. INTERVIEW 1. Ask the doctors and nurses in the ER, wards or ICU on how they involve the patients' families on making care decisions with ethical issues 2. Ask the patient or patient's family (ER, wards or ICU) if the doctor/hospital staff involves them in making care decisions with ethical issues e.g. In medicine ward, you may ask about advance directives, truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy consent. In surgery and OB wards - procedures involving reproductive tract (BTL, hysterectomy, oophorectomy, sexual reassignment)
__ 1.2.b.1 The organization encourages and promotes opportunities to involve patients and their families in their care. Patients and their families Presence of policies and are involved in making care procedures on involvement of patients and families in decisions with ethical issues, such as withholding making care decisions on resuscitation, foregoing life- ethical issues sustaining treatment, end- such as withholding resuscitation, foregoing lifeof-life care, etc. sustaining treatment, end-oflife care, etc.
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CODE 1.3.a.2 STANDARDS The organization documents and follows policies and procedures for addressing patients' needs for confidentiality, privacy, security, religious counseling and communication. CRITERIA Hospital staff is aware of and follows policies and procedures in addressing patients needs for confidentiality, privacy, security, counseling, and communication. INDICATOR Proof of hospital staff awareness and compliance with the policy in addressing patients needs for confidentiality, privacy, security, religious counseling, and communication. HOSP PHIC DOCUMENT Security logs (ER, entrance) INTERVIEW 1. Ask patients from the wards, ER and imaging if they feel secured 2. Ask patients from the wards, ER and imaging if their privacy is respected 3. Ask staff regarding provisions of the policy addressing needs for privacy, confidentiality, religious counseling and communication OBSERVATION 1. Observe if patients privacy is respected in all areas of the hospital e.g.. partitioning in patients room for those who will undergo procedures and examination that require privacy. 2. The structures of emergency room and OPD allow for auditory and visual privacy. 3. Observe if all areas in which patients receive care are secured. Observe the vicinity (outside the building). DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures EVIDENCE REMARKS
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__ __ 1.5.b.1 The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. The organization identifies and monitors personnel compliance with the code of ethics relevant to their respective disciplines. Presence of policies and procedures on monitoring compliance of personnel with codes of professional conduct relevant to their respective disciplines
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CODE 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of signages, posters Information detailing the 2.1.1.a.1 The organization informs the and other information clinical services offered community about the services it materials/media detailing the and hours of their provides and the hours of their availability is strategically clinical and ancillary services availability. distributed and prominently offered and hours of availability posted. 2.1.1.b.1 The organization informs the core 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 2 surgical capability, level 3 ICU, level 4 teaching and training hospital) CORE OBSERVATION 1. Look for signage/s of services offered or presence of flyers, posters, pamphlets about the services offered and the hours of their availability at the ER, OPD, lobby and hospital perimeter 2. The hours of availability are indicated in the signage/s, flyers, posters or pamphlets at the ER, OPD, lobby and hospital perimeter 3. " PhilHealth Accredited" signage, if applicable DOCUMENT REVIEW 1. List of services available 2. DOH License 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 STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE REMARKS
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2.1.1.c.1 The organization informs the community about the services it provides and the hours of their availability.
The community is aware of Percentage of patients who are aware of the services clinical services offered provided by the hospital and times of availability
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INTERVIEW Ask patients or relatives/caregivers from ER and OPD if they are aware of the clinical services offered and times of availability Note: Ask only about the services relevant to the patient or caregiver . Formula: Number of respondents who are aware of the services/ number of respondents X 100 Sample size: Rule of 10 (10 patients or 10% whichever is lower)
2.1.2.a.1 Physical access to the core 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 CORE
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OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 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)
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CODE STANDARDS CRITERIA Directional signs are prominently posted to help locate service areas within the organization. INDICATOR Presence of directional signages to locate service areas CORE HOSP PHIC EVIDENCE OBSERVATION Directional signs are prominently posted. Check ER, OPD, wards and lobby. NOTE: For smaller hospitals, look for labels/signages in major areas including comfort rooms. 2.1.2.c.1 Physical access to the core organization and its services is facilitated and is appropriate to patients' needs. Alternative passageways for patients with special needs (e.g. ramps) are available, clearly and prominently marked and free of any obstruction Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture Presence of alternative passageways (ramps, elevators) that are prominently marked and free from obstruction for patients with special needs CORE Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture __ __ __ __ __ __ 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. REMARKS
2.1.2.b.1 Physical access to the core organization and its services is facilitated and is appropriate to patients' needs.
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OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual
The organization documents, follows policies and procedures, and provides resources for the safe and efficient direction of patients, their families and visitors and staff traffic.
Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic are followed
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CODE 2.1.2.f.1 STANDARDS Physical access to the organization and its services is facilitated and is appropriate to patients' needs. CRITERIA Patients, their visitors and staff can efficiently and safely move within the confines of the organization. INDICATOR Presence of safe and spacious hallways/ passageways HOSP PHIC EVIDENCE OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.) REMARKS
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. Percentage of patients who Patient waiting times are 2.2.1.a.3 Patients receive prompt and INTERVIEW __ __ Interview patients from ER, OPD, imaging or laboratory regarding waiting have been attended to in routinely monitored, timely attention by qualified accordance with the hospital evaluated and improved professionals upon entry. times. Verify the time the patient was seen from ER chart or logbook policy based on standards and from ER, OPD, imaging or laboratory procedures developed by the organization. Formula: Number of patients who waited based on the prescribed waiting Depending on their needs, time/total number of patients interviewed x 100 patients are seen within the Sample size: Rule of 10 planned waiting period. 2.2.1.b.2 Patient receive prompt and timely Patients are informed of the cause of any delay in attention by qualified the delivery of services. professionals upon entry. Percentage of patients informed of the cause of any delay INTERVIEW Ask patients from ER, OPD, wards, imaging or laboratory if they were informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10 2.2.1.c.1 Patient receive prompt and timely Patients are satisfied with the actual waiting time. attention by qualified professionals upon entry. Percentage of patients satisfied with actual waiting time INTERVIEW Ask patients from ER, OPD, imaging or laboratory if they are satisfied with the waiting time Formula: Number of patients satisfied with actual waiting time/total number of patients interviewed x 100 Sample size: 10 patients or 10% whichever is lower
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CODE STANDARDS CRITERIA The staff follows policies and procedures in determining admissibility of patients or the need for referral to other organizations. INDICATOR Presence of policies and procedures in determining and prioritizing admissibility of patients or the need for referral to other organizations HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing admissibility of patients or the need for referral to other organizations 2. Policies and procedures in determining and prioritizing the need for referral to other organizations 3. ER/OPD logbook of admissions and referrals INTERVIEW Ask ER/OPD staff on procedures of admission and referrals Note : identify personnel to be interviewed. May obtain chart from wards and look for the chief complaint, determine admissibility and need for referral. 2.2.3.a.2 The organization uniquely core identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel. 2.2.3.b.1 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 CORE __ __ 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 Formula: Number of charts correctly identified with patient / total number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower The patient charts contain Percentage of charts with identifiers unique to each unique identifiers for each patient patient __ __ DOCUMENT Patient chart from ER, OPD, wards and ICU Note: Review patients charts and look for patients complete name, address, birthday, demographic data (sex, age, civil status), hospital number. For newborns, look for parents' names and footprint of the baby, attending physician, room number Formula: Number of charts with unique identifiers/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower REMARKS
2.2.2.b.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging.
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2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. All patients have An appropriately 2.3.1.a.1 Each patient's physical, __ core psychological and social status is comprehensive history and comprehensive history and PE within 24 hours from physical examination is assessed. performed on every patient admission CORE within 24 hours from admission. The history includes present illness, past medical, family, social and personal history. 2.3.2.a.2 Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition. Based on collaboratively developed policies and procedures, qualified personnel conduct initial assessments in an efficient and systematic manner to avoid repetition. Proof that health professionals who conduct initial assessmenst are qualified
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DOCUMENT Patient chart from wards or ER NOTE: comprehensive history includes present illness, review of systems, past medical, family and personal history Formula: Number of charts with comprehensive history and PE within 24 hours from admission/number of charts reviewed x 100 Sample size: Rule of 10 INTERVIEW 1. Ask the staff from the ER and wards who did the initial assessments. Verify if the identified staff is qualified. 2. Ask the patient from the ER and wards who did the initial assessments. Verify if the identified staff is qualified.
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2.3.2.b.1 Appropriate professionals perform The order of assessment is determined by the patient's coordinated and sequenced prioritized needs patient assessment to reduce waste and unnecessary repetition.
Proof that order of assessment was determined by the patient's prioritized needs
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2.3.4.b.1 Assessment are documented and used by the health care team to ensure effective communication and continuity of care.
Medical records are stored Presence of safe and in an area that is safe and accessible area for keeping of accessible to all members medical records of the health care team, and whenever appropriate, to external providers
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OBSERVATION Safe and accessible area for keeping of medical records in the wards, ER, OPD and ICU. Records should be safe from unauthorized access.
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2.4 CARE PLANNING Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. Presence of 2.4.1.a.1 The care plan addresses patient's The plan, aside from __ __ relevant clinical, social, emotional delineating responsibilities, adopted/developed protocols, __ __ CPGs or pathways containing includes goals to be and religious needs. __ goals to be achieved, services __ achieved, services to be __ __ provided, patient education to be provided, patient __ __ education strategies to be strategies to be __ __ implemented, time frames implemented, time frames to to be met, resources to be be met and resources to be used used.
DOCUMENT Adopted/developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education strategies to be implemented time frames to be met resources to be used Footnote : Clinical pathways derived from clinical practice guidelines and other types of clinical evidence should be developed or implemented for the top 10 cases of admissions and/or consultations DOCUMENT Documentation of care plan in patient chart (from wards, ICU, ER or OPD) - Look at the following: 1. Detailed clinical history 2. SOAP format 3. Admitting orders 4. Doctor's orders 5. Nurses notes 6. Medication sheet 7. TPR sheet 8. Laboratories
Presence of documentation of Care planning is 2.4.3.a.1 The organization ensures that documented in the patient care plan in the patient chart information about the patient's proposed care is clear and readily chart. accessible to designated multidisciplinary health care providers and other relevant persons.
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. All doctors, nurses and Only qualified personnel 2.5.5.c.1 Drugs are administered in a order, prescribe, prepare, pharmacists have updated core standardized and systematic licenses dispense and administer manner in the provider CORE drugs organization.
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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 DOCUMENT 1. Review patient chart and verify appropriateness of treatment procedures. 2. For hospitals with operating rooms: WHO surgical safety checklist is incorporated in the charts of surgery patients INTERVIEW 1. Ask staff how they ensure performing treatment procedures in a timely manner. 2. Ask staff how they ensure performing procedures in a safe and controlled manner 3. Ask patients/caregivers how certain procedures such as IV insertion, catheterization were done? Note : Treatment procedures include but are not limited to appendectomy, CS, hydration for AGE, suturing, excision, incision and drainage, thoracotomy, chest tube insertion, IV insertion
__ 2.5.6.a.2 Treatment procedures are performed in a standardized and systematic manner in the provider organization. Treatment procedures are performed in a timely, safe, appropriate and controlled manner Proof that treatment procedures are performed in a timely, safe, appropriate and controlled manner
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CODE STANDARDS CRITERIA Orders are verified and patients are identified before treatment procedures are performed. INDICATOR Proof that orders are verified and patients are identified before procedures are performed HOSP PHIC EVIDENCE INTERVIEW Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly identified prior to performance of procedures OBSERVATION Observe if staff verifies the orders for procedures with the doctor and how the staff identify the patients e.g.., arm banding DOCUMENT Verify from doctor's orders in patient chart the legibility and accuracy of documentation of treatment procedures. Ask the nurse/hospital staff to read the orders from the chart. Formula: Number of charts with legibly and accurately documented treatment procedures / total number of charts reviewed with procedures x 100 Sample size: rule of 10 2.7. DISCHARGE 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. 3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Percentage of staff aware of 3.1.1.x.2 The provider organization's INTERVIEW their leadership team __ __ Ask 10 staff to identify the management team (hospital director or chief of management team provides leadership, acts according to the hospital or chief health officer together with the administrative officer or organization's policies and has administrator and service/department heads) overall responsibility for the organization's operation, and the Formula: Number of staff aware of their leadership/total number of staff quality of its services and its interview x 100 resources Sample size: Rule of 10 REMARKS
2.5.6.d.1 Treatment procedures are performed in a standardized and systematic manner in the provider organization.
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__ 2.5.6.e.1 Treatment procedures are performed in a standardized and systematic manner in the provider organization. Treatment procedures are legibly and accurately documented in the patient chart by qualified personnel. Percentage of charts with legible and accurate documentation of treatment procedures by qualified personnel
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' by-laws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures REMARKS
3.1.5.d.1 The organization develops and implements policies and procedures which cover the major services and aspects of operations.
Issuances on policies and The organization communicates its policies procedures are known to all and procedures to all levels levels of the workforce of the workforce.
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Presence of HR contingency Appropriate policies and 4.1.2.b.1 Workload is monitored and DOCUMENT REVIEW __ HR contingency plan e.g. recall system to address inadequate staff due __ appropriate guidelines consulted procedures are monitored plan e.g. recall system to to temporarily compensate address inadequate staff due to ensure that appropriate staff to absences, leaves, resignations and increased patient load to absences, leaves, for, and to definitively, numbers and skill mix are resignations and increased address inadequacies in available to achieve desired INTERVIEW staff numbers or expertise. patient load. patient and organizational Ask HR, Wards and ER staff: __ 1. What happens when one staff is absent? __ outcomes. __ 2. When one staff goes AWOL? __ __ 3. When there are too many patients? __ __ 4. What is the back up system to maintain appropriate number of staff? __ 4.1.2.b.2 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. Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise. Proof of implementation and monitoring of HR contingency plan (e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load). DOCUMENT REVIEW 1. Mandatory Monthly Hospital Report (take note of Maximum Bed Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate exceeding 100% to identify occasions of increased patient load); 2. Actual plan and monitoring report showing how the increased patient load was addressed. INTERVIEW Ask HR, doctors, nurses and staff how the appropriate number of staff was maintained and what monitoring procedure was made?
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4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open & selection are consistent with transparent, is consistent the policies of the CSC (for procedures ensure appropriate government) or the competence, training, experience, with legal and ethical INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all requirements, and allows a organization. fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees. Percentage of randomly selected professional personnel with updated licenses OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size: At least 10 professional staff or 10% of the total professional staff DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10
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Percentage of doctors, nurses All doctors, nurses and midwives providing clinical and midwives with valid care have current licenses licenses and documented evidence of appropriate training and experience.
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4.3 STAFF TRAINING AND DEVELOPMENT Goal: A comprehensive program of staff training and development meets individual and organizational needs. Policies and procedures for Presence of policies and 4.3.1.b.1 There are relevant orientation, DOCUMENT REVIEW __ __ Policies and procedures on orientation of new employees to general procedures for the orientation orientation of new training and development programs to meet the educational management and staff are of new employees on general hospital policies needs of management and staff. documented and monitored hospital policies INTERVIEW __ __ Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented.
6. SAFE PRACTICE AND ENVIRONMENT 6.1 PATIENT AND STAFF SAFETY Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. Presence of operating 6.1.1.c.2 The organization plans a safe and There are management DOCUMENT __ __ Operating manuals for the medical equipment manuals of the medical plans for the safe and core effective environment of care equipment efficient use of medical consistent with its mission, CORE equipment according to services, and with laws and specifications regulations.
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CODE STANDARDS CRITERIA INDICATOR Percentage of personnel who understand and fulfill their role in safe practice HOSP PHIC EVIDENCE INTERVIEW Ask personnel to describe their roles in safe practice Examples: identify safety issues and ask personnel how he/she will address this issue Formula: Number of personnel who understands role in safe practice/number of personnel interviewed x 100 Sample size: Rule of 10 REMARKS
6.1.2.d.1 The organization provides a safe All personnel understand and effective environment of care and fulfill their role in safe practice consistent with its mission and services, and with laws and regulations.
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used. 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, blood transfusion reactions, falls, etc) CORE
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DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge.
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6.1.3.b.1 The organization routinely collects core and evaluates information to improve the safety and adequacy of the environment of care.
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. Presence of a coordinated The organization takes 6.3.2.b.1 The organization uses a DOCUMENT REVIEW __ __ Procedures on isolation of nosocomial infections system-wide procedure for steps to prevent and core coordinated system-wide isolation of nosocomial control outbreaks of approach to reduce the risks of infections nosocomial infections nosocomial infections. INTERVIEW CORE __ __ Ask staff in ER, wards and ICU the procedures on isolation isolation - physical isolation of a patient with infection
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6.5 ENERGY AND WASTE MANAGEMENT Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. Proof of implementation of 6.5.2.x.2 The organization implements a DOCUMENT REVIEW __ 1. Issuances - memos, guidelines on waste disposal __ policies and procedures on core waste disposal program which __ 2. Contracts with waste handlers or disposal contractors, (if applicable) __ waste disposal involves reuse, reduction an CORE recycling. 3. Hospital policy that conforms to the joint DOH-DENR circular on waste __ management for LGUs __ INTERVIEW Ask staff regarding SOPs on actual procedure waste disposal __ __ OBSERVATION 1. Segregation of waste 2. Proper labeling of waste receptacles 3. Recyclable waste staging areas 4. Proper management of temporary storage areas prior to hauling for disposal
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7. 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 Clinical practice guidelines Proof of dissemination of 7.2.b.1 New processes of care are DOCUMENT REVIEW __ __ Documentation of dissemination of PhilHealth-adopted CPGs e.g. PhilHealth-adopted CPGs for designed collaboratively based on for the top 10 causes of the 10 conditions as contained admissions and/or scientific evidence, clinical Conferences- topics, meetings - look at the minutes, agenda, memos and in HTA Forum (if CPG is consultations and standards, cultural values and other issuances applicable in the hospital) PhilHealth-adopted patient preferences. guidelines are OBSERVATION __ __ CPGs or IEC materials available in the wards, nurses station, and disseminated and monitored emergency room, doctors' offices/clinics 7.2.b.2 New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. Clinical practice guidelines Proof of dissemination of CPGs for the top 10 causes of for the top 10 causes of admission and/or consultation admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Proof that all service units and staff are responsible for, and demonstrate involvement in performance improvement that results in better services for internal and external clients __ __ DOCUMENT REVIEW Documentation of dissemination and monitoring of CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and other issuances OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics DOCUMENT REVIEW 1. Policies or issuances on CQI Program 2. QA/CQI manual 3. Patient satisfaction survey results/ratings 4. Staff satisfaction survey INTERVIEW Validate the activities thru interview of any staff including the frontliners, patients, external clients
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SECTION 6 - OUT- PATIENT DEPARTMENT

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.1.c.1 Organizational policies and Patients receive written Proof that patients are DOCUMENT or OBSERVATION __ procedures respect and support statements of their rights informed of their rights and __ Written statements of patient rights and responsibilities given to patients patients' right to quality care and and responsibilities. responsibilities through IEC or Information Education Campaign (IEC) materials on patient rights and their responsibilities in that care. materials; e.g., posters, responsibilities such as posters, flyers, pamphlets, audio-visual flyers, pamphlets, audiopresentation, etc. Check the following areas: admitting section, ER, visual presentation, etc. wards and OPD. INTERVIEW Ask patients from ER, wards or OPD what their rights and responsibilities are DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of signages, 2.1.1.a.1 The organization informs the Information detailing the posters and other information community about the services it clinical services offered materials/media detailing the provides and the hours of their and hours of their availability. availability is strategically clinical and ancillary services distributed and prominently offered and hours of availability posted. OBSERVATION 1. Look for signage/s of services offered or presence of flyers, posters, pamphlets about the services offered and the hours of their availability at the ER, OPD, lobby and hospital perimeter 2. The hours of availability are indicated in the signage/s, flyers, posters or pamphlets at the ER, OPD, lobby and hospital perimeter 3. " PhilHealth Accredited" signage, if applicable
__ 1.5.b.1 The organization's personnel discharge their functions according to codes of ethical behavior and other relevant professional and statutory standards. The organization identifies and monitors personnel compliance with the code of ethics relevant to their respective disciplines. Presence of policies and procedures on monitoring compliance of personnel with codes of professional conduct relevant to their respective disciplines
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CODE STANDARDS CRITERIA 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. INDICATOR Presence of facilities consistent with clinical service capability based on DOH license in accordance with the hospitals level (e.g. level 2 surgical capability, level 3 ICU, level 4 teaching and training hospital) CORE HOSP PHIC DOCUMENT REVIEW 1. List of services available 2. DOH License 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 EVIDENCE REMARKS
2.1.1.b.1 The organization informs the core community about the services it provides and the hours of their availability.
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2.1.1.c.1 The organization informs the community about the services it provides and the hours of their availability.
The community is aware of Percentage of patients who clinical services offered are aware of the services and times of availability provided by the hospital
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INTERVIEW Ask patients or relatives/caregivers from ER and OPD if they are aware of the clinical services offered and times of availability Note: Ask only about the services relevant to the patient or caregiver . Formula: Number of respondents who are aware of the services/ number of respondents X 100 Sample size: Rule of 10 (10 patients or 10% whichever is lower)
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 CORE
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2.1.2.b.1 Physical access to the core 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 CORE
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OBSERVATION Directional signs are prominently posted. Check ER, OPD, wards and lobby. NOTE: For smaller hospitals, look for labels/signages in major areas including comfort rooms.
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CODE STANDARDS CRITERIA Alternative passageways for patients with special needs (e.g. ramps) are available, clearly and prominently marked and free of any obstruction Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture INDICATOR Presence of alternative passageways (ramps, elevators) that are prominently marked and free from obstruction for patients with special needs CORE Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture HOSP PHIC EVIDENCE 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. REMARKS
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OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.)
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.1.a.3 Patients receive prompt and Patient waiting times are Percentage of patients who INTERVIEW have been attended to in __ __ Interview patients from ER, OPD, imaging or laboratory regarding timely attention by qualified routinely monitored, accordance with the hospital professionals upon entry. evaluated and improved waiting times. Verify the time the patient was seen from ER chart or policy based on standards and logbook from ER, OPD, imaging or laboratory procedures developed by the organization. Formula: Number of patients who waited based on the prescribed Depending on their needs, waiting time/total number of patients interviewed x 100 patients are seen within Sample size: Rule of 10 the planned waiting period. 2.2.1.b.2 Patient receive prompt and timely Patients are informed of attention by qualified the cause of any delay in professionals upon entry. the delivery of services. Percentage of patients informed of the cause of any delay INTERVIEW Ask patients from ER, OPD, wards, imaging or laboratory if they were informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10 2.2.1.c.1 Patient receive prompt and timely Patients are satisfied with Percentage of patients attention by qualified the actual waiting time. satisfied with actual waiting professionals upon entry. time __ __ INTERVIEW Ask patients from ER, OPD, imaging or laboratory if they are satisfied with the waiting time Formula: Number of patients satisfied with actual waiting time/total number of patients interviewed x 100 Sample size: 10 patients or 10% whichever is lower 2.2.2.b.1 The organization documents and follows policies and procedures, and provides resources to ensure proper patient triaging. The staff follows policies Presence of policies and procedures in determining and procedures in determining admissibility of and prioritizing admissibility of patients or the need for patients or the need for referral to other organizations referral to other organizations. __ __ __ __ __ __ DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing admissibility of patients or the need for referral to other organizations 2. Policies and procedures in determining and prioritizing the need for referral to other organizations 3. ER/OPD logbook of admissions and referrals INTERVIEW Ask ER/OPD staff on procedures of admission and referrals Note : identify personnel to be interviewed. May obtain chart from wards and look for the chief complaint, determine admissibility and need for referral.
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CODE STANDARDS CRITERIA All patients are correctly identified by their patient charts INDICATOR All patients are correctly identified by their charts CORE HOSP PHIC EVIDENCE 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 Formula: Number of charts correctly identified with patient / total number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower The patient charts contain Percentage of charts with identifiers unique to each unique identifiers for each patient patient __ __ DOCUMENT Patient chart from ER, OPD, wards and ICU Note: Review patients charts and look for patients complete name, address, birthday, demographic data (sex, age, civil status), hospital number. For newborns, look for parents' names and footprint of the baby, attending physician, room number Formula: Number of charts with unique identifiers/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower 2.2.3.c.1 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. Patient charts are appropriately and systematically indexed to facilitate retrieval and storage and to avoid duplication or loss Percentage of charts properly indexed __ __ OBSERVATION Look at how the charts in the OPD, wards and medical records are indexed and arranged in the chart tray Formula: Number of charts properly indexed/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower REMARKS
2.2.3.a.2 The organization uniquely core identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel. 2.2.3.b.1 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.
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2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. 2.3.4.b.1 Assessment are documented and Medical records are stored Presence of safe and __ used by the health care team to in an area that is safe and accessible area for keeping ensure effective communication accessible to all members of medical records and continuity of care. of the health care team, and whenever appropriate, to external providers
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DOCUMENT Adopted/developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education strategies to be implemented time frames to be met resources to be used Footnote : Clinical pathways derived from clinical practice guidelines and other types of clinical evidence should be developed or implemented for the top 10 cases of admissions and/or consultations DOCUMENT Documentation of care plan in patient chart (from wards, ICU, ER or OPD) - Look at the following: 1. Detailed clinical history 2. SOAP format 3. Admitting orders 4. Doctor's orders 5. Nurses notes 6. Medication sheet 7. TPR sheet 8. Laboratories
Care planning is Presence of documentation 2.4.3.a.1 The organization ensures that documented in the patient of care plan in the patient information about the patient's chart proposed care is clear and readily chart. accessible to designated multidisciplinary health care providers and other relevant persons.
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. Proof of individual patient The organization 2.5.4.a.2 Appropriate personnel educate education by appropriate documents and patients and/or their families to health care professional implements policies and help them understand patients' diagnosis, prognosis, treatment procedures, and provides resources to promote options, health promotion and interactive, appropriate illness prevention strategies. and relevant educational programs for patients.
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DOCUMENT Look at the doctor's orders in the patient chart for the documentation of patient education (wards). Note : The word 'advised' is sufficient proof of compliance. INTERVIEW Ask patient if they were advised/educated by any of the health care team. Cross refer to patient's chart if relevant and appropriate Note : Health care professionals are not limited to doctors only. It also includes nurses, physical therapists, dentists, etc.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE INTERVIEW Ask patients their role and responsibilities in their health Formula: Number of patients aware of their roles and responsibilities in their care/number of patients interviewed x 100 Sample size: Rule of 10 Only qualified personnel order, prescribe, prepare, dispense and administer drugs All doctors, nurses and pharmacists have updated licenses CORE __ __ INTERVIEW Randomly check the licenses of doctors, nurses and pharmacists if they are updated Formula: Number of doctors, nurses and pharmacists with updated licenses/number of doctors, nurses and pharmacists interviewed x 100 Sample size: Rule of 10 3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Percentage of staff aware of 3.1.1.x.2 The provider organization's INTERVIEW their leadership team __ __ Ask 10 staff to identify the management team (hospital director or chief management team provides leadership, acts according to the of hospital or chief health officer together with the administrative officer organization's policies and has or administrator and service/department heads) overall responsibility for the organization's operation, and the Formula: Number of staff aware of their leadership/total number of staff quality of its services and its interview x 100 resources Sample size : Rule of 10 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all levels of the workforce procedures which cover the major and procedures to all services and aspects of levels of the workforce. operations. DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures REMARKS
2.5.4.b.1 Appropriate personnel educate patients and/or their families to help them understand patients' diagnosis, prognosis, treatment options, health promotion and illness prevention strategies. 2.5.5.c.1 Drugs are administered in a core standardized and systematic manner in the provider organization.
Patients are aware of their Percentage of patients who roles and responsibilities in are aware of their roles and their health care responsibilities in their care
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4. HUMAN RESOURCE MANAGEMENT 4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open selection are consistent with the policies of the CSC (for & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and government) or the INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all ethical requirements, and organization. allows a fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees. Percentage of randomly selected professional personnel with updated licenses OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10
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4.3 STAFF TRAINING AND DEVELOPMENT Goal: A comprehensive program of staff training and development meets individual and organizational needs. 4.3.1.b.1 There are relevant orientation, Policies and procedures Presence of policies and DOCUMENT REVIEW for orientation of new procedures for the orientation __ __ Policies and procedures on orientation of new employees to general training and development programs to meet the educational management and staff are of new employees on general hospital policies hospital policies needs of management and staff. documented and monitored INTERVIEW __ __ Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented.
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.c.1 The organization provides a safe core 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) CORE OBSERVATION 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 REMARKS
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INTERVIEW Ask personnel to describe their roles in safe practice Examples: identify safety issues and ask personnel how he/she will address this issue Formula: Number of personnel who understands role in safe practice/number of personnel interviewed x 100 Sample size: Rule of 10
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7. 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 7.2.b.1 New processes of care are Clinical practice guidelines Proof of dissemination of DOCUMENT REVIEW PhilHealth-adopted CPGs for __ __ Documentation of dissemination of PhilHealth-adopted CPGs e.g. for the top 10 causes of designed collaboratively based the 10 conditions as on scientific evidence, clinical admissions and/or Conferences- topics, meetings - look at the minutes, agenda, memos contained in HTA Forum (if consultations and standards, cultural values and and other issuances CPG is applicable in the patient preferences. PhilHealth-adopted hospital) guidelines are OBSERVATION disseminated and __ __ CPGs or IEC materials available in the wards, nurses station, and monitored emergency room, doctors' offices/clinics 7.2.b.2 New processes of care are designed collaboratively based on scientific evidence, clinical standards, cultural values and patient preferences. Clinical practice guidelines for the top 10 causes of admissions and/or consultations and PhilHealth-adopted guidelines are disseminated and monitored Proof of dissemination of CPGs for the top 10 causes of admission and/or consultation __ __ DOCUMENT REVIEW Documentation of dissemination and monitoring of CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and other issuances OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics DOCUMENT REVIEW 1. Policies or issuances on CQI Program 2. QA/CQI manual 3. Patient satisfaction survey results/ratings 4. Staff satisfaction survey INTERVIEW Validate the activities thru interview of any staff including the frontliners, patients, external clients
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Proof that all service units and staff are responsible for, and demonstrate involvement in performance improvement that results in better services for internal and external clients
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SECTION 7 - INTENSIVE CARE UNIT

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.2.b.1 The organization encourages and Patients and their families Presence of policies and DOCUMENT REVIEW __ Policies and procedures on involvement of patients and families in procedures on involvement of __ promotes opportunities to involve are involved in making patients and their families in their care decisions with ethical patients and families in making care decisions on ethical issues to include the ff: making care decisions on care. issues, such as Right of unconscious patients withholding resuscitation, ethical issues Right to dignity such as withholding foregoing life-sustaining Right to appropriate care based on religious and personal beliefs etc. treatment, end-of-life care, resuscitation, foregoing lifesustaining treatment, end-ofetc. INTERVIEW life care, etc. 1. Ask the doctors and nurses in the ER, wards or ICU on how they __ __ involve the patients' families on making care decisions with ethical issues 2. Ask the patient or patient's family (ER, wards or ICU) if the __ __ doctor/hospital staff involves them in making care decisions with ethical issues e.g. In medicine ward, you may ask about advance directives, truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy consent. In surgery and OB wards - procedures involving reproductive tract (BTL, hysterectomy, oophorectomy, sexual reassignment) 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of facilities 2.1.1.b.1 The organization informs the Clinical services are consistent with clinical service core community about the services it appropriate to patients' capability based on DOH provides and the hours of their needs and the former's license in accordance with availability. availability is consistent the hospitals level (e.g. level with the organization's service capability and role 2 surgical capability, level 3 ICU, level 4 teaching and in the community. training hospital) CORE DOCUMENT REVIEW 1. List of services available 2. DOH License 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
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CODE STANDARDS CRITERIA Entrances and exits are clearly and prominently marked, free of any obstruction and readily accessible. INDICATOR Presence of entrances and exits that are readily accessible and free from obstruction CORE HOSP PHIC EVIDENCE OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 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) 2.1.2.d.1 Physical access to the organization and its services is facilitated and is appropriate to patients' needs. Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture __ __ __ __ __ __ __ __ __ __ OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.) REMARKS
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.2.c.1 The organization documents and Patients are correctly and Percentage of patients DOCUMENT __ __ Patient chart from ward and ICU follows policies and procedures, efficiently assigned to the correctly assigned to the clinical services appropriate and provides resources to ensure clinical services proper patient triaging. appropriate to their needs to their needs Note: Determine if the service the patient is admitted to coincides with the patient's chief complaint and working diagnosis. Formula: Number of patients correctly assigned to the clinical services appropriate to their needs / total number of patients interviewed x 100 Sample Size: Rule of 10 2.2.3.a.2 The organization uniquely core identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel. 2.2.3.b.1 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 CORE 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 Formula: Number of charts correctly identified with patient / total number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower The patient charts contain Percentage of charts with identifiers unique to each unique identifiers for each patient patient __ __ DOCUMENT Patient chart from ER, OPD, wards and ICU Note: Review patients charts and look for patients complete name, address, birthday, demographic data (sex, age, civil status), hospital number. For newborns, look for parents' names and footprint of the baby, attending physician, room number Formula: Number of charts with unique identifiers/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower
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CODE STANDARDS CRITERIA Prior to admission, patients and/or their families are appropriately informed by authorized qualified personnel of their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options, and the likely costs of treatment. Patient and/or their families demonstrate knowledge of their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options, and the likely costs of treatment. Patients and/or their families are informed of the expected (barring any complications) approximate duration of treatment, the extent or frequency of reassessment, the likely outcomes and their need for follow-up care after discharge INDICATOR Percentage of patients admitted who are appropriately informed by authorized qualified personnel of their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely costs of treatment HOSP PHIC EVIDENCE INTERVIEW Ask patient/family from the wards/ICU if they were appropriately informed by authorized qualified personnel (doctor, nurse or other allied medical staff) about the following: their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely cost of treatment Formula: Number of patients/families who were appropriately informed by authorized qualified personnel/Total number of patients/families interviewed x 100 Sample size: 10 charts or 10% whichever is lower REMARKS
2.2.4.a.1 The health professional responsible for the care of the patient obtains informed consent for treatment.
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2.2.4.b.1 The health professional responsible for the care of the patient obtains informed consent for treatment.
Percentage of patients/relatives who have knowledge about their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options and the likely costs of treatment
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INTERVIEW Ask the patients/relatives from wards or ICU about the following: their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options and the likely costs of treatment Formula: Number of patients/relatives who have knowledge about their disease/total number of patients /relatives interviewed x 100 Sample size: 10 patients or 10% whichever is lower
2.2.5.a.1 Planning for discharge begins upon entry into the organization and ensures a coordinated approach to discharge and continuing management.
Percentage of patients/relatives who were informed of the approximate duration of treatment, the extent or frequency of reassessment, the likely outcomes and their need for follow up care after discharge
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INTERVIEW Ask patients/relatives if any member of the health care team has informed them of the following: approximate duration of treatment, extent or frequency of reassessment, likely outcomes and need for follow up care after discharge. Note : The surveyor should look for patients who are admitted within the last 48h and are not yet for discharge Formula: Number of patients or their relatives who were informed of approximate duration of treatment , etc/total number of patients or relatives interviewed x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA Patients and/or their families are informed of the need for and availability of resources to continue care after discharge INDICATOR Percentage of patients and/or their families informed of the need and availability of resources to continue care after discharge HOSP PHIC EVIDENCE INTERVIEW Ask patients and/or relatives if they were informed of the need and availability of resources to continue care after discharge Formula: Number of patients and/or relatives informed of the need and availability of resources to continue care after discharge/total number of patients and/or relatives interviewed Sample size: Rule of 10 REMARKS
2.2.5.b.1 Planning for discharge begins upon entry into the organization and ensures a coordinated approach to discharge and continuing management.
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2.3. ASSESSMENT Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. 2.3.2.b.1 Appropriate professionals The order of assessment Proof that order of perform coordinated and is determined by the assessment was determined __ sequenced patient assessment to patient's prioritized needs by the patient's prioritized reduce waste and unnecessary needs repetition. 2.3.4.b.1 Assessment are documented and used by the health care team to ensure effective communication and continuity of care. Medical records are stored Presence of safe and in an area that is safe and accessible area for keeping accessible to all members of medical records of the health care team, and whenever appropriate, to external providers
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DOCUMENT Adopted/developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education strategies to be implemented time frames to be met resources to be used Footnote : Clinical pathways derived from clinical practice guidelines and other types of clinical evidence should be developed or implemented for the top 10 cases of admissions and/or consultations
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CODE STANDARDS CRITERIA Expert judgment, practice standards and patients values are considered in developing care plans. INDICATOR Proof that practice standards and when necessary, expert judgment and patient's values are considered in the care plan HOSP PHIC EVIDENCE DOCUMENT Patient chart from wards or ICU - doctor's orders Review management if based on practice standards or if expert judgment (specialists) and patient values were considered as needed INTERVIEW Ask doctors their basis for their management, whether they use practice guidelines, protocols, journal articles or books. DOCUMENT Documentation of care plan in patient chart (from wards, ICU, ER or OPD) - Look at the following: 1. Detailed clinical history 2. SOAP format 3. Admitting orders 4. Doctor's orders 5. Nurses notes 6. Medication sheet 7. TPR sheet 8. Laboratories REMARKS
2.4.2.c.1 The care plan is consistent with scientific evidence, professional standards, cultural values, medico-legal and statutory requirements.
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.2.b.2 Rights and needs of patients are Patients wish to decline Percentage of patients whose considered and respected by all tests or treatments is wish to decline tests or the staff. respected treatments was respected
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INTERVIEW Ask patients who wish to decline tests if their wish was respected. Formula: Number of patients whose wish to decline tests or treatments were respected/ number of patients interviewed who declined tests or treatments x 100 Sample size: Rule of 10 Note : If there are no patients (who wish to decline test) around, ask for charts from the medical records section and look for HAMA, DNR, refuse IV, refuse BT, unnecessary drugs or procedures. The signed waiver could be in the doctors orders, progress notes or waiver forms.
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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 DOCUMENT Look at the telephone orders in the charts. Take note of the time of receipt of order and time of countersigning; validate with hospital standard/policy Note : All telephone orders should be countersigned within 24 hours or within the time set by the hospital Formula: Number of countersigned telephone orders/number of telephone orders x 100 (should be applied per chart; overall rating for the indicator will be the mean of ratings) Sample size: Rule of 10
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CODE STANDARDS CRITERIA INDICATOR Proof that treatment procedures are performed in a timely, safe, appropriate and controlled manner HOSP PHIC EVIDENCE DOCUMENT 1. Review patient chart and verify appropriateness of treatment procedures. 2. For hospitals with operating rooms: WHO surgical safety checklist is incorporated in the charts of surgery patients INTERVIEW 1. Ask staff how they ensure performing treatment procedures in a timely manner. 2. Ask staff how they ensure performing procedures in a safe and controlled manner 3. Ask patients/caregivers how certain procedures such as IV insertion, catheterization were done? Note : Treatment procedures include but are not limited to appendectomy, CS, hydration for AGE, suturing, excision, incision and drainage, thoracotomy, chest tube insertion, IV insertion 2.5.6.c.1 Treatment procedures are Only qualified personnel performed in a standardized and order, plan, perform and systematic manner in the provider assist in performing organization. procedures Percentage of charts with orders for treatment procedures performed by qualified personnel DOCUMENT Verify from patient chart if the orders for treatment procedures were performed by qualified personnel Formula: Number of charts with orders for treatment procedures performed by qualified personnel/number of charts reviewed x 100 Sample size: rule of 10 2.5.6.d.1 Treatment procedures are Orders are verified and performed in a standardized and patients are identified systematic manner in the provider before treatment organization. procedures are performed. Proof that orders are verified and patients are identified before procedures are performed INTERVIEW Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly identified prior to performance of procedures OBSERVATION Observe if staff verifies the orders for procedures with the doctor and how the staff identify the patients e.g.., arm banding DOCUMENT Verify from doctor's orders in patient chart the legibility and accuracy of documentation of treatment procedures. Ask the nurse/hospital staff to read the orders from the chart. Formula: Number of charts with legibly and accurately documented treatment procedures / total number of charts reviewed with procedures x 100 Sample size: rule of 10
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REMARKS
2.5.6.a.2 Treatment procedures are Treatment procedures are performed in a standardized and performed in a timely, systematic manner in the provider safe, appropriate and organization. controlled manner
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2.7. DISCHARGE 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. Proof that the patients are 2.7.2.x.1 The organization provides INTERVIEW informed of the continuing __ __ Ask patients how they were informed of the continuing management information about continuing management plan while management plan to the patient plan, may ask about home medications (if applicable), follow up maintaining confidentiality and relevant health care visits/schedule and other home care/advise. Use chart of the patient as and privacy providers in a manner that reference during interview. maintains patient confidentiality and privacy. 2.7.2.x.2 The organization provides information about continuing management plan to the patient and relevant health care providers in a manner that maintains patient confidentiality and privacy. 2.7.3.x.1 The organization arranges access to other relevant community health services in a timely manner, and ensures that patients are aware of appropriate services before discharge. Proof that the relevant health care providers are informed of the continuing management plan while maintaining confidentiality and privacy Proof that the organization arranges access to other relevant community health services in a timely manner __ __ INTERVIEW Ask staff how they inform other health care providers regarding continuing management plans for referred patients. Use chart of patient as reference during interview.
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DOCUMENT Patient chart - check for discharge orders and arrangements, referral forms to community health services (e.g. RHU, CHO) Footnote: Examples of other relevant community health services include, but are not limited to, RHUs, Botika sa Barangay, etc. INTERVIEW Ask staff how such arrangements are made, who is in charge, what facilities they make arrangements with for provision of health care services; validate answers to such with the patients INTERVIEW Ask patients if they are aware of the appropriate services in the community before discharge
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2.7.3.x.2 The organizations arranges access to other relevant community health services in a timely manner, and ensures that patient are aware of appropriate services before discharge.
Proof that the organization ensures that patients are aware of the appropriate services in the community before discharge.
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CODE STANDARDS CRITERIA INDICATOR Percentage of patients who understand their discharge plans HOSP PHIC EVIDENCE INTERVIEW Ask patients about their knowledge and understanding of the care plan and their responsibilities for continuing management Formula: Number of patients who understand their discharge plans and responsibilities for continuing management / total number of patients for discharge interviewed x 100 Sample size: rule of 10 Note : Interview patients for discharge. If there are no in-patients for discharge, interview patients from the OPD or ER. 4. HUMAN RESOURCE MANAGEMENT 4.2 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. Relevant licenses are Percentage of randomly 4.2.1.e.1 Recruitment, selection, OBSERVATION selected professional __ __ Ask personnel from each area to present their current licenses or PRC appointment and reappointment routinely monitored for renewal. personnel with updated procedures ensure appropriate claim stub for PRC cards that are still being processed licenses competence, training, experience, licensing and credentialing of all Formula: Number of professionals with updated licenses/number of appointees. professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff 4.2.4.a.1 All services are provided by staff members with appropriate qualifications, experience or training. Percentage of doctors, All doctors, nurses and midwives providing clinical nurses and midwives with care have current licenses valid licenses and documented evidence of appropriate training and experience. DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10 REMARKS
2.7.4.x.1 Patients understand the discharge plans and their responsibilities for continuing management.
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For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys
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CODE STANDARDS CRITERIA Policies and procedures for the safe and efficient use of medical equipment according to specifications are documented and implemented INDICATOR Proof of the implementation of the policies and procedures for the safe and efficient use of medical equipment CORE HOSP PHIC EVIDENCE 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 OBSERVATION 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 REMARKS
6.1.2.b.2 The organization provides a safe core and effective environment of care consistent with its mission and services, and with laws and regulations.
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used.
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DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate
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CODE STANDARDS CRITERIA The effectiveness of safety procedures and devices are routinely tested, monitored and improved INDICATOR Proof of monitoring and action to improve the effectiveness of safety procedures and devices HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge. REMARKS
6.1.3.a.1 The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care.
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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, blood transfusion reactions, falls, etc) CORE
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. 6.3.2.b.1 The organization uses a The organization takes Presence of a coordinated DOCUMENT REVIEW core coordinated system-wide steps to prevent and system-wide procedure for __ __ Procedures on isolation of nosocomial infections approach to reduce the risks of control outbreaks of isolation of nosocomial nosocomial infections. nosocomial infections infections INTERVIEW CORE __ __ Ask staff in ER, wards and ICU the procedures on isolation isolation - physical isolation of a patient with infection
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6.4 EQUIPMENT AND SUPPLIES Goal: The provision of equipment and supplies supports the organization's role. 6.4.2.x.1 Specialized equipment is Proof that specialized operated according to equipment is operated only specifications and only by by a trained staff appropriately -trained staff.
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6.5 ENERGY AND WASTE MANAGEMENT Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. 6.5.2.x.2 The organization implements a Proof of implementation of DOCUMENT REVIEW __ 1. Issuances - memos, guidelines on waste disposal policies and procedures on __ core waste disposal program which __ 2. Contracts with waste handlers or disposal contractors, (if applicable) involves reuse, reduction an waste disposal __ CORE recycling. 3. Hospital policy that conforms to the joint DOH-DENR circular on __ waste management for LGUs __ INTERVIEW Ask staff regarding SOPs on actual procedure waste disposal __ __ OBSERVATION 1. Segregation of waste 2. Proper labeling of waste receptacles 3. Recyclable waste staging areas 4. Proper management of temporary storage areas prior to hauling for disposal
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SECTION 8 - OPERATING ROOM

CODE 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of facilities 2.1.1.b.1 The organization informs the Clinical services are consistent with clinical service core community about the services it appropriate to patients' capability based on DOH needs and the former's provides and the hours of their license in accordance with availability. availability is consistent the hospitals level (e.g. level with the organization's service capability and role 2 surgical capability, level 3 ICU, level 4 teaching and in the community. training hospital) CORE 2.1.2.a.1 Physical access to the core 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 CORE DOCUMENT REVIEW 1. List of services available 2. DOH License 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 STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE REMARKS
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DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual
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CODE 2.1.2.f.1 STANDARDS Physical access to the organization and its services is facilitated and is appropriate to patients' needs. CRITERIA INDICATOR HOSP PHIC EVIDENCE OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.) REMARKS
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.6.a.2 Treatment procedures are Treatment procedures are Proof that treatment performed in a standardized and performed in a timely, procedures are performed in systematic manner in the provider safe, appropriate and a timely, safe, appropriate organization. controlled manner and controlled manner
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DOCUMENT 1. Review patient chart and verify appropriateness of treatment procedures. 2. For hospitals with operating rooms: WHO surgical safety checklist is incorporated in the charts of surgery patients INTERVIEW 1. Ask staff how they ensure performing treatment procedures in a timely manner. 2. Ask staff how they ensure performing procedures in a safe and controlled manner 3. Ask patients/caregivers how certain procedures such as IV insertion, catheterization were done? Note : Treatment procedures include but are not limited to appendectomy, CS, hydration for AGE, suturing, excision, incision and drainage, thoracotomy, chest tube insertion, IV insertion
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2.5.6.d.1 Treatment procedures are Orders are verified and performed in a standardized and patients are identified systematic manner in the provider before treatment organization. procedures are performed.
Proof that orders are verified and patients are identified before procedures are performed
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INTERVIEW Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly identified prior to performance of procedures OBSERVATION Observe if staff verifies the orders for procedures with the doctor and how the staff identify the patients e.g.., arm banding
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Proof of implementation and Appropriate policies and 4.1.2.b.2 Workload is monitored and DOCUMENT REVIEW __ 1. Mandatory Monthly Hospital Report (take note of Maximum Bed appropriate guidelines consulted procedures are monitored monitoring of HR contingency __ to temporarily compensate plan (e.g. recall system to to ensure that appropriate staff Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate address inadequate staff due for, and to definitively, numbers and skill mix are exceeding 100% to identify occasions of increased patient load); __ 2. Actual plan and monitoring report showing how the increased patient __ to absences, leaves, address inadequacies in available to achieve desired staff numbers or expertise. resignations and increased patient and organizational load was addressed. patient load). outcomes. INTERVIEW __ Ask HR, doctors, nurses and staff how the appropriate number of staff __ was maintained and what monitoring procedure was made? 4.2 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. Relevant licenses are Percentage of randomly 4.2.1.e.1 Recruitment, selection, OBSERVATION selected professional __ __ Ask personnel from each area to present their current licenses or PRC appointment and reappointment routinely monitored for renewal. personnel with updated procedures ensure appropriate claim stub for PRC cards that are still being processed licenses competence, training, experience, licensing and credentialing of all Formula: Number of professionals with updated licenses/number of appointees. professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff 4.2.4.a.1 All services are provided by staff members with appropriate qualifications, experience or training. Percentage of doctors, All doctors, nurses and midwives providing clinical nurses and midwives with care have current licenses valid licenses and documented evidence of appropriate training and experience. DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10
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For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys
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CODE STANDARDS CRITERIA Policies and procedures for the safe and efficient use of medical equipment according to specifications are documented and implemented INDICATOR Proof of the implementation of the policies and procedures for the safe and efficient use of medical equipment CORE HOSP PHIC EVIDENCE 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 OBSERVATION 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 REMARKS
6.1.2.b.2 The organization provides a safe core and effective environment of care consistent with its mission and services, and with laws and regulations.
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CODE STANDARDS CRITERIA The effectiveness of safety procedures and devices are routinely tested, monitored and improved INDICATOR Proof of monitoring and action to improve the effectiveness of safety procedures and devices HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or proceedings on sentinel events INTERVIEW Ask leaders and staff from wards and ER how the incident reporting system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge. REMARKS
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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, blood transfusion reactions, falls, etc) CORE
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1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.3.a.2 The organization documents and Hospital staff is aware of Proof of hospital staff DOCUMENT __ Security logs (ER, entrance) __ awareness and compliance follows policies and procedures and follows policies and for addressing patients' needs for procedures in addressing with the policy in addressing patients needs for confidentiality, privacy, security, patients needs for INTERVIEW __ 1. Ask patients from the wards, ER and imaging if they feel secured __ confidentiality, privacy, confidentiality, privacy, religious counseling and __ 2. Ask patients from the wards, ER and imaging if their privacy is security, counseling, and security, religious counseling, __ communication. and communication. communication. respected __ 3. Ask staff regarding provisions of the policy addressing needs for __ privacy, confidentiality, religious counseling and communication OBSERVATION 1. Observe if patients privacy is respected in all areas of the hospital e.g.. partitioning in patients room for those who will undergo procedures and examination that require privacy. 2. The structures of emergency room and OPD allow for auditory and visual privacy. 3. Observe if all areas in which patients receive care are secured. Observe the vicinity (outside the building). DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures
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CODE 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. 2.1.2.a.1 Physical access to the Entrances and exits are Presence of entrances and core organization and its services is clearly and prominently exits that are readily marked, free of any facilitated and is appropriate to accessible and free from patients' needs. obstruction and readily obstruction accessible. CORE OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 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) 2.1.2.d.1 Physical access to the organization and its services is facilitated and is appropriate to patients' needs. Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture __ __ __ __ __ __ __ __ __ __ OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE REMARKS
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.1.a.3 Patients receive prompt and Patient waiting times are Percentage of patients who INTERVIEW have been attended to in __ __ Interview patients from ER, OPD, imaging or laboratory regarding timely attention by qualified routinely monitored, accordance with the hospital professionals upon entry. evaluated and improved waiting times. Verify the time the patient was seen from ER chart or policy based on standards and logbook from ER, OPD, imaging or laboratory procedures developed by the organization. Formula: Number of patients who waited based on the prescribed Depending on their needs, waiting time/total number of patients interviewed x 100 patients are seen within Sample size: Rule of 10 the planned waiting period. 2.2.1.b.2 Patient receive prompt and timely Patients are informed of attention by qualified the cause of any delay in professionals upon entry. the delivery of services. Percentage of patients informed of the cause of any delay INTERVIEW Ask patients from ER, OPD, wards, imaging or laboratory if they were informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10 2.2.1.c.1 Patient receive prompt and timely Patients are satisfied with Percentage of patients attention by qualified the actual waiting time. satisfied with actual waiting professionals upon entry. time __ __ INTERVIEW Ask patients from ER, OPD, imaging or laboratory if they are satisfied with the waiting time Formula: Number of patients satisfied with actual waiting time/total number of patients interviewed x 100 Sample size: 10 patients or 10% whichever is lower
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. Proof that medical devices 2.5.6.f.1 Treatment procedures are Medical devices and and equipment are used performed in a standardized and equipment are used, maintained, stored and systematic manner in the provider maintained, stored and organization. disposed based on disposed based on technical technical specifications. specifications.
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DOCUMENT 1. Policies and procedures on use and maintenance of medical devices 2. Policies and procedures on storage and disposal of medical devices 3. Schedule of equipments maintenance check, calibration of equipment 4. Logbook on preventive maintenance INTERVIEW Ask personnel how they use, maintain, store and dispose medical devices
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Percentage of staff aware of 3.1.1.x.2 The provider organization's INTERVIEW their leadership team __ __ Ask 10 staff to identify the management team (hospital director or chief management team provides leadership, acts according to the of hospital or chief health officer together with the administrative officer organization's policies and has or administrator and service/department heads) overall responsibility for the organization's operation, and the Formula: Number of staff aware of their leadership/total number of staff quality of its services and its interview x 100 resources Sample size : Rule of 10 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all levels of the workforce procedures which cover the major and procedures to all services and aspects of levels of the workforce. operations. DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Proof of implementation and Appropriate policies and 4.1.2.b.2 Workload is monitored and DOCUMENT REVIEW __ 1. Mandatory Monthly Hospital Report (take note of Maximum Bed appropriate guidelines consulted procedures are monitored monitoring of HR contingency __ to temporarily compensate plan (e.g. recall system to to ensure that appropriate staff Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate address inadequate staff due for, and to definitively, numbers and skill mix are exceeding 100% to identify occasions of increased patient load); __ 2. Actual plan and monitoring report showing how the increased patient __ to absences, leaves, address inadequacies in available to achieve desired staff numbers or expertise. resignations and increased patient and organizational load was addressed. patient load). outcomes. INTERVIEW __ Ask HR, doctors, nurses and staff how the appropriate number of staff __ was maintained and what monitoring procedure was made? 4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open selection are consistent with the policies of the CSC (for & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and government) or the INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all ethical requirements, and organization. allows a fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants
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CODE STANDARDS CRITERIA INDICATOR Percentage of randomly selected professional personnel with updated licenses HOSP PHIC EVIDENCE OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10 DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Example of technical staff: engineer Formula: Number of technical staff with current licenses /number of technical staff who should have license x 100 Sample size: Rule of 10 REMARKS
Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees.
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4.2.4.b.3 All services are provided by staff members with appropriate qualifications, experience or training.
All administrative, business and technical services staff have current licenses and documented evidence of appropriate training and experience
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4.3 STAFF TRAINING AND DEVELOPMENT Goal: A comprehensive program of staff training and development meets individual and organizational needs. 4.3.1.b.1 There are relevant orientation, Policies and procedures Presence of policies and DOCUMENT REVIEW for orientation of new __ Policies and procedures on orientation of new employees to general training and development procedures for the orientation __ programs to meet the educational management and staff are of new employees on general hospital policies needs of management and staff. documented and hospital policies monitored INTERVIEW __ __ Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented.
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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 1. electrical safety 2. medical device safety 3. chemical safety 4. radiation safety 5. mechanical safety 6. water safety 7. combustible material safety 8. waste management 9. hospital safety program (fire, emergency and disaster preparedness) CORE
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DOCUMENT REVIEW 1. Water safety - water analysis results for the past 6 months 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 & non-infectious, hazardous & non hazardous) 2. Hospital safety programs 3. Mechanical safety program of the hospital 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
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used. The effectiveness of safety procedures and devices are routinely tested, monitored and improved Proof of monitoring and action to improve the effectiveness of safety procedures and devices
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DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems
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6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. Presence of operating 6.2.4.x.1 Current information and scientific manuals equipment core data from manufacturers CORE concerning their products are available for reference and guidance in the operation and maintenance of plant and equipment.
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1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.3.a.2 The organization documents and Hospital staff is aware of Proof of hospital staff DOCUMENT __ Security logs (ER, entrance) __ awareness and compliance follows policies and procedures and follows policies and for addressing patients' needs for procedures in addressing with the policy in addressing patients needs for confidentiality, privacy, security, patients needs for INTERVIEW __ 1. Ask patients from the wards, ER and imaging if they feel secured __ confidentiality, privacy, confidentiality, privacy, religious counseling and __ 2. Ask patients from the wards, ER and imaging if their privacy is security, counseling, and security, religious counseling, __ communication. and communication. communication. respected __ 3. Ask staff regarding provisions of the policy addressing needs for __ privacy, confidentiality, religious counseling and communication OBSERVATION 1. Observe if patients privacy is respected in all areas of the hospital e.g.. partitioning in patients room for those who will undergo procedures and examination that require privacy. 2. The structures of emergency room and OPD allow for auditory and visual privacy. 3. Observe if all areas in which patients receive care are secured. Observe the vicinity (outside the building). DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures
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CODE 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. 2.1.2.a.1 Physical access to the Entrances and exits are Presence of entrances and core organization and its services is clearly and prominently exits that are readily marked, free of any facilitated and is appropriate to accessible and free from patients' needs. obstruction and readily obstruction accessible. CORE OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 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) 2.1.2.d.1 Physical access to the organization and its services is facilitated and is appropriate to patients' needs. Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture __ __ __ __ __ __ __ __ __ __ OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE REMARKS
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2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. 2.2.1.a.3 Patients receive prompt and Patient waiting times are Percentage of patients who INTERVIEW have been attended to in __ __ Interview patients from ER, OPD, imaging or laboratory regarding timely attention by qualified routinely monitored, accordance with the hospital professionals upon entry. evaluated and improved waiting times. Verify the time the patient was seen from ER chart or policy based on standards and logbook from ER, OPD, imaging or laboratory procedures developed by the organization. Formula: Number of patients who waited based on the prescribed Depending on their needs, waiting time/total number of patients interviewed x 100 patients are seen within Sample size: Rule of 10 the planned waiting period. 2.2.1.b.2 Patient receive prompt and timely Patients are informed of attention by qualified the cause of any delay in professionals upon entry. the delivery of services. Percentage of patients informed of the cause of any delay INTERVIEW Ask patients from ER, OPD, wards, imaging or laboratory if they were informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10 2.2.1.c.1 Patient receive prompt and timely Patients are satisfied with Percentage of patients attention by qualified the actual waiting time. satisfied with actual waiting professionals upon entry. time __ __ INTERVIEW Ask patients from ER, OPD, imaging or laboratory if they are satisfied with the waiting time Formula: Number of patients satisfied with actual waiting time/total number of patients interviewed x 100 Sample size: 10 patients or 10% whichever is lower
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. Proof that medical devices 2.5.6.f.1 Treatment procedures are Medical devices and and equipment are used performed in a standardized and equipment are used, maintained, stored and systematic manner in the provider maintained, stored and organization. disposed based on disposed based on technical technical specifications. specifications.
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Proof of implementation and Appropriate policies and 4.1.2.b.2 Workload is monitored and DOCUMENT REVIEW __ 1. Mandatory Monthly Hospital Report (take note of Maximum Bed appropriate guidelines consulted procedures are monitored monitoring of HR contingency __ to temporarily compensate plan (e.g. recall system to to ensure that appropriate staff Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate address inadequate staff due for, and to definitively, numbers and skill mix are exceeding 100% to identify occasions of increased patient load); __ 2. Actual plan and monitoring report showing how the increased patient __ to absences, leaves, address inadequacies in available to achieve desired staff numbers or expertise. resignations and increased patient and organizational load was addressed. patient load). outcomes. INTERVIEW __ Ask HR, doctors, nurses and staff how the appropriate number of staff __ was maintained and what monitoring procedure was made? 4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open selection are consistent with the policies of the CSC (for & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and government) or the INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all ethical requirements, and organization. allows a fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants
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CODE STANDARDS CRITERIA INDICATOR Percentage of randomly selected professional personnel with updated licenses HOSP PHIC EVIDENCE OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10 DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Example of technical staff: engineer Formula: Number of technical staff with current licenses /number of technical staff who should have license x 100 Sample size: Rule of 10 REMARKS
Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees.
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used. The effectiveness of safety procedures and devices are routinely tested, monitored and improved Proof of monitoring and action to improve the effectiveness of safety procedures and devices
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DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems
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6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. Presence of operating 6.2.4.x.1 Current information and scientific manuals equipment core data from manufacturers CORE concerning their products are available for reference and guidance in the operation and maintenance of plant and equipment.
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6.3 INFECTION CONTROL Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. 6.3.2.b.3 The organization uses a The organization takes Presence of a coordinated DOCUMENT REVIEW steps to prevent and system-wide procedure for __ __ Procedures on asepsis core coordinated system-wide approach to reduce the risks of control outbreaks of asepsis nosocomial infections CORE nosocomial infections. INTERVIEW __ __ Ask staff from ER, wards, laboratory and ICU about the approaches for asepsis during diagnostic and treatment procedures 6.3.3.a.1 The organization uses a core coordinated system-wide approach to reduce the risks of infection the staff are exposed to in the performance of their duties. There are programs for prevention and treatment of needle stick injuries, and policies and procedures for the safe disposal of used needles are documented and monitored Presence of policies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles CORE __ __ __ __ DOCUMENT REVIEW 1. Policies and procedures for prevention and treatment of needle stick injuries 2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks INTERVIEW Interview hospital staff on how they handle and dispose needles OBSERVATION Presence of receptacles for proper disposal of sharps
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SECTION 11 - HUMAN RESOURCE

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations The organization identifies Presence of programs on 1.5.a.2 The organization's personnel DOCUMENT REVIEW improving staff awareness on __ __ Documents related to implementation of the program e.g. copy of relevant codes of discharge their functions professional conduct and codes of professional conduct according to codes of ethical lectures on professional conduct and related topics other statutory standards and other statutory standards behavior and other relevant and informs its personnel professional and statutory INTERVIEW __ __ Ask staff (HR) about the programs on awareness on codes of about these codes and standards. standards. professional conduct and other statutory standards
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. The organization Presence of policies and 4.1.1.b.1 Planning ensures that DOCUMENT REVIEW documents and follows procedures on hiring of staff __ __ Policies and procedures for hiring of staff appropriately trained and policies and procedures qualified (and where relevant, credentialed) staff are available for hiring, credentialing, INTERVIEW __ __ Ask appropriate personnel a certain procedure for hiring of staff. to undertake the type and level of and privileging of its staff. activity performed by the organization. This includes those Note: The surveyor can randomly pick out a doctor, a nurse, an admin who are consulted when suitable staff, both newly hired or old, and ask them the process of selection, expertise is not available within hiring and screening and performance appraisal; when was it last the organization. conducted and by whom. Staff numbers and skill mix Presence of human resource 4.1.2.a.1 Workload is monitored and inventory system appropriate guidelines consulted are based on actual clinical needs. to ensure that appropriate staff numbers and skill mix are available to achieve desired patient and organizational outcomes. DOCUMENT REVIEW List of personnel, staffing pattern, or documents related to the HR inventory system Note: The hospital may document and analyze information like daily patient loads, utilization rates and services, turn-around times to determine staff size and mix. INTERVIEW Ask appropriate personnel (e.g. HR manager) how the right number and mix of competent staff are maintained to meet the needs of internal and external clients. DOCUMENT REVIEW HR contingency plan e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load INTERVIEW Ask HR, Wards and ER staff: 1. What happens when one staff is absent? 2. When one staff goes AWOL? 3. When there are too many patients? 4. What is the back up system to maintain appropriate number of staff?
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Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise.
Presence of HR contingency plan e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load.
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CODE STANDARDS CRITERIA Appropriate policies and procedures are monitored to temporarily compensate for, and to definitively, address inadequacies in staff numbers or expertise. INDICATOR Proof of implementation and monitoring of HR contingency plan (e.g. recall system to address inadequate staff due to absences, leaves, resignations and increased patient load). HOSP PHIC EVIDENCE DOCUMENT REVIEW 1. Mandatory Monthly Hospital Report (take note of Maximum Bed Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate exceeding 100% to identify occasions of increased patient load); 2. Actual plan and monitoring report showing how the increased patient load was addressed. INTERVIEW Ask HR, doctors, nurses and staff how the appropriate number of staff was maintained and what monitoring procedure was made? REMARKS
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4.2 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. The organization defines, Proof that the organization 4.2.1.a.1 Recruitment, selection, DOCUMENT REVIEW __ __ 1. Policies and procedures governing personnel recruitment, selection appointment and reappointment disseminates and ensures defines, disseminates and ensures compliance with compliance with policies procedures ensure appropriate and appointments. __ __ 2. Memos/endorsements reflecting the dissemination of policies and competence, training, experience, and procedures governing policies and procedures governing personnel licensing and credentialing of all personnel recruitment, procedures governing personnel recruitment, selection and recruitment, selection and selection and appointees. appointments. __ __ 3. Actions of the board/owner e.g. those reflected in its minutes, appointments. appointments resolutions, etc. showing that the organization ensures compliance to policies and procedures on personnel recruitment, selection and appointments. INTERVIEW Interview HR and wards staff for validation if the organization's policies and procedures on personnel recruitment, selection and appointments are actually being implemented. DOCUMENT REVIEW Corporate policy on recruitment, selection and appointment of staff INTERVIEW 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It should be known to all staff and managers. 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities and maintenance and other areas for what conditions will lead to their firing 3. Ask staff regarding the process of their selection
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The recruitment and 4.2.1.b.1 Recruitment, selection, appointment and reappointment selection process is open & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and licensing and credentialing of all ethical requirements, and allows a fair and unbiased appointees. evaluation of the qualifications and competencies of all applicants
Proof that recruitment and selection are consistent with the policies of the CSC (for government) or the organization.
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CODE STANDARDS CRITERIA Written job descriptions are given to and discussed with all newly-appointed staff members. INDICATOR Proof that newly appointed staff are given written job descriptions and the corresponding orientation/briefing. HOSP PHIC EVIDENCE DOCUMENT Written job descriptions signed by the newly appointed personnel. INTERVIEW 1. Interview newly-hired staff to determine if they received their written job description 2. Ask staff if the job descriptions were discussed with them particularly on their accountabilities and responsibilities that specifies their role and how it contributes to the attainment of the goals and maintaining quality of care Note: Newly-hired personnel is defined as those who are appointed/hired within the previous 6 months. If no newly appointed staff is available, the surveyor may interview the most recently hired staff. 4.2.4.b.1 All services are provided by staff members with appropriate qualifications, experience or training. All administrative, business and technical services staff have current licenses and documented evidence of appropriate training and experience Percentage of personnel performing administrative functions with current licenses and/or documented evidence of appropriate training and experience __ __ DOCUMENT PRC License or related documents (e.g.. certificate of training) Formula: Number of administrative staff with current licenses/ number of administrative staff who should have license x 100 Sample size: Rule of 10 REMARKS
4.2.2.a.1 Upon appointment, staff members receive a written statement of their accountabilities and responsibilities that specifies their role and how it contributes to the attainment of the goals and maintaining quality of care. The statements are reviewed when necessary.
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DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Certificate of training will do since in small hospitals. Sometimes it is the owner who possesses a different license is doing the work due to his/her training certificate for the present job. Example of business staff: accountant Formula: Number of business staff with current licenses/number of business staff who should have license x 100 Sample size : Rule of 10
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4.3.2.a.1 The organization clearly defines New personnel - including Proof that new personnel are and ensures compliance with the trainees, volunteers, new adequately supervised lines of authority and supervision. graduates and external contractors- are adequately supervised by qualified staff
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DOCUMENT Organizational chart INTERVIEW Ask new personnel about the lines of authority and supervision and if the supervision is adequate
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6. SAFE PRACTICE AND ENVIRONMENT 6.1 PATIENT AND STAFF SAFETY Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys
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SECTION 12 - MEDICAL RECORDS

2. PATIENT CARE 2.2. ENTRY Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment. Percentage of charts properly Patient charts are 2.2.3.c.1 The organization uniquely OBSERVATION indexed __ __ Look at how the charts in the OPD, wards and medical records are appropriately and identifies all patients including systematically indexed to newborn infants, and creates a indexed and arranged in the chart tray facilitate retrieval and specific patient chart for each patient that is readily accessible storage and to avoid Formula: Number of charts properly indexed/Number of charts duplication or loss to authorized personnel. reviewed x 100 Sample size: 10 charts or 10% whichever is lower 4. HUMAN RESOURCE MANAGEMENT 4.2 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. Percentage of personnel 4.2.4.b.1 All services are provided by staff All administrative, DOCUMENT performing administrative __ __ PRC License or related documents (e.g.. certificate of training) members with appropriate business and technical qualifications, experience or services staff have current functions with current training. licenses and documented licenses and/or documented Formula: Number of administrative staff with current licenses/ number evidence of appropriate evidence of appropriate of administrative staff who should have license x 100 training and experience training and experience Sample size: Rule of 10
5. INFORMATION MANAGEMENT 5.1 DATA COLLECTION, AGGREGATION AND USE Goal: Collection and aggregation of data are done for patient care, management of services, education and research. 5.1.1.b.2 Relevant, accurate, quantitative The organization defines Presence of qualified staff DOCUMENT REVIEW __ 1. Proof of training/seminar or certificate on records management of __ and qualitative data are collected data sets, data generation, involved in data definition, and used in a timely and efficient collection and aggregation generation, collection and staff involved in data definition __ 2. Document (memo or issuance) designating a staff for data definition, __ methods and the qualified aggregation manner for delivery of patient staff who are involved in care and management of generation, collection and aggragation each stage services. INTERVIEW __ Interview staff regarding their qualifications and functions __
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CODE STANDARDS CRITERIA The organization provides resources and opportunities to enable management and staff to use data in their decision and policymaking activities. INDICATOR Presence of budget or resources needed to collect, maintain, process and analyze data HOSP PHIC EVIDENCE DOCUMENT REVIEW Plans, which include the budget for procurement of computers, software and other resources (including training for data management), research outputs, reports or budget execution report showing that such budget has been disbursed INTERVIEW Ask leaders the content of plans and actual activities pertaining to collection, maintenance, processing and analysis of data OBSERVATION Presence of computers, software, personnel, storage area for hard copies of records REMARKS
5.1.1.d.1 Relevant, accurate, quantitative and qualitative data are collected and used in a timely and efficient manner for delivery of patient care and management of services.
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5.2 RECORDS MANAGEMENT Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met. Percentage of charts When patients are 5.2.1.a.2 Clinical records are readily retrieved within the standard __ __ admitted or are seen for accessible to facilitate patient ambulatory or emergency time set by the organization care, are kept confidential and safe, and comply with all relevant care, patient charts statutory requirements and codes documenting any previous care can be quickly of practice. retrieved for review, updating and concurrent use
OBSERVATION Ask the records keeper to retrieve a chart, then note the actual length of time of retrieval Formula: Number of charts retrieved within the time interval set by the organization/Number of charts retrieved x 100 Sample size: Rule of 10 Note: If organization has not set a time interval, use 15 minutes.
5.2.1.b.1 Clinical records are readily core accessible to facilitate patient care, are kept confidential and safe, and comply with all relevant statutory requirements and codes of practice.
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
Presence of procedures to protect records and patient charts against loss, destruction, tampering and unauthorized access or use CORE
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE DOCUMENT Logbooks for borrowing and retrieval of charts REMARKS
5.2.1.b.2 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.
Presence of logbooks for The organization has policies and procedures, borrowing and retrieval of charts 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
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6. SAFE PRACTICE AND ENVIRONMENT 6.1 PATIENT AND STAFF SAFETY Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys
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SECTION 13 - PHARMACY

2. PATIENT CARE 2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. All doctors, nurses and 2.5.5.c.1 Drugs are administered in a Only qualified personnel core standardized and systematic order, prescribe, prepare, pharmacists have updated manner in the provider dispense and administer licenses drugs CORE organization.
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2.5.5.h.1 Drugs are administered in a standardized and systematic manner in the provider organization.
Drugs are selected and procured based on the organization's usual case mix and according to policies and procedures that are consistent with scientific evidence and government policies.
Presence of policies and procedures on selection and procurement of drugs, consistent with scientific evidence and government policies
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DOCUMENT REVIEW 1. Policies and procedures on drug selection and procurement 2. Policies and procedures on drug selection and procurement are consistent with scientific evidence 3. Policies and procedures on drug selection and procurement are consistent with government policies e.g.. National Drug Policy INTERVIEW Ask the members of therapeutics committee regarding manner of selection and procurement of drugs OBSERVATION Observe actual supply of drugs in the pharmacy in accordance with the organization's policies
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Percentage of staff aware of 3.1.1.x.2 The provider organization's INTERVIEW their leadership team __ __ Ask 10 staff to identify the management team (hospital director or chief management team provides leadership, acts according to the of hospital or chief health officer together with the administrative officer organization's policies and has or administrator and service/department heads) overall responsibility for the organization's operation, and the Formula: Number of staff aware of their leadership/total number of staff quality of its services and its interview x 100 resources Sample size : Rule of 10 3.1.5.d.1 The organization develops and The organization Issuances on policies and implements policies and communicates its policies procedures are known to all procedures which cover the major and procedures to all levels of the workforce services and aspects of levels of the workforce. operations. DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10 REMARKS
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.c.1 The organization provides a safe core 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) CORE OBSERVATION 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 REMARKS
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SECTION 14 - FACILITIES MAINTENANCE

2. PATIENT CARE 2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. 2.5.6.f.1 Treatment procedures are Medical devices and Proof that medical devices performed in a standardized and equipment are used, and equipment are used systematic manner in the provider maintained, stored and maintained, stored and disposed based on disposed based on technical organization. technical specifications. specifications.
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4. HUMAN RESOURCE MANAGEMENT 4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open selection are consistent with the policies of the CSC (for & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and government) or the INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all ethical requirements, and organization. allows a fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants 4.2.4.b.3 All services are provided by staff members with appropriate qualifications, experience or training. All administrative, business and technical services staff have current licenses and documented evidence of appropriate training and experience Percentage of personnel performing technical functions with current licenses and/or documented evidence of appropriate training and experience DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Example of technical staff: engineer Formula: Number of technical staff with current licenses /number of technical staff who should have license x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.b.2 The organization provides a safe core 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 CORE __ __ __ __ __ __ 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 REMARKS
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The effectiveness of safety procedures and devices are routinely tested, monitored and improved
Proof of monitoring and action to improve the effectiveness of safety procedures and devices
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DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment 2. Preventive and corrective maintenance logbooks 3. Incident reports regarding operation of medical devices 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report in radiology department 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems
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6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. Presence of 6.2.1.x.1 Emergency light and / or power generator/emergency light, core supply, water and ventilation water system, adequate systems are provided for, in ventilation or air conditioning. keeping with relevant statutory CORE requirements and codes of practice.
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DOCUMENT Preventive and corrective maintenance logbooks for generator/ emergency light/ water tanks/ aircons OBSERVATION 1. Presence of generator/emergency light, water tanks, adequate ventilation or air conditioning 2. Test if faucets and water closets are working 3. Check if emergency light and generators are functional
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CODE STANDARDS CRITERIA INDICATOR Presence of written cleaning schedules, logbooks and checklists for grounds, facilities and equipment corrective and preventive maintenance HOSP PHIC EVIDENCE DOCUMENT REVIEW MOA/Contract for outsourced services for maintenance of equipment, janitorial services, etc. DOCUMENT 1. Cleaning schedule and checklist of facilities and equipment 2. Preventive and corrective maintenance logbook for equipment OBSERVATION Cleanliness of surroundings especially comfort rooms 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) INTERVIEW Ask about how equipment (generator, airconditioner, medical devices and other equipment etc.) are maintained DOCUMENT Operating manual of generators, air conditioners and other non-medical equipment REMARKS
6.2.2.x.1 Regular maintenance of grounds, facilities and equipment in keeping with relevant statutory requirements, codes of practice, or manufacturers' specifications are done to ensure a clean and safe environment.
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__ 6.2.3.x.1 Equipment is serviced only by core 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 CORE
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6.4 EQUIPMENT AND SUPPLIES Goal: The provision of equipment and supplies supports the organization's role. Presence of policies, 6.4.3.x.1 Items designated by the procedures and guidelines for core manufacturer for single use are safe reuse of items which not reused unless the comply with relevant statutory organization has specific policies requirements and guidelines for safe reuse CORE which take into consideration relevant statutory requirements and codes of practice.
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1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations 1.1.c.1 Organizational policies and Patients receive written Proof that patients are DOCUMENT or OBSERVATION __ procedures respect and support statements of their rights informed of their rights and __ Written statements of patient rights and responsibilities given to patients patients' right to quality care and and responsibilities. responsibilities through IEC or Information Education Campaign (IEC) materials on patient rights and their responsibilities in that care. materials; e.g., posters, responsibilities such as posters, flyers, pamphlets, audio-visual flyers, pamphlets, audiopresentation, etc. Check the following areas: admitting section, ER, visual presentation, etc. wards and OPD. INTERVIEW Ask patients from ER, wards or OPD what their rights and responsibilities are
__ 2. PATIENT CARE 2.1. ACCESS Goal: The organization is accessible to the community that it aims to serve. Presence of signages, 2.1.1.a.1 The organization informs the Information detailing the posters and other information community about the services it clinical services offered materials/media detailing the provides and the hours of their and hours of their availability. availability is strategically clinical and ancillary services distributed and prominently offered and hours of availability posted. 2.1.2.b.1 Physical access to the core 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 CORE
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OBSERVATION 1. Look for signage/s of services offered or presence of flyers, posters, pamphlets about the services offered and the hours of their availability at the ER, OPD, lobby and hospital perimeter 2. The hours of availability are indicated in the signage/s, flyers, posters or pamphlets at the ER, OPD, lobby and hospital perimeter 3. " PhilHealth Accredited" signage, if applicable OBSERVATION Directional signs are prominently posted. Check ER, OPD, wards and lobby. NOTE: For smaller hospitals, look for labels/signages in major areas including comfort rooms.
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 CORE
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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.
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CODE STANDARDS CRITERIA Major service areas have nearby waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture INDICATOR Presence of waiting facilities that are clean, well-lit, adequately ventilated and equipped with appropriate fixtures and furniture HOSP PHIC EVIDENCE OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic. Note: Take note of the provisions of the policies for use in interview during survey of wards, ER, OPD, ICU, OR, imaging and laboratory. INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and efficient direction of patients, their families and visitors. Verify if answer is consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.) REMARKS
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2.5 IMPLEMENTATION OF CARE Goal: Care is delivered to ensure the best possible outcomes for the patients. Proof of provision of The organization 2.5.4.a.3 Appropriate personnel educate resources for patient documents and patients and/or their families to educational programs implements policies and help them understand patients' diagnosis, prognosis, treatment procedures, and provides resources to promote options, health promotion and interactive, appropriate illness prevention strategies. and relevant educational programs for patients. 2.5.5.b.2 Drugs are administered in a standardized and systematic manner in the provider organization. The provider organization documents and follows policies and procedures and allocates resources for the training, supervision, and evaluation of professionals who administer drugs Presence of resources allocated for training, supervision and evaluation of professionals who administer drugs
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DOCUMENT REVIEW Approved budget to support patient educational programs OBSERVATION Presence of materials, equipment, structures to support the patient educational programs e.g.. LCD, posters, venue
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DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who administer drugs 2. Training plan, training modules/materials, evaluation forms Note : Use organizational chart as guide/reference. OBSERVATION Observe presence of related structures present, e.g.. training room, conference room, libraries DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who perform procedures 2. Training plan, training modules/materials, organizational chart, evaluation forms OBSERVATION Observe related structures present, e.g.. training room, conference room, libraries
__ The provider organization 2.5.6.b.2 Treatment procedures are performed in a standardized and documents and reviews systematic manner in the provider policies and procedures organization. and allocates resources for the training, supervision, and evaluation of professionals who perform procedures. Presence of resources allocated for training, supervision and evaluation of professionals who perform procedures
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3. LEADERSHIP AND MANAGEMENT 3.1 THE 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 Presence of organizational 3.1.1.x.1 The provider organization's DOCUMENT REVIEW structure __ __ Organizational structure/chart or manual of operations management team provides leadership, acts according to the organization's policies and has OBSERVATION __ __ Observe if the organizational structure/chart is posted conspicuously in overall responsibility for the organization's operation, and the appropriate areas (Lobby) quality of its services and its resources
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CODE STANDARDS CRITERIA INDICATOR Percentage of staff aware of their leadership team HOSP PHIC EVIDENCE INTERVIEW Ask 10 staff to identify the management team (hospital director or chief of hospital or chief health officer together with the administrative officer or administrator and service/department heads) Formula: Number of staff aware of their leadership/total number of staff interview x 100 Sample size : Rule of 10 DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' bylaws, policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures REMARKS
3.1.1.x.2 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
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3.1.5.d.1 The organization develops and The organization Issuances on policies and communicates its policies procedures are known to all implements policies and procedures which cover the major and procedures to all levels of the workforce services and aspects of levels of the workforce. operations.
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3.2 EXTERNAL SERVICES Goal: The organization ensures that services provided by external contractors meet appropriate standards. Presence of MOA/contract for 3.2.1.x.1 Documented agreements and all outsourced services (e.g. __ __ core contracts cover external service dialysis unit, dietary, __ __ providers and specify that the laboratory, radiology) quality of services provided must CORE be consistent with appropriate set __ __ standards.
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4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES 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. Proof of implementation and Appropriate policies and 4.1.2.b.2 Workload is monitored and DOCUMENT REVIEW __ 1. Mandatory Monthly Hospital Report (take note of Maximum Bed appropriate guidelines consulted procedures are monitored monitoring of HR contingency __ to temporarily compensate plan (e.g. recall system to to ensure that appropriate staff Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate address inadequate staff due for, and to definitively, numbers and skill mix are exceeding 100% to identify occasions of increased patient load); __ 2. Actual plan and monitoring report showing how the increased patient __ to absences, leaves, address inadequacies in available to achieve desired staff numbers or expertise. resignations and increased patient and organizational load was addressed. patient load). outcomes. INTERVIEW __ Ask HR, doctors, nurses and staff how the appropriate number of staff __ was maintained and what monitoring procedure was made? 4.2 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. Proof that recruitment and The recruitment and 4.2.1.b.1 Recruitment, selection, DOCUMENT REVIEW __ Corporate policy on recruitment, selection and appointment of staff __ appointment and reappointment selection process is open selection are consistent with the policies of the CSC (for & transparent, is procedures ensure appropriate competence, training, experience, consistent with legal and government) or the INTERVIEW __ 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It __ licensing and credentialing of all ethical requirements, and organization. allows a fair and unbiased appointees. should be known to all staff and managers. __ 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities __ evaluation of the qualifications and and maintenance and other areas for what conditions will lead to their competencies of all firing __ 3. Ask staff regarding the process of their selection __ applicants Relevant licenses are 4.2.1.e.1 Recruitment, selection, appointment and reappointment routinely monitored for renewal. procedures ensure appropriate competence, training, experience, licensing and credentialing of all appointees. Percentage of randomly selected professional personnel with updated licenses OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Formula: Number of professionals with updated licenses/number of professionals randomly selected x 100 Sample size : At least 10 professional staff or 10% of the total professional staff
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CODE STANDARDS CRITERIA All administrative, business and technical services staff have current licenses and documented evidence of appropriate training and experience INDICATOR Percentage of personnel performing administrative functions with current licenses and/or documented evidence of appropriate training and experience HOSP PHIC EVIDENCE DOCUMENT PRC License or related documents (e.g.. certificate of training) Formula: Number of administrative staff with current licenses/ number of administrative staff who should have license x 100 Sample size: Rule of 10 REMARKS
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Percentage of personnel performing business functions with current licenses and/or documented evidence of appropriate training and experience
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DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Certificate of training will do since in small hospitals. Sometimes it is the owner who possesses a different license is doing the work due to his/her training certificate for the present job. Example of business staff: accountant Formula: Number of business staff with current licenses/number of business staff who should have license x 100 Sample size : Rule of 10
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DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Example of technical staff: engineer Formula: Number of technical staff with current licenses /number of technical staff who should have license x 100 Sample size: Rule of 10
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CODE STANDARDS CRITERIA INDICATOR HOSP PHIC EVIDENCE For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys 6.1.2.b.2 The organization provides a safe core 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 CORE __ __ __ __ __ __ 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 DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate REMARKS
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Presence of risk identification Risks are identified, and assessment system assessed and appropriately controlled. Where elimination or substitution is not possible, adequate warning and protection devices are used.
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CODE 6.1.2.f.2 core STANDARDS The organization provides a safe and effective environment of care consistent with its mission and services, and with laws and regulations. CRITERIA A coordinated security arrangements in the organization assures protection of patients, staff and visitors INDICATOR Presence of an appointed personnel in charge of security CORE HOSP PHIC EVIDENCE DOCUMENT REVIEW Contract of security agency or appointment of in-house security 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 REMARKS
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__ 6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE Goal: A comprehensive maintenance program ensures a clean and safe environment. Presence of 6.2.1.x.1 Emergency light and / or power generator/emergency light, core supply, water and ventilation water system, adequate systems are provided for, in ventilation or air conditioning. keeping with relevant statutory CORE requirements and codes of practice.
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DOCUMENT Preventive and corrective maintenance logbooks for generator/ emergency light/ water tanks/ aircons OBSERVATION 1. Presence of generator/emergency light, water tanks, adequate ventilation or air conditioning 2. Test if faucets and water closets are working 3. Check if emergency light and generators are functional DOCUMENT Operating manual of generators, air conditioners and other non-medical equipment
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6.2.4.x.1 Current information and scientific core data from manufacturers concerning their products are available for reference and guidance in the operation and maintenance of plant and equipment.
Presence of operating manuals equipment CORE
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Benchbook for Hospitals
Score Sheet
CODE
HOSP PHIC
EVIDENCE
SECTION
SELFASSESSMENT SCORE 1 4
SURVEYOR SCORE 1 4
REMARKS
1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS Wards 1.1.a.1 DOCUMENT __ __ Patient charts - sample charts of patients currently admitted. If hospital is core departmentalized, get samples during tour of the different departments. Formula: No. of patient charts with signed consent / no. of patient charts reviewed x 100 Sample size:10% or 10 charts whichever is lower Note: *Informed consent - includes a patient-doctor discussion of the ff 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.
1.1.b.1 __ __ __ __ 1.1.c.1 __ __ __ __ __ __
DOCUMENT REVIEW 1. Policies and procedures on patients' rights: 2. Policies and procedures on patients' rights: 3. Policies and procedures on patients' rights: 4. Policies and procedures on patients' rights: patients (minors)
Document review right to care right to consent freedom of choice rights of incompetent
1 2 3 4
1 2 3 4
ER DOCUMENT or OBSERVATION Written statements of patient rights and responsibilities given to patients or Wards OPD Information Education Campaign (IEC) materials on patient rights and Others - admitting responsibilities such as posters, flyers, pamphlets, audio-visual section presentation, etc. Check the following areas: admitting section, ER, wards and OPD. INTERVIEW Ask patients from ER, wards or OPD what their rights and responsibilities are DOCUMENT REVIEW Policies and procedures on conduct of research involving patients: benefits and risks, informed consent, etc. INTERVIEW If hospital has done or has an ongoing research study involving patients: Ask leaders/researcher during leadership meeting regarding recruitment of participants, informed consent, confidentiality, etc DOCUMENT REVIEW 1. Policies on patient education 2. Policies on family education 3. Policies on patient involvement in care decision-making 4. Policies on family involvement in care decision-making CHART REVIEW Patient charts from medical records - check the nurses' notes/doctor's orders for health education, advice and home instructions Formula: Number of charts with health education, advice and home instructions/ Number of charts reviewed Sample size: 10 charts from the medical records or 10% whichever is lower Document review Document review Leadership meeting
1 3 4
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1 3 4
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1.2.a.1 __ __ __ __ 1.2.a.2 __ __ __ __ __ __
1 2 3 4 1 2 3 4
1 2 3 4 1 2 3 4
Chart review
1.2.a.3 __ __
DOCUMENT REVIEW Monitoring reports related to patient or family education program/policy
Document review
4 1.2.b.1 __ __ DOCUMENT REVIEW Policies and procedures on involvement of patients and families in making care decisions on ethical issues to include the ff: Right of unconscious patients Right to dignity Right to appropriate care based on religious and personal beliefs etc. INTERVIEW 1. Ask the doctors and nurses in the ER, wards or ICU on how they involve the patients' families on making care decisions with ethical issues 2. Ask the patient or patient's family (ER, wards or ICU) if the doctor/hospital staff involves them in making care decisions with ethical issues e.g. In medicine ward, you may ask about advance directives, truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy consent. In surgery and OB wards - procedures involving reproductive tract (BTL, hysterectomy, oophorectomy, sexual reassignment) Document review ER Wards ICU 1 2 3 4
4 1 2 3 4
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1.3.a.1 __ __ __ __ __ __ __ __ __ __
Document review DOCUMENT REVIEW 1. Policies and procedures that address patients' needs for confidentiality 2. Policies and procedures that address patients' needs for privacy 3. Policies and procedures that address patients' needs for security 4. Policies and procedures that address patients' needs for religious counseling 5. Policies and procedures that address patients' needs for communication Note : Take note of the provisions of the policies for use in interview during survey of wards, ER, imaging and laboratory
1 2 3 4
1 2 3 4
Scoring: 1: 2: 3: 4: 0% compliance to the indicator 1 - 49% compliance to the indicator 50 - 99% compliance to the indicator 100% compliance to the indicator
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Score Sheet
CODE 1.3.a.2
HOSP PHIC DOCUMENT Security logs (ER, entrance)
EVIDENCE
SECTION Wards ER Imaging Laboratory
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INTERVIEW 1. Ask patients from the wards, ER and imaging if they feel secured 2. Ask patients from the wards, ER and imaging if their privacy is respected 3. Ask staff regarding provisions of the policy addressing needs for privacy, confidentiality, religious counseling and communication OBSERVATION 1. Observe if patients privacy is respected in all areas of the hospital e.g.. partitioning in patients room for those who will undergo procedures and examination that require privacy. 2. The structures of emergency room and OPD allow for auditory and visual privacy. 3. Observe if all areas in which patients receive care are secured. Observe the vicinity (outside the building). DOCUMENT REVIEW Any reports on patient feedback monitoring e.g. analysis of patients' suggestions, complaints and other feedback or patient satisfaction survey result INTERVIEW Ask leaders about their patient feedback mechanism and/or their patient satisfaction survey
SELFASSESSMENT SCORE 1 2 3 4
SURVEYOR SCORE 1 2 3 4
REMARKS
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1.3.b.1 __ __
Document review Leadership meeting
1 3 4
1 3 4
__ 1.4.a.1 __ __
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Document review DOCUMENT REVIEW 1. Policies for routinely determining and improving the level of patient satisfaction 2. Patient satisfaction questionnaire/survey or patient satisfaction survey results or documentation of actions to address the identified gaps DOCUMENT REVIEW 1. Policies and procedures on addressing and resolving patients complaints 2. Minutes of meetings that address/resolve patients' complaints or patient satisfaction survey results DOCUMENT REVIEW Policies and procedures on codes of professional conduct Policies and procedures on codes of professional conduct are consistent with relevant statutory standards such as, but not limited to: 1. Codes of professional standards (PRC, PMA, PNA, PAMET, CSC, DOLE, etc) 2. Patient detention (RA 9434) and 3. Anti-deposit law (RA 8344) 4. Sexual harassment law (RA 7877). Document review
1 3 4
1 3 4
1.4.b.1 __ __ 1.5.a.1 __ __ __ __
1 3 4
1 3 4 1 2 3 4
Document review
1 2 3 4
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Document review DOCUMENT REVIEW Documents related to implementation of the program e.g. copy of lectures HR on professional conduct and related topics INTERVIEW Ask staff (HR) about the programs on awareness on codes of professional conduct and other statutory standards DOCUMENT REVIEW Policies and procedures on monitoring compliance to codes of professional conduct relevant to their respective discipline INTERVIEW 1. Ask leaders regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies 2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging and laboratory regarding their compliance with the codes of professional conduct e.g. advertisement of services by doctors, sponsorship of hospital activities by drug companies Note : Proof of compliance may include: the establishment of an Ethics Committee that will regularly review these codes, undertake education of staff on ethical conduct, recommend regulatory policies and disciplinary measures Document review Leadership meeting Wards ER OPD Imaging Laboratory
1 3 4
1 3 4
__ 1.5.b.1 __
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1 2 3 4
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1.5.c.1 __ __ __ __
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Document review DOCUMENT REVIEW Leadership meeting 1. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest 2. Policies and procedures for resolving ethical issues related to professional practice or to conflicts of interest are based on relevant codes of ethics and other professional and legal standards 3. Proof of compliance to the policies and procedures, which may include the establishment of an Ethics Committee that will resolve issues related to professional practice or to conflicts of interest or minutes of meeting of the committee INTERVIEW Ask leaders how they handle ethical issues related to professional practice or conflicts of interest Document review DOCUMENT REVIEW Policies and procedures for resolving ethical issues arising from patient care or reports or records of resolution of ethical dilemmas arising in the course of providing care e.g. disclosure of treatment-related injuries or adverse events
1 2 3 4
1 2 3 4
__ 1.6.a.1 __
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Score Sheet
CODE 1.6.a.2
HOSP PHIC
EVIDENCE
SECTION
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Document review DOCUMENT REVIEW Annual reports of the Ethics Committee (if present) or any similar reports on ethical issues by any hospital committee or body
SELFASSESSMENT SCORE 1
SURVEYOR SCORE 1
REMARKS
4 2. PATIENT CARE 2.1. ACCESS 2.1.1.a.1 __
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__ __ 2.1.1.b.1 core __ __
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OBSERVATION 1. Look for signage/s of services offered or presence of flyers, posters, pamphlets about the services offered and the hours of their availability at the ER, OPD, lobby and hospital perimeter 2. The hours of availability are indicated in the signage/s, flyers, posters or pamphlets at the ER, OPD, lobby and hospital perimeter 3. " PhilHealth Accredited" signage, if applicable DOCUMENT REVIEW 1. List of services available 2. DOH License
ER OPD Other Areas: lobby, hospital perimeter
1 2 3 4
1 2 3 4
Document review
1 4
1 4
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ER OPD ICU OBSERVATION: Look at the facilities, structure, manpower, equipment and supply. Check OR/RR/PACU if the service capability of the hospital is in accordance with the hospital level Document review DOCUMENT REVIEW Leadership meeting 1. Inpatient census 2. Outpatient census. 3. The hospital should have services that address the top ten diseases in their census. 4. The hospital should have services in accordance to the 'Mother-Baby Friendly Hospital Initiative" 5. The hospital should have services for newborn screening INTERVIEW Interview leaders regarding availability of services for endemic and most common diseases in the community based on their census ER INTERVIEW Ask patients or relatives/caregivers from ER and OPD if they are aware of OPD the clinical services offered and times of availability Note: Ask only about the services relevant to the patient or caregiver. Formula: Number of respondents who are aware of the services/ number of respondents X 100 Sample size: Rule of 10 (10 patients or 10% whichever is lower)
2.1.1.b.2 __ __ __ __ __ __ __ __ __ __
1 2 3 4
1 2 3 4
__ 2.1.1.c.1 __
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1 2 3 4
1 2 3 4
2.1.2.a.1 core
__ __
__ __
OBSERVATION 1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging and laboratory 2. Entrances and exits are accessible and free from any obstruction
ER OPD Wards ICU OR/RR/DR/PACU Imaging Note: Exit signs should be luminous or illuminated and prominently marked. There should be exit signs in major areas of the hospital and all Laboratory doors leading to the outside.(Reference: RA 6541 Building Code of the Philippines) OBSERVATION Directional signs are prominently posted. Check ER, OPD, wards and lobby. NOTE: For smaller hospitals, look for labels/signages in major areas including comfort rooms. ER OPD Wards Other Areas - Lobby
1 4
1 4
2.1.2.b.1 core
1 4
1 4
__
__
2.1.2.c.1 core
__ __ __
__ __ __ __
2.1.2.d.1
__
__ __ __ __ 2.1.2.e.1 __
__ __ __ __
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. OBSERVATION 1. Waiting area/room/facility are provided in the ER, OPD, imaging, laboratory, ICU and other areas 2. Waiting facilities are clean: 3. Waiting facilities are well-lit 4. Waiting facilities are adequately ventilated and 5. Waiting facilities are equipped with appropriate fixtures and furniture DOCUMENT REVIEW Policies and procedures for the safe and efficient direction of patients, their families and visitors and staff traffic.
ER OPD Wards Other Areas ER OPD Imaging Laboratory ICU Other Areas
1 4
1 4
1 2 3 4
1 2 3 4
Document review
__
__
__
ER OPD Note: Take note of the provisions of the policies for use in interview during Wards ICU survey of wards, ER, OPD, ICU, OR, imaging and laboratory. OR/RR/DR/PACU Imaging INTERVIEW Ask nurses and staff regarding policies and procedures for the safe and Laboratory efficient direction of patients, their families and visitors. Verify if answer is Other Areas consistent with written hospital policy. OBSERVATION The staff, patients and visitors follow the policies and procedures. Visiting hours posted may be considered; may also be found in hospital manual
1 2 3 4
1 2 3 4
__
__
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Score Sheet
CODE 2.1.2.f.1
HOSP PHIC
EVIDENCE OBSERVATION Patients, visitors and staff can efficiently and safely move within the confines of the organization (e.g. non-slippery floors, spacious passageways, etc.)
SECTION ER OPD Wards ICU OR/RR/DR/PACU Imaging Laboratory Other Areas Document review
SURVEYOR SCORE 1
REMARKS
__
__
2.2. ENTRY 2.2.1.a.1 __ __
DOCUMENT REVIEW Policies and procedures on patient waiting time
4 2.2.1.a.2 __ __ DOCUMENT REVIEW Monitoring and evaluation reports on patient waiting time Note: Hospitals should set the patient waiting time. 2.2.1.a.3 __ __ INTERVIEW Interview patients from ER, OPD, imaging or laboratory regarding waiting times. Verify the time the patient was seen from ER chart or logbook from ER, OPD, imaging or laboratory Formula: Number of patients who waited based on the prescribed waiting time/total number of patients interviewed x 100 Sample size: Rule of 10 2.2.1.b.1 __ __ Document review DOCUMENT REVIEW Policies and procedures on informing patients for any cause of delay in the delivery of services INTERVIEW Ask patients from ER, OPD, wards, imaging or laboratory if they were informed about possible causes of delay of care if applicable Formula: Number patients informed of the cause of any delay in delivery of services / number of patients with delayed provision of services x 100 Sample size: Rule of 10 2.2.1.c.1 __ __ ER OPD Wards Imaging Laboratory 1 ER OPD Imaging Laboratory Document review 1
4 1
4 1 2 3 4
4 1 2 3 4
4 2.2.1.b.2 __ __ 1 2 3 4
4 1 2 3 4
ER INTERVIEW Ask patients from ER, OPD, imaging or laboratory if they are satisfied with OPD Imaging the waiting time Laboratory Formula: Number of patients satisfied with actual waiting time/total number of patients interviewed x 100 Sample size: 10 patients or 10% whichever is lower DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing patients' clinical needs 2. Policies and procedures in identifying clinical services that will best address patient's clinical needs DOCUMENT REVIEW 1. Policies and procedures in determining and prioritizing admissibility of patients or the need for referral to other organizations 2. Policies and procedures in determining and prioritizing the need for referral to other organizations 3. ER/OPD logbook of admissions and referrals INTERVIEW Ask ER/OPD staff on procedures of admission and referrals Note : identify personnel to be interviewed. May obtain chart from wards and look for the chief complaint, determine admissibility and need for referral. Document review
1 2 3 4
1 2 3 4
2.2.2.a.1 __ __ 2.2.2.b.1 __ __ __ __ __ __ __ __
1 3 4
1 3 4 1 2 3 4
Document review ER OPD
1 2 3 4
__
__
2.2.2.c.1 __ __
DOCUMENT Patient chart from ward and ICU Note: Determine if the service the patient is admitted to coincides with the patient's chief complaint and working diagnosis. Formula: Number of patients correctly assigned to the clinical services appropriate to their needs / total number of patients interviewed x 100 Sample Size: Rule of 10
Wards ICU
1 2 3 4
1 2 3 4
2.2.3.a.1 __ __
DOCUMENT REVIEW Policies and procedures for correctly identifying patients by their chart Footnote: to uniquely identify a patient may mean making the patient number a lifetime number.
Document review
2.2.3.a.2 core
__
__
ER DOCUMENT and INTERVIEW Patient chart from ER, ward, OPD and ICU and verify with patient if he/she OPD Wards really is the person indicated in the chart ICU Formula: Number of charts correctly identified with patient / total number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower
1 4
1 4
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Score Sheet
CODE 2.2.3.b.1
HOSP PHIC
EVIDENCE DOCUMENT Patient chart from ER, OPD, wards and ICU Note: Review patients charts and look for patients complete name, address, birthday, demographic data (sex, age, civil status), hospital number. For newborns, look for parents' names and footprint of the baby, attending physician, room number Formula: Number of charts with unique identifiers/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower
SECTION ER OPD Wards ICU
__
__
REMARKS
2.2.3.c.1 __ __
OBSERVATION Look at how the charts in the OPD, wards and medical records are indexed and arranged in the chart tray Formula: Number of charts properly indexed/Number of charts reviewed x 100 Sample size: 10 charts or 10% whichever is lower
OPD Wards Medical Records
1 2 3 4
1 2 3 4
2.2.4.a.1 __ __
Wards INTERVIEW Ask patient/family from the wards/ICU if they were appropriately informed ICU by authorized qualified personnel (doctor, nurse or other allied medical staff) about the following: their disease, condition or disability, its severity, likely prognosis, benefits and possible adverse effects of various treatment options and the likely cost of treatment Formula: Number of patients/families who were appropriately informed by authorized qualified personnel/Total number of patients/families interviewed x 100 Sample size: 10 charts or 10% whichever is lower
1 2 3 4
1 2 3 4
2.2.4.b.1 __ __
Wards INTERVIEW ICU Ask the patients/relatives from wards or ICU about the following: their disease, condition or disability, its severity, likely prognosis, benefits, and possible adverse effects of various treatment options and the likely costs of treatment Formula: Number of patients/relatives who have knowledge about their disease/total number of patients /relatives interviewed x 100 Sample size: 10 patients or 10% whichever is lower
1 2 3 4
1 2 3 4
2.2.5.a.1 __ __
Wards INTERVIEW Ask patients/relatives if any member of the health care team has informed ICU them of the following: approximate duration of treatment, extent or frequency of reassessment, likely outcomes and need for follow up care after discharge. Note : The surveyor should look for patients who are admitted within the last 48h and are not yet for discharge Formula: Number of patients or their relatives who were informed of approximate duration of treatment , etc/total number of patients or relatives interviewed x 100 Sample size: Rule of 10
1 2 3 4
1 2 3 4
2.2.5.b.1 __ __
INTERVIEW Ask patients and/or relatives if they were informed of the need and availability of resources to continue care after discharge Formula: Number of patients and/or relatives informed of the need and availability of resources to continue care after discharge/total number of patients and/or relatives interviewed Sample size: Rule of 10
Wards ICU
1 2 3 4
1 2 3 4
2.3. ASSESSMENT 2.3.1.a.1 __ core
__
DOCUMENT Patient chart from wards or ER NOTE: comprehensive history includes present illness, review of systems, past medical, family and personal history Formula: Number of charts with comprehensive history and PE within 24 hours from admission/number of charts reviewed x 100 Sample size: Rule of 10
Wards ER
1 4
1 4
2.3.1.b.1 __ __
CHART REVIEW Patient charts from medical records Note: Review charts and look for records of mental status examination, psychological evaluations, nutritional and functional assessments, as applicable Formula : Number of patients who underwent mental status examination, psychological evaluation, nutritional and functional assessment/Number of patients who should have undergone such examinations or assessments x 100 Sample size: Rule of 10
Chart review
1 2 3 4
1 2 3 4
2.3.2.a.1 __ __
DOCUMENT REVIEW Policies and procedures on conducting initial assessments in an efficient and systematic manner
Document review
4 2.3.2.a.2 __ __ __ __ ER INTERVIEW 1. Ask the staff from the ER and wards who did the initial assessments. Wards Verify if the identified staff is qualified. 2. Ask the patient from the ER and wards who did the initial assessments. Verify if the identified staff is qualified. 1 3 4
4 1 3 4
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Score Sheet
CODE 2.3.2.b.1
HOSP PHIC
EVIDENCE INTERVIEW Ask health care professional, e.g.. physician, nurse, PT, etc. how he/she assessed the patient and relate it to the needs of the patient Note: The patient's prioritized needs are based on the priority medical needs as determined by the health care professional.
SECTION ER Wards ICU
SURVEYOR SCORE 1
REMARKS
__
__
2.3.2.c.1 core
__
__
CHART REVIEW Patient chart from medical records Note: The progress notes should be done regularly and documented in the patient chart either as separate 'progress notes' sheets or side notes in the doctor's order sheets. Formula: Number of charts with progress notes by attending health care professional/total number of charts reviewed x 100 Sample size: Rule of 10
Chart review
1 4
1 4
2.3.2.c.2 __ __
CHART REVIEW Patient chart from medical records Note: Look for nurses' progress notes Formula: Number of charts with progress notes by attending health care professional/total number of charts reviewed x 100 Sample size: Rule of 10
Chart review
1 2 3 4
1 2 3 4
2.3.3.a.1 __ __
CHART REVIEW Patient chart from medical records Note: Check if the health professional doing the re-assessment is licensed and qualified.
Chart review
4 Chart review 1 2 3 4
4 1 2 3 4
2.3.3.b.1 __ __
CHART REVIEW Patient chart from medical records Note: Ask for charts with unexpected outcomes/turn of events, e.g. adverse events, morbidities, mortalities. Formula: Number of charts with progress notes/total number of charts reviewed x 100 Sample size: Rule of 10
2.3.3.c.1 __ __
CHART REVIEW Patient chart from medical records Note : Look at the progress notes and doctor's orders. Look for the reassessments done. These should be followed correspondingly by doctor's orders pertaining to the management of the patient (e.g. continue present management, an order for an additional medication, diagnostic or referral)
Chart review
2.3.3.d.1 __ __ 2.3.3.d.2 __ __ __ __
DOCUMENT REVIEW 1. Policies and procedures regarding pre-operative assessment e.g.. cardio-pulmonary clearance 2. Policies and procedures regarding pre-anesthetic assessment CHART REVIEW Patient chart from medical records (surgery patients) Note : Look for pre-operative assessment, e.g.. Cardio-pulmonary clearance Formula : Number of patients with pre-operative assessments performed by qualified personnel / Number of patients for surgery reviewed x 100 Sample size: Rule of 10
Document review
1 2 3 4 1 2 3 4
1 2 3 4 1 2 3 4
Chart review
2.3.3.d.3 core
__
__
CHART REVIEW Patient chart from medical records (surgery patients) Note: Look for pre-operative anesthetic evaluation in the patient chart. Pre-operative assessment should be done for patients requiring more than local anesthesia. Formula: Number of patients with pre-operative assessments performed by qualified personnel / Number of patients for surgery reviewed x 100 Sample size: Rule of 10
Chart review
1 4
1 4
2.3.3.e.1 __ __
CHART REVIEW Patient chart from medical records (surgery patients) Formula: Number of patients with post-operative assessments / Number of patients for surgery reviewed x 100 Sample size: Rule of 10
Chart review
1 2 3 4
1 2 3 4
2.3.4.a.1 __ __
CHART REVIEW Patient chart from medical records Note: Look at progress notes, side notes or doctor's orders. To test for legibility, ask the staff nurses to read the entries of the doctors. Formula : Number of charts with legibly written entries of the initial and ongoing assessments/total number of charts reviewed x 100 Sample size: Rule of 10
Chart review
1 2 3 4
1 2 3 4
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Score Sheet
CODE 2.3.4.b.1
HOSP PHIC
EVIDENCE
SECTION
__
__
ER OBSERVATION Safe and accessible area for keeping of medical records in the wards, ER, OPD Wards OPD and ICU. Records should be safe from unauthorized access. ICU Document review DOCUMENT REVIEW 1. Policies and procedures for the standard performance of diagnostic examinations 2. Policies and procedures for the monitoring of diagnostic examinations 3. Policies and procedures for the quality control of diagnostic examinations Document review 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.) Document review DOCUMENT REVIEW Policies and procedures on accessing and referring patients to approved external providers (outside laboratories, imaging, etc) DOCUMENT REVIEW Logbooks for monitoring referral to approved external providers, monitoring reports or documented actions or Monitoring reports on documented actions e.g. memos Note : Hospitals without policies on referral get an automatic score of 1. Document review
SURVEYOR SCORE 1
REMARKS
4 1 2 3 4
4 1 2 3 4
2.3.5.a.1 __ __ __ 2.3.5.a.2 core __ __ __
1 4
1 4
__
__
2.3.5.b.1 __ __
4 2.3.5.b.2 __ __ 1
4 1
2.3.6.a.1 __ __ __ __
DOCUMENT REVIEW 1. Policies and procedures that identify patients with special needs 2. Policies and procedures that identify the specific type of assessment appropriate to the needs of patients with special needs Note : For hospitals not handling patients with special needs, their policies should clearly indicate this. Footnote: Patients with special needs include infants, school-aged children, adolescents, the elderly and the disabled, victims of alleged sexual abuse or violence, patients with emotional or behavioral disorder, patients with drug dependencies or alcoholism
Document review
1 3 4
1 3 4
2.4 CARE PLANNING 2.4.1.a.1 __ __ __ __ __ __ __ __ __ __ __ __
DOCUMENT Adopted/developed protocols, CPGs or pathways containing goals to be achieved services to be provided patient education strategies to be implemented time frames to be met resources to be used Footnote : Clinical pathways derived from clinical practice guidelines and other types of clinical evidence should be developed or implemented for the top 10 cases of admissions and/or consultations
Wards ICU ER OPD
1 2 3 4
1 2 3 4
2.4.2.a.1 __ __
2.4.2.b.1 __ __
__ 2.4.2.c.1 __
__
Document review DOCUMENT REVIEW Documents (memos, issuances, orders) stating the involvement of a multidisciplinary team (doctors, nurses, dietitians, social worker and other medical and paramedical staff) in the development of protocols, guidelines or pathways Document review DOCUMENT REVIEW 1. Documents (memos, issuances, orders) stating that evidence based approaches (systematic literature search and appraisal using accepted tools) were used in adopting/developing the protocols, CPGs and pathways. 2. Minutes of meetings on development/adoption of the protocols, guidelines or pathways Wards DOCUMENT ICU Patient chart from wards or ICU - doctor's orders Review management if based on practice standards or if expert judgment (specialists) and patient values were considered as needed INTERVIEW Ask doctors their basis for their management, whether they use practice guidelines, protocols, journal articles or books. ER DOCUMENT Documentation of care plan in patient chart (from wards, ICU, ER or OPD) OPD Wards - Look at the following: ICU 1. Detailed clinical history 2. SOAP format 3. Admitting orders 4. Doctor's orders 5. Nurses notes 6. Medication sheet 7. TPR sheet 8. Laboratories DOCUMENT Clinical pathways, algorithms or problem-oriented notes in SOAP format should be incorporated in the chart/medical record Wards
4 1 3 4
4 1 3 4
1 3 4
1 3 4
__
__
__
2.4.3.a.1
__ __ __ __ __ __ __ __ 2.4.3.b.1 __
__ __ __ __ __ __ __ __ __
1 2 3 4
1 2 3 4
4 2.5 IMPLEMENTATION OF CARE 2.5.1.a.1 DOCUMENT REVIEW __ __ Policies and procedures on implementation/compliance to clinical pathways Document review 1
4 1
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Score Sheet
CODE 2.5.1.a.2
HOSP PHIC
EVIDENCE DOCUMENT Ask for charts with clinical pathway-covered conditions. Formula: Number of charts managed according to clinical pathways/total number of charts reviewed Sample size: Rule of 10
SECTION Wards
__
__
REMARKS
2.5.1.b.1 __ __
DOCUMENT REVIEW Policies and procedures on time intervals to act on orders for treatment e.g. doctors orders must be carried out within 30 minutes; time intervals for IV medications DOCUMENT REVIEW Monitoring reports, if none, ask for patient charts and look at the doctors orders and medication sheet INTERVIEW 1. Ask nurses regarding time intervals established by the hospital and how they are implemented 2. Ask patients regarding time intervals of treatment e.g. what time usually are medications given, etc. Note : If hospital has no policy on time intervals to act on orders of treatment, automatic score of 1.
Document review
4 Document review 1 2 3 4
4 1 2 3 4
2.5.1.b.2 __ __
__ __
__ __
2.5.1.c.1 __ __
Chart review CHART REVIEW Patient charts - Verify if orders for referrals (or nonreferrals) are consistent with related CPGs and clinical pathways Formula: Number of charts with referral made according to pathway/ number of charts with referrals x 100 Sample size: Rule of 10
1 2 3 4
1 2 3 4
2.5.1.d.1 __ __
CHART REVIEW Patient charts - Check charts if results of referrals are communicated to relevant members of the health care team and if these are considered in the management Formula: Number of charts with referral communicated to relevant health care team and considered in the management/ number of charts with referrals x 100 Sample size: Rule of 10
Chart review
1 2 3 4
1 2 3 4
2.5.2.a.1 __ __
INTERVIEW Ask patient if he/she received explanations on the nature of a test or treatment, the need for it prior to admission, its likely effects and side effects, and what patients can do to cope with them Formula: Number of patients who received explanation on the nature, necessity, effects, and side effects and coping with side effects of a test or treatment/ number of patients interviewed x 100 Sample size: Rule of 10
Wards
1 2 3 4
1 2 3 4
2.5.2.b.1 __ __
DOCUMENT REVIEW Policy on refusal of test or treatment
Document review
4 2.5.2.b.2 __ __ INTERVIEW Ask patients who wish to decline tests if their wish was respected. Formula: Number of patients whose wish to decline tests or treatments were respected/ number of patients interviewed who declined tests or treatments x 100 Sample size: Rule of 10 Note : If there are no patients (who wish to decline test) around, ask for charts from the medical records section and look for HAMA, DNR, refuse IV, refuse BT, unnecessary drugs or procedures. The signed waiver could be in the doctors orders, progress notes or waiver forms. 2.5.3.a.1 __ __ __ __ Document review DOCUMENT REVIEW 1. Policies and procedures indicating extent of duplicate assessments and treatments performed by trainees 2. Policies and procedures indicating the extent of duplicate assessments and treatments performed by trainees respect patients' rights Document review DOCUMENT REVIEW Monitoring reports in compliance to policies and procedures on duplicate Leadership meeting assessments and treatments INTERVIEW Interview management or QA team on how they monitor compliance to the policies DOCUMENT REVIEW Policies and procedures promoting interactive, appropriate and relevant educational programs for patients DOCUMENT Look at the doctor's orders in the patient chart for the documentation of patient education (wards). Note : The word 'advised' is sufficient proof of compliance. INTERVIEW Ask patient if they were advised/educated by any of the health care team. Cross refer to patient's chart if relevant and appropriate Note : Health care professionals are not limited to doctors only. It also includes nurses, physical therapists, dentists, etc. Document review 1 1 3 4 Wards ICU 1 2 3 4
4 1 2 3 4
1 3 4
2.5.3.a.2 __ __
1 3 4
1 3 4
__ 2.5.4.a.1 __
__
__
4 2.5.4.a.2 __ __ OPD Wards 1 3 4
4 1 3 4
__
__
8 of 23
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Score Sheet
CODE 2.5.4.a.3
HOSP PHIC
EVIDENCE DOCUMENT REVIEW Approved budget to support patient educational programs OBSERVATION Presence of materials, equipment, structures to support the patient educational programs e.g.. LCD, posters, venue INTERVIEW Ask patients their role and responsibilities in their health Formula: Number of patients aware of their roles and responsibilities in their care/number of patients interviewed x 100 Sample size: Rule of 10
SECTION Document review Wards Other Areas
SELFASSESSMENT SCORE 1 3 4
SURVEYOR SCORE 1 3 4
REMARKS
__
__
__ 2.5.4.b.1 __
__
__
OPD Wards
1 2 3 4
1 2 3 4
2.5.5.a.1 __ __
DOCUMENT REVIEW Policies and procedures on drug administration
Document review
4 2.5.5.a.2 core __ __ Chart review CHART REVIEW Patient chart from the medical records 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 Formula: Number of drugs administered to the right patient at the correct time, manner, and route/number of drugs x 100. Sample size: 10 drugs (may come from different charts) Note: Surveyor may also check for administration of any of the following: antibiotics, anticonvulsants, MgSO4, KCl drip and other drips, calcium gluconate, sodium bicarbonate, etc. For oral medications, do direct observation 2.5.5.b.1 __ __ __ 2.5.5.b.2 __ __ __ __ __ __ __ Document review DOCUMENT REVIEW 1. Policies and procedures for training of professionals who administer drugs 2. Policies and procedures for supervision of professionals who administer drugs 3. Policies and procedures for evaluation of professionals who administer drugs DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who administer drugs 2. Training plan, training modules/materials, evaluation forms Note : Use organizational chart as guide/reference. OBSERVATION Observe presence of related structures present, e.g.. training room, conference room, libraries DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who administer drugs 2. Evaluation reports of professionals who administer drugs 3. Proof of training, e.g.. certificates of training INTERVIEW Ask leaders how the supervision of professionals who administer drugs are conducted INTERVIEW Randomly check the licenses of doctors, nurses and pharmacists if they are updated Formula: Number of doctors, nurses and pharmacists with updated licenses/number of doctors, nurses and pharmacists interviewed x 100 Sample size: Rule of 10 2.5.5.c.2 __ __ CHART REVIEW Doctor's orders in patient chart from the medical records Orders that were made by interns should be countersigned by licensed residents or consultants Formula: Number of charts with orders for drug administration made by licensed doctors/number of charts reviewed x 100 Sample size: Rule of 10 2.5.5.d.1 __ __ __ __ Document review DOCUMENT REVIEW Leadership meeting 1. Policy on regular review of prescription orders 2. Evaluation reports by nurses/doctors in the floors, clinical pharmacist or therapeutics committee or minutes of meeting of the therapeutics committee INTERVIEW Ask leaders about utilization review activities, audit/peer review, other activities where appropriateness and safety of drug use are discussed Footnote: This is to ensure that prescriptions are written correctly (e.g.. in generic form), and that precautions for drug-drug and drug-food interactions have been adequately addressed. 1 2 3 4 Chart review 1 2 3 4 Wards Pharmacy ER OPD 1 4 Document review Leadership meeting 1 2 3 4 Document review Other areas 1 2 3 4 1 4
4 1 4
1 2 3 4
1 2 3 4
1 2 3 4
__ 2.5.5.b.3 __ __ __
__
__ __ __
1 2 3 4
__ 2.5.5.c.1 core
__
1 4
__
__
1 2 3 4
1 2 3 4
__
__
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Score Sheet
CODE 2.5.5.e.1 core
HOSP PHIC
EVIDENCE DOCUMENT Procedures on verification of prescriptios and orders INTERVIEW Ask staff how they verify orders from doctors prior to drug administration OBSERVATION 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
SECTION Wards ER ICU
SURVEYOR SCORE 1 4
REMARKS
__
__
__
__
__
__
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Score Sheet
CODE 2.5.5.e.2 core
HOSP PHIC
EVIDENCE 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 DOCUMENT REVIEW Policies and procedures regarding telephone orders
SECTION Wards ER ICU
SURVEYOR SCORE 1 4
REMARKS
__
__
__ 2.5.5.f.1 __
__
Document review
__
4 2.5.5.f.2 __ __ Wards DOCUMENT Look at the telephone orders in the charts. Take note of the time of receiptICU of order and time of countersigning; validate with hospital standard/policy Note : All telephone orders should be countersigned within 24 hours or within the time set by the hospital Formula: Number of countersigned telephone orders/number of telephone orders x 100 (should be applied per chart; overall rating for the indicator will be the mean of ratings) Sample size: Rule of 10 2.5.5.g.1 __ __ 2.5.5.g.2 __ __ __ __ DOCUMENT REVIEW 1. Policies and procedures on retrieval of drugs 2. Policies and procedures on safety disposal of drugs DOCUMENT Look for documents such as memos, issuances or receipts showing that recalled or discontinued drugs are either returned to manufacturers/distributors or disposed of properly. INTERVIEW Ask staff the actual practice of retrieval and safe disposal of recalled or discontinued drugs. OBSERVATION Ask staff to show where they dispose recalled, discontinued or expired drugs. DOCUMENT REVIEW 1. Policies and procedures on drug selection and procurement 2. Policies and procedures on drug selection and procurement are consistent with scientific evidence 3. Policies and procedures on drug selection and procurement are consistent with government policies e.g.. National Drug Policy INTERVIEW Ask the members of therapeutics committee regarding manner of selection and procurement of drugs OBSERVATION Observe actual supply of drugs in the pharmacy in accordance with the organization's policies CHART REVIEW Medication sheet in patient chart from medical records Formula: Number of charts with proper documentation of drug administration/total charts reviewed x 100 Sample size: rule of 10 2.5.5.j.1 __ __ __ 2.5.5.j.2 __ __ 2.5.6.a.1 __ __ 2.5.6.a.2 __ __ __ __ __ __ __ __ __ __ __ DOCUMENT REVIEW 1. Policies and procedures for detecting adverse effects 2. Policies and procedures for reporting adverse effects 3. Policies and procedures for monitoring adverse effects Document review 1 2 3 4 1 3 4 1 3 4 1 2 3 4 Chart review 1 4 Document review Leadership meeting Pharmacy 1 2 3 4 Document review 1 3 4 Pharmacy Wards 1 2 3 4 1 2 3 4
4 1 2 3 4
1 3 4 1 2 3 4
__
__
__ 2.5.5.h.1 __ __ __
__
__ __ __
1 2 3 4
__
__
__ 2.5.5.i.1 core
__
1 4
__
__
1 2 3 4 1 3 4 1 3 4 1 2 3 4
Document review DOCUMENT REVIEW 1. Forms for reporting incidents, adverse drug events, sentinel events or adverse events 2. Regular monitoring reports on adverse events Document review DOCUMENT REVIEW 1. Policies on treatment procedures, clinical pathways, CPGs, flowcharts or algorithms 2. For hospitals with operating rooms: WHO surgical safety checklist is included in the policies on treatment procedures DOCUMENT 1. Review patient chart and verify appropriateness of treatment procedures. 2. For hospitals with operating rooms: WHO surgical safety checklist is incorporated in the charts of surgery patients INTERVIEW 1. Ask staff how they ensure performing treatment procedures in a timely manner. 2. Ask staff how they ensure performing procedures in a safe and controlled manner 3. Ask patients/caregivers how certain procedures such as IV insertion, catheterization were done? Note : Treatment procedures include but are not limited to appendectomy, CS, hydration for AGE, suturing, excision, incision and drainage, thoracotomy, chest tube insertion, IV insertion Wards ICU OR/RR/DR/PACU ER
__ __ __
__ __ __
2.5.6.b.1 __ __ __ __ __ __
DOCUMENT REVIEW 1. Policies and procedures for training of professionals who perform the procedures 2. Policies and procedures for supervision of professionals who perform the procedures 3. Policies and procedures for evaluation of professionals who perform the procedures
Document review
1 2 3 4
1 2 3 4
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Score Sheet
CODE 2.5.6.b.2
HOSP PHIC
EVIDENCE DOCUMENT REVIEW 1. Budget allocated for training, supervision and evaluation of professionals who perform procedures 2. Training plan, training modules/materials, organizational chart, evaluation forms OBSERVATION Observe related structures present, e.g.. training room, conference room, libraries DOCUMENT REVIEW 1. Reports on performance monitoring of professionals who perform the procedure or evaluation reports 2. Proof of training, e.g.. certificates of training INTERVIEW Validate with leaders regarding supervision of performance of procedures and training. DOCUMENT Verify from patient chart if the orders for treatment procedures were performed by qualified personnel Formula: Number of charts with orders for treatment procedures performed by qualified personnel/number of charts reviewed x 100 Sample size: rule of 10
SECTION Document review Other areas
__ __
__ __
REMARKS
__ 2.5.6.b.3 __ __
__
__ __
1 2 3 4
1 2 3 4
__ 2.5.6.c.1 __
__
__
Wards ICU
1 2 3 4
1 2 3 4
2.5.6.d.1 __ __
INTERVIEW Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly identified prior to performance of procedures OBSERVATION Observe if staff verifies the orders for procedures with the doctor and how the staff identify the patients e.g.., arm banding DOCUMENT Verify from doctor's orders in patient chart the legibility and accuracy of documentation of treatment procedures. Ask the nurse/hospital staff to read the orders from the chart. Formula: Number of charts with legibly and accurately documented treatment procedures / total number of charts reviewed with procedures x 100 Sample size: rule of 10
ER Wards OR/RR/DR ICU
1 3 4
1 3 4
__ 2.5.6.e.1 __
__
__
Wards ICU ER
1 2 3 4
1 2 3 4
2.5.6.f.1 __ __ __ __ __ __ __ __ __ __
Document review Facilities and Maintenance Imaging Laboratory
1 2 3 4
1 2 3 4
2.5.6.g.1 __ __ __ __
__ __
__ __
DOCUMENT REVIEW 1. Policies and procedures on selection and procurement of medical devices and equipment 2. Policies and procedures on selection and procurement of medical devices and equipment are based on organization's case mix, staff expertise, and service capability 3. Policies and procedures on selection and procurement of medical devices and equipment are consistent with scientific evidence 4. Policies and procedures on selection and procurement of medical devices and equipment are consistent with government policies DOCUMENT REVIEW List of equipment procured the previous year/s. Check if procured according to policies and procedures. INTERVIEW Ask management team regarding basis for procurement of the listed equipment DOCUMENT Policies and procedures that govern care of patients with special needs Examples: care of pregnant patients in radiology department, care of victims of sexual or child abuse in the ER Footnote: Patients with special needs include infants, school-age children, adolescents, the elderly and the disabled, victims of alleged or suspected sexual abuse or violence, patients with emotional or behavioral disorders, patients with drug dependencies or alcoholism
Document review
1 2 3 4
1 2 3 4
2.5.6.g.2 __ __
1 3 4
1 3 4
__ 2.5.7.a.1 __
__
Document review
__
2.6 EVALUATION OF CARE 2.6.1.a.1 DOCUMENT REVIEW Process and outcomes data reports such as but not limited to: __ __ 1. medical audit reports __ __ 2. morbidity and mortality reports __ __ 3. hospital infection data __ __ 4. adverse event reports __ __ 5. evaluation reports of diagnostics, procedures and treatment __ __ 6. other reports: disposition data, variance reports, etc
Document review
1 2 3 4
1 2 3 4
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Score Sheet
CODE 2.6.1.b.1
HOSP PHIC
__
__
__
__
SELFASSESSMENT SCORE Document review DOCUMENT REVIEW 1 1. Budget or resource allocation for collection of data related to process Leadership meeting 2 and outcomes of care such as the following: medical audit, morbidity and 3 mortality reports, adverse event and hospital infection data, etc 4 2. Budget or resource allocation for analysis of data related to process and outcomes of care such as: medical audit, mortality and morbidity conferences, etc EVIDENCE SECTION INTERVIEW Ask QA committee what are the resources provided by the organization for CQI activities DOCUMENT REVIEW Documents showing that results of evaluation of care are fed back to concerned health care providers such as issuances, memos or reports INTERVIEW Verify with health care providers if they were given the results of the evaluation of care Document review DOCUMENT REVIEW Documents showing that results of evaluation of care were presented and Leadership meeting discussed in meetings of top management such as issuances, memos, directives, excerpts/minutes/agenda of meetings INTERVIEW Ask management team if the QA committee presents and discusses the results of evaluation DOCUMENT REVIEW Policies /memo/ letters regarding any collaborative performance improvement activities as a result of evaluation of care INTERVIEW Verify with health care team if there are performance improvement activities as a stemming from results of evaluation of care. Document review DOCUMENT REVIEW Minutes of QA committee meetings, reports, memoranda/ orders/policies Leadership meeting emanating from resolution of cases INTERVIEW Ask leaders on QI activities, specific cases brought to the attention of the QC/QT DOCUMENT REVIEW Reports of CQI activities INTERVIEW Validate with QA committee members regarding the (4) elements of CQI activities Chart review CHART REVIEW Patient chart from medical records, look at the discharge orders. It 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 Formula: Number of charts with discharge plans/number of charts reviewed x 100 Sample size: Rule of 10 Note : Discharge plan is not synonymous with discharge summary Document review Leadership meeting 1 3 4 1 3 4 Document review Leadership meeting 1 3 4 1 3 4 Document review Wards 1 3 4
REMARKS
__ 2.6.1.c.1 __
__
1 3 4
__
__ 2.6.1.d.1 __
__
1 3 4
__
__
__
2.6.2.a.1 __ __
1 3 4
__ 2.6.3.x.1 __
__
1 3 4
__
__ 2.6.3.x.2 __
__
1 3 4
__
__ 2.7. DISCHARGE 2.7.1.x.1 __ core
__
1 4
1 4
__
2.7.2.x.1 __ __
Wards INTERVIEW Ask patients how they were informed of the continuing management plan, ICU may ask about home medications (if applicable), follow up visits/schedule and other home care/advise. Use chart of the patient as reference during interview. Wards INTERVIEW Ask staff how they inform other health care providers regarding continuing ICU management plans for referred patients. Use chart of patient as reference during interview. DOCUMENT Patient chart - check for discharge orders and arrangements, referral forms to community health services (e.g. RHU, CHO) Footnote: Examples of other relevant community health services include, but are not limited to, RHUs, Botika sa Barangay, etc. INTERVIEW Ask staff how such arrangements are made, who is in charge, what facilities they make arrangements with for provision of health care services; validate answers to such with the patients INTERVIEW Ask patients if they are aware of the appropriate services in the community before discharge Wards ICU Wards ICU
4 1
4 1
2.7.2.x.2 __ __
4 1 3 4
4 1 3 4
2.7.3.x.1 __ __
__
__
2.7.3.x.2 __ __
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Score Sheet
CODE 2.7.4.x.1
HOSP PHIC
EVIDENCE INTERVIEW Ask patients about their knowledge and understanding of the care plan and their responsibilities for continuing management Formula: Number of patients who understand their discharge plans and responsibilities for continuing management / total number of patients for discharge interviewed x 100 Sample size: rule of 10 Note : Interview patients for discharge. If there are no in-patients for discharge, interview patients from the OPD or ER.
SECTION Wards ICU
__
__
REMARKS
3. LEADERSHIP AND MANAGEMENT 3.1 THE MANAGEMENT TEAM 3.1.1.x.1 DOCUMENT REVIEW __ __ Organizational structure/chart or manual of operations OBSERVATION Observe if the organizational structure/chart is posted conspicuously in appropriate areas (Lobby) INTERVIEW Ask 10 staff to identify the management team (hospital director or chief of hospital or chief health officer together with the administrative officer or administrator and service/department heads) Formula: Number of staff aware of their leadership/total number of staff interview x 100 Sample size: Rule of 10 3.1.2.x.1 __ __
Document review Other Areas (Lobby)
1 3 4
1 3 4
__ 3.1.1.x.2 __
__
__
ER OPD Wards Imaging Laboratory Pharmacy HRD Other Areas
1 2 3 4
1 2 3 4
Document review DOCUMENT REVIEW Reports on the results of staff satisfaction survey, and should include the following: analysis, conclusion and recommendation DOCUMENT REVIEW 1. Documentation of team building activities Examples: christmas party, sports activities, outing, etc. 2. Community outreach program Examples : medical mission, charity service, special clinic, community service DOCUMENT REVIEW Proof of the creation of all committees which includes the terms of reference for membership e.g. memo, office order, etc INTERVIEW Ask leaders what the committees in their hospital are and ask for the order that created these committees Document review DOCUMENT REVIEW 1. Minutes of meetings for Quality Assurance Committee (level 1, 2, 3 and Leadership meeting 4) 2. Minutes of meetings for Therapeutics Committee (level 2, 3 and 4) 3. Minutes of meetings for Infection Control Committee (level 3 and 4) 4. Minutes of meetings for other committees Note: Level I hospitals may not necessarily have TC or infection committee, but there should at least be 2 persons looking at the use of therapeutic drugs & infection control INTERVIEW Committee members to validate the above activities Document review
4 3.1.2.x.2 __ __ __ __ 1 3 4
4 1 3 4
3.1.3.x.1 core
__
__
1 4
1 4
__ 3.1.3.x.2 __ __ __ __
__
__ __ __ __
1 2 3 4
1 2 3 4
__ 3.1.4.x.1 core
__ DOCUMENT REVIEW Documentation of evaluation activities to assess management and organizational performance such as monthly, quarterly, semestral or annual reports as applicable 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 DOCUMENT REVIEW 1. Written vision 2. Written mission 3. Written goals Note: Content of the Vision, Mission & Goals should include addressing the health needs of the community. Document review 1 2 3 4 1 2 3 4 Document review Leadership meeting 1 4 1 4
__
__
__ __ 3.1.5.a.1 __ __ __
__ __
__ __ __
3.1.5.a.2 __ __
INTERVIEW Ask the management team about how the vision and mission were developed. Note: Content of the Vision, Mission & Goals should include addressing the health needs of the community.
Leadership meeting
3.1.5.b.1 __ __ __ __ __ __ __ __
DOCUMENT REVIEW 1. Written by-laws 2. Policies and procedures 3. Written by-laws are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities 4. Policies and procedures are consistent with goals, statutory requirements, accepted standards and community and regional responsibilities INTERVIEW Ask leaders how their by-laws, policies and procedures were developed
1 2 3 4
1 2 3 4
__
__
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Score Sheet
CODE 3.1.5.c.1
HOSP PHIC
EVIDENCE DOCUMENT REVIEW 1. Memos or issuances on review and/or revision of policies 2. Minutes of meetings on the review and/or revision of policies INTERVIEW Ask leaders how they review and revise policies and procedures DOCUMENT REVIEW 1. Communication or dissemination plans for policies and procedures 2. Attendance to orientation/information dissemination activities
__ __
__ __
SELFASSESSMENT SCORE Document review 1 Leadership meeting 2 3 4 SECTION
REMARKS
__ 3.1.5.d.1 __ __
__ __ __
__ __ __ __
__ __ __ __
ER OPD INTERVIEW 1. Ask leaders about how the vision/mission statement are communicated Wards Pharmacy to the hospital staff. 2. Ask leaders about how policies and procedures are communicated to HRD Imaging all levels of workforce. 3. Ask leaders and staff about their knowledge of organizations' by-laws, Laboratory Other areas policies and procedures 4. Ask staff (from different levels) about their knowledge of certain policies and procedures Document review DOCUMENT REVIEW Proof of designation of a person responsible for information dissemination Leadership meeting INTERVIEW Ask leaders who the responsible person for information dissemination is
1 2 3 4
1 2 3 4
3.1.5.d.2 __ __
1 3 4
1 3 4
__
__
3.2 EXTERNAL SERVICES 3.2.1.x.1 DOCUMENT REVIEW __ __ 1. Contracts/MOA for outsourced services core __ __ 2. Valid licenses of all providers of the outsourced services 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
Document review Imaging Laboratory Other areas
1 4
1 4
__
__
4. HUMAN RESOURCE MANAGEMENT 4.1 HUMAN RESOURCES PLANNING 4.1.1.a.1 DOCUMENT REVIEW Job descriptions of personnel specifying the following: __ __ 1. functions __ __ 2. duties and responsibilities and the __ __ 3. required qualifications and competencies 4.1.1.b.1 __ __ DOCUMENT REVIEW Policies and procedures for hiring of staff INTERVIEW Ask appropriate personnel a certain procedure for hiring of staff. Note: The surveyor can randomly pick out a doctor, a nurse, an admin staff, both newly hired or old, and ask them the process of selection, hiring and screening and performance appraisal; when was it last conducted and by whom. 4.1.1.b.2 core 4.1.2.a.1 __ __ __ __ DOCUMENT REVIEW Policies and procedures for credentialing and privileging of staff DOCUMENT REVIEW List of personnel, staffing pattern, or documents related to the HR inventory system Note: The hospital may document and analyze information like daily patient loads, utilization rates and services, turn-around times to determine staff size and mix. INTERVIEW Ask appropriate personnel (e.g. HR manager) how the right number and mix of competent staff are maintained to meet the needs of internal and external clients. DOCUMENT REVIEW Employee report card or its equivalent (e.g.. DTR, logbook)
Document review
1 2 3 4 1 3 4
1 2 3 4 1 3 4
Document review HRD Wards
__
__
Document review
1 4 1 3 4
1 4 1 3 4
Document review Leadership meeting HRD
__
__
4.1.2.a.2 __ __
Document review
4 4.1.2.a.3 core __ __ __ __ __ __ DOCUMENT REVIEW 1. List of total number of licensed doctors, 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 registered with DOH and actually being used. OBSERVATION Number of beds. Document review DOCUMENT REVIEW HR contingency plan e.g. recall system to address inadequate staff due to HRD absences, leaves, resignations and increased patient load Wards ER INTERVIEW Ask HR, Wards and ER staff: 1. What happens when one staff is absent? 2. When one staff goes AWOL? 3. When there are too many patients? 4. What is the back up system to maintain appropriate number of staff? 1 2 3 4 Document review Wards 1 4
4 1 4
__ 4.1.2.b.1 __
__ __
1 2 3 4
__ __ __ __
__ __ __ __
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Score Sheet
CODE 4.1.2.b.2
HOSP PHIC
EVIDENCE DOCUMENT REVIEW 1. Mandatory Monthly Hospital Report (take note of Maximum Bed Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate exceeding 100% to identify occasions of increased patient load); 2. Actual plan and monitoring report showing how the increased patient load was addressed. INTERVIEW Ask HR, doctors, nurses and staff how the appropriate number of staff was maintained and what monitoring procedure was made?
SECTION Document review HRD Wards ER Imaging Laboratory OR/RR/DR/PACU
__
__
REMARKS
__
__
__
__
4.2 STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES Document review 4.2.1.a.1 DOCUMENT REVIEW __ __ 1. Policies and procedures governing personnel recruitment, selection HRD and appointments. __ __ 2. Memos/endorsements reflecting the dissemination of policies and Wards procedures governing personnel recruitment, selection and appointments. 3. Actions of the board/owner e.g. those reflected in its minutes, __ __ resolutions, etc. showing that the organization ensures compliance to policies and procedures on personnel recruitment, selection and appointments. INTERVIEW Interview HR and wards staff for validation if the organization's policies and procedures on personnel recruitment, selection and appointments are actually being implemented. DOCUMENT REVIEW Corporate policy on recruitment, selection and appointment of staff Document review
1 2 3 4
1 2 3 4
__
__
4.2.1.b.1 __ __
__ __
__ __
__ 4.2.1.c.1 __
__
Wards ER INTERVIEW OPD 1. Ask leaders and staff on the process of hiring, re-hiring and firing. It HRD should be known to all staff and managers. 2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities and Imaging Laboratory maintenance and other areas for what conditions will lead to their firing Facilities and 3. Ask staff regarding the process of their selection Maintenance Other areas Document review DOCUMENT REVIEW 1. Special/Office Orders or similar issuances defining the membership of Leadership meeting the body/committee/group tasked to develop and implement personnel recruitment, selection and appointment; 2. Proof/minutes of meetings 3. Attendance of members INTERVIEW Ask leaders which team screens and appoints people and how members of the team are selected. DOCUMENT REVIEW Committee reports on selection and appointment Document review
1 2 3 4
1 2 3 4
__
1 2 3 4
1 2 3 4
__ __
__ __
__ 4.2.1.d.1 __
__
__
4 4.2.1.e.1 __ __ ER OPD Wards ICU OR/RR/DR Formula: Number of professionals with updated licenses/number of Imaging professionals randomly selected x 100 Sample size: At least 10 professional staff or 10% of the total professional Laboratory Pharmacy staff Other areas OBSERVATION Ask personnel from each area to present their current licenses or PRC claim stub for PRC cards that are still being processed Document review DOCUMENT REVIEW 1. Certificates of attendance to trainings and formal continuing education for personnel; 2. Monitoring reports on CME and training of staff DOCUMENT Written job descriptions signed by the newly appointed personnel. INTERVIEW 1. Interview newly-hired staff to determine if they received their written job description 2. Ask staff if the job descriptions were discussed with them particularly on their accountabilities and responsibilities that specifies their role and how it contributes to the attainment of the goals and maintaining quality of care Note: Newly-hired personnel is defined as those who are appointed/hired within the previous 6 months. If no newly appointed staff is available, the surveyor may interview the most recently hired staff. 4.2.3.a.1 __ __ DOCUMENT REVIEW Written job description and/or relevant document defining the job functions, accountabilities and responsibilities of personnel and the corresponding credentials, training and experience required and match this with the credentials of the doctor/nurse/staff chosen for the job. Formula: Number of staff with job description matching their credentials, training and experience/number of staff interviewed x 100 Sample size: Rule of 10 Document review 1 2 3 4 HRD 1 2 3 4
4 1 2 3 4
4.2.1.f.1 __ __ 4.2.2.a.1 __ __ __ __
1 3 4 1 2 3 4
1 3 4 1 2 3 4
__ __
__ __
1 2 3 4
4.2.4.a.1 __ __
DOCUMENT PRC License and all appropriate certifications of training Formula: Number of doctors, nurses and midwives with current licenses and certifications of training/number of doctors, nurses and midwives x 100 Sample size: Rule of 10
ER OPD Wards ICU OR/RR/DR Imaging Laboratory Pharmacy
1 2 3 4
1 2 3 4
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Score Sheet
CODE 4.2.4.b.1
HOSP PHIC
EVIDENCE DOCUMENT PRC License or related documents (e.g.. certificate of training) Formula: Number of administrative staff with current licenses/ number of administrative staff who should have license x 100 Sample size: Rule of 10
SECTION Medical Records HRD Other areas
__
__
REMARKS
4.2.4.b.2 __ __
DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Certificate of training will do since in small hospitals. Sometimes it is the owner who possesses a different license is doing the work due to his/her training certificate for the present job. Example of business staff: accountant Formula: Number of business staff with current licenses/number of business staff who should have license x 100 Sample size: Rule of 10
HRD Other areas
1 2 3 4
1 2 3 4
4.2.4.b.3 __ __
DOCUMENT PRC License or related documents (e.g.. certificate of training) Note: Example of technical staff: engineer Formula: Number of technical staff with current licenses /number of technical staff who should have license x 100 Sample size: Rule of 10
Facilities & Maintenance Imaging Laboratory Other areas
1 2 3 4
1 2 3 4
4.3 STAFF TRAINING AND DEVELOPMENT 4.3.1.a.1 DOCUMENT REVIEW __ __ TNA report or its equivalent
Document review
4 4.3.1.a.2 __ __ Document review DOCUMENT REVIEW Annual plan (including resource/budgetary allocation) on training activities 1
4 1
4 4.3.1.b.1 __ __ DOCUMENT REVIEW Policies and procedures on orientation of new employees to general hospital policies INTERVIEW Randomly pick newly hired doctor, nurse, admin staff and ask them how they were oriented. Document review Wards ER OPD HRD Imaging Laboratory Facilities and Maintenance Other areas Document review 1 3 4
4 1 3 4
__
__
4.3.1.c.1 __ __
DOCUMENT REVIEW Evaluation reports on the training and development program
4 4.3.1.c.2 __ __ DOCUMENT REVIEW End of training assessment report or its equivalent Document review 1
4 1
4 4.3.2.a.1 __ __ DOCUMENT Organizational chart INTERVIEW Ask new personnel about the lines of authority and supervision and if the supervision is adequate DOCUMENT REVIEW Written job descriptions with conforme Formula: Number of written job descriptions with conforme/number of written job descriptions reviewed Sample size: Rule of 10 5. INFORMATION MANAGEMENT 5.1 DATA COLLECTION, AGGREGATION AND USE 5.1.1.a.1 DOCUMENT REVIEW __ __ Policies and procedures on data collection relevant to delivery of patient care and management of services 5.1.1.b.1 __ __ __ __ __ __ __ __ Document review HRD 1 3 4
4 1 3 4
__ 4.3.2.b.1 __
__
__
1 2 3 4
1 2 3 4
Document review
4 Document review DOCUMENT REVIEW 1. Annual Hospital Statistical Reports 2. Annual reports submitted to the DOH 3. MMHR submitted to PhilHealth 4. Other additional statistics as determined by the management or hospital forms that serve as data aggregation instruments or data sets and methods in preparation for statistical reports Document review DOCUMENT REVIEW 1. Proof of training/seminar or certificate on records management of staff Medical records involved in data definition 2. Document (memo or issuance) designating a staff for data definition, generation, collection and aggragation INTERVIEW Interview staff regarding their qualifications and functions DOCUMENT REVIEW 1. Policies and procedures to monitor the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations 2. Policies and procedures to improve the accuracy, completeness and reliability of relevant qualitative and quantitative data relating to its operations Document review 1 3 4 1 2 3 4
4 1 2 3 4
5.1.1.b.2 __ __ __ __
1 2 3 4
1 2 3 4
__ 5.1.1.c.1 __
__ __
1 3 4
__
__
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Score Sheet
CODE 5.1.1.d.1
HOSP PHIC
__
__
SELFASSESSMENT SCORE Document review 1 DOCUMENT REVIEW Plans, which include the budget for procurement of computers, software Leadership meeting 2 and other resources (including training for data management), research 3 outputs, reports or budget execution report showing that such budget has Medical records 4 been disbursed EVIDENCE SECTION INTERVIEW Ask leaders the content of plans and actual activities pertaining to collection, maintenance, processing and analysis of data OBSERVATION Presence of computers, software, personnel, storage area for hard copies of records Document review DOCUMENT REVIEW Policies and procedures on record storage, safekeeping and maintenance, retention and disposal Note: Policies and procedures on records management are updated every 5 years 1 4
REMARKS
__
__
__ 5.1.1.e.1 core
__
1 4
__
__
5.1.2.a.1 __ __ __ __
DOCUMENT REVIEW 1. MMHR - Submitted every 10th day of the succeeding month 2. DOH reports - annual statistical reports Note: For annual reports, look for the reports of the previous year, for quarterly reports, previous quarter
Document review
1 3 4
1 3 4
5.1.3.a.1 __ __
CHART REVIEW Patient charts from medical records (surgical and medical cases) Formula: Number of properly accomplished patient records/Number of records retrieved Sample size: 10 charts or 10%, whichever is lower Scoring for properly accomplished charts 1. legibility 2. date, time & signature 3. completeness of entries (SOAP, review of systems, medication treatment) Note: Documentation in patient charts should be sufficiently detailed to enable any member of the health care team to understand care plans and care provision. Clinical pathways are excellent means to achieve this.
Chart review
1 2 3 4
1 2 3 4
5.1.3.b.1 __ __
DOCUMENT REVIEW Checklist for the completeness of the chart accomplished by the records officer or other proof that charts are routinely checked for completeness and accuracy.
Document review
4 1 3 4
4 1 3 4
5.1.4.a.1 __ __
__
__
Document review DOCUMENT REVIEW 1. Policies & procedures on routine collection and aggregation of data from patient charts for use in quality improvement, administrative purposes and for mandatory reporting to Department of Health and PhilHealth 2. Policies & procedures on routine reporting of data from patient charts for use in quality improvement, administrative purposes and for mandatory reporting to Department of Health and PhilHealth DOCUMENT REVIEW Minutes of Quality Circle Meetings or Report/s on status of routine data collection and aggregation from patient charts INTERVIEW Ask leaders on procedures on collection and aggregation of data from patient charts for purposes of quality improvement activities, administrative and mandatory reporting to DOH and PhilHealth Document review Leadership meeting
5.1.4.a.2 __ __
1 3 4
1 3 4
__
__
5.2 RECORDS MANAGEMENT Document review 5.2.1.a.1 DOCUMENT REVIEW __ __ Policies and procedures on systematic filing, retrieval and management of core medical records 5.2.1.a.2 __ __ OBSERVATION Ask the records keeper to retrieve a chart, then note the actual length of time of retrieval Formula: Number of charts retrieved within the time interval set by the organization/Number of charts retrieved x 100 Sample size: Rule of 10 Note: If organization has not set a time interval, use 15 minutes. 5.2.1.b.1 core __ __ Document review DOCUMENT REVIEW Policies and procedures on records management for the entire hospital to Wards maintain privacy, accuracy and prevent loss and destruction Medical records OBSERVATION Observe nurses in the wards and records personnel on how they protect patient chart against loss, tampering and unauthorized use DOCUMENT Logbooks for borrowing and retrieval of charts Medical records Medical records
1 4 1 2 3 4
1 4 1 2 3 4
1 4
1 4
__ 5.2.1.b.2 __
__
__
4 6. SAFE PRACTICE AND ENVIRONMENT 6.1 PATIENT AND STAFF SAFETY 6.1.1.a.1 DOCUMENT REVIEW __ __ 1. Updated DOH license core __ __ 2. If facility has nuclear medicine, ask for the certificate issued by the Philippine Nuclear Research Institute (PNRI)
Document review
1 4
1 4
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Score Sheet
CODE 6.1.1.b.1 core
HOSP PHIC
EVIDENCE
SECTION
__ __ __ __ __ __ __
__ __ __ __ __ __ __
Document review DOCUMENT REVIEW Management plan which includes policies, procedures and programs, risk assessment, hazard 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
SURVEYOR SCORE 1 4
REMARKS
6.1.1.c.1 __ __
DOCUMENT Management plan which includes policies / procedures and programs such as equipment maintenance programs for safe and efficient use of medical equipment DOCUMENT Operating manuals for the medical equipment
Document review
4 ER OPD Wards ICU OR/DR/RR Facilities and maintenance Imaging Laboratory Other areas Document review Leadership meeting 1 4
4 1 4
6.1.1.c.2 core
__
__
6.1.2.a.1 __ __ __ __ __ __ __ __ __ __ __ __ __ __
DOCUMENT REVIEW Policies and procedures that address the following: 1. Safety 2. Security 3. Control of hazardous material and biological wastes (including the implementation of the gradual phase-out of mercury) 4. Emergency and disaster preparedness 5. Fire safety 6. Radiation safety 7. Utility systems safety Existence of safety programs such as: 1. Electrical safety 2. Medical device safety 3. Chemical safety 4. Radiation safety 5. Mechanical safety 6. Water safety 7. Combustible material safety 8. Waste management 9. Hospital safety program (fire, emergency and disaster preparedness) 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
1 2 3 4
1 2 3 4
__ __ __ __ __ __ __ __ __
__ __ __ __ __ __ __ __ __
__ __
__ __
6.1.2.a.2 core
__ __ __
__ __ __
__
__
__ __
__ __
Document review DOCUMENT REVIEW 1. Water safety - water analysis results for the past 6 months ER 2. Fire and emergency preparedness - check for exit plans, plans for OPD earthquake and other disasters 3. Control of hazardous materials - MOA/Contract of outsourced services Wards Imaging for waste management Laboratory Pharmacy INTERVIEW 1. Ask staff from ER, Wards, OPD, Laboratory, Pharmacy and Facilities Facilities and maintenance and maintenance on the manner of waste segregation and disposal Other areas (general waste, liquid & solid waste, infectious & non-infectious, hazardous & non hazardous) 2. Hospital safety programs 3. Mechanical safety program of the hospital 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 For hospitals with radiologic facilities 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 Observe if staff performs necessary precaution safety procedures such as: red light is on while x-ray procedure is being done Note: if not x-ray facility, may observe other areas with other mechanical equipment e.g. generator (may look at the maintenance logbook, elevators, gurneys
1 4
1 4
__ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __
__
__
__
__
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Score Sheet
CODE 6.1.2.b.1 core
HOSP PHIC
EVIDENCE DOCUMENT REVIEW Policies and procedures on the safe and efficient use of medical equipment (including the implementation of DOH AO# 2008-0021on the gradual phase-out of mercury) DOCUMENT 1. Operating manual 2. Preventive and corrective maintenance logbook 3. Qualifications of staff handling medical equipment
SECTION Document review
REMARKS
__
__
6.1.2.b.2 core
__ __ __
__ __ __
__
__
__ 6.1.2.c.1 core __ __ __
__
ER ICU Wards OR/RR/DR Facilities and maintenance INTERVIEW 1. Ask staff in the ER, ICU, wards, OR/RR/DR, facilities and maintenance, Imaging Laboratory imaging and laboratory about the policies and procedures for use of Other areas 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 OBSERVATION 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 ER OPD Wards ICU OR/RR/DR Imaging Laboratory Pharmacy ER OPD Wards Pharmacy Laboratory Imaging ICU OR/RR/DR Facilities and maintenance Document review
1 4
1 4
__ __ __
6.1.2.d.1 __ __
1 2 3 4
1 2 3 4
6.1.2.e.1 core 6.1.2.e.2
__
__
DOCUMENT REVIEW Policies and procedures on risk identification, assessment and control, security risks, use of personal protective equipment, etc. DOCUMENT REVIEW Risk assessment reports OBSERVATION 1. Presence of warning signs where appropriate 2. Use of protective devices or personal protective equipment when appropriate DOCUMENT REVIEW Policy on facility security measures
1 4 1 2 3 4
1 4 1 2 3 4
Document review ER Wards ICU Laboratory Imaging Other areas Document review
__
__
__ __
__ __
6.1.2.f.1 __ __
4 6.1.2.f.2 core __ __ DOCUMENT REVIEW Contract of security agency or appointment of in-house security 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 Document review DOCUMENT REVIEW 1. Preventive maintenance programs for the equipment Facilities and 2. Preventive and corrective maintenance logbooks maintenance 3. Incident reports regarding operation of medical devices Imaging 4. Logbook of quality control results 5. Record of length of time per exposure of personnel or film badge report Laboratory ICU in radiology department OR/RR/DR 6. Document showing action to improve the effectiveness of safety procedures INTERVIEW Ask staff in facilities and maintenance, imaging, laboratory, ICU and OR/RR/DR about past problems regarding use of devices and what was done to resolve these problems Document review DOCUMENT REVIEW Incident/sentinel event reports or communications/ memoranda/orders or Leadership meeting proceedings on sentinel events Wards ER INTERVIEW ICU Ask leaders and staff from wards and ER how the incident reporting OR system works "Sentinel event" refers to injuries caused by medical management (and not necessarily the disease process) that either caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of discharge. 6.1.3.b.2 __ __ __ __ DOCUMENT REVIEW 1. Incident/sentinel event reports 2. Written documents showing corrective and/or preventive actions addressing the reported incidents e.g. memos, office orders, root cause analysis etc. INTERVIEW Ask leaders how incidents/ adverse events/ sentinel events are handled Document review Leadership meeting 1 2 3 4 1 4 1 2 3 4 Document review Other areas 1 4
4 1 4
__
__
__ 6.1.3.a.1 __ __ __ __ __ __
__ __ __ __ __ __ __
1 2 3 4
__
__
6.1.3.b.1 core
1 4
__
__
__
__
1 2 3 4
__
__
20 of 23
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Score Sheet
CODE
HOSP PHIC
EVIDENCE
SECTION
SURVEYOR SCORE 1 4
REMARKS
6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE 6.2.1.x.1 DOCUMENT __ __ Preventive and corrective maintenance logbooks for generator/ core emergency light/ water tanks/ aircons OBSERVATION 1. Presence of generator/emergency light, water tanks, adequate ventilation or air conditioning 2. Test if faucets and water closets are working 3. Check if emergency light and generators are functional DOCUMENT REVIEW MOA/Contract for outsourced services for maintenance of equipment, janitorial services, etc. DOCUMENT 1. Cleaning schedule and checklist of facilities and equipment 2. Preventive and corrective maintenance logbook for equipment OBSERVATION Cleanliness of surroundings especially comfort rooms
Facilities and maintenance Other areas
__ __ __ 6.2.2.x.1 __
__ __ __ __
Document review Facilities and maintenance
1 2 3 4
1 2 3 4
__ __
__ __
__ 6.2.3.x.1 core __
__ __
Document review DOCUMENT REVIEW Proof of training of service personnel if in-house or Certificate of training, Facilities and attendance sheet, certificate of attendance, diploma, citation or MOA/Contract for outsourced services (verify qualification of technicians) maintenance INTERVIEW Ask about how equipment (generator, airconditioner, medical devices and other equipment etc.) are maintained DOCUMENT REVIEW 1. Preventive and corrective maintenance logbook for equipment 2. Operating manual 3. Equipment management plan which includes: - who will maintain - qualifications of those who maintain and - schedule of maintenance DOCUMENT Operating manual of generators, air conditioners and other non-medical equipment Document review
1 4
1 4
__ 6.2.3.x.2 __ __ __
__
__ __ __
1 2 3 4
1 2 3 4
6.2.4.x.1 core
__
__
Facilities and maintenance Imaging Laboratory Other areas Document review Leadership meeting
1 4
1 4
6.3 INFECTION CONTROL 6.3.1.x.1 DOCUMENT REVIEW __ __ 1. ICC composition (for a primary hospital - proof of designation of a core doctor and nurse in-charge of infection control) __ __ 2. ICC functions and activities __ __ 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
1 4
1 4
__ 6.3.1.x.2 core
__
__ __
__ __
__ 6.3.2.a.1 __ __ __ 6.3.2.b.1 core
__
Document review 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 DOCUMENT REVIEW 1. Surveillance forms for nosocomial infection 2. Nosocomial Infection Case Reports 3. Hospital Acquired Infection Reports: semi annual infection rates, antibiotic resistance pattern DOCUMENT REVIEW Procedures on isolation of nosocomial infections INTERVIEW Ask staff in ER, wards and ICU the procedures on isolation isolation - physical isolation of a patient with infection 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 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 2. Policies and procedures on proper handling and safe disposal of sharps/needle sticks INTERVIEW Interview hospital staff on how they handle and dispose needles OBSERVATION Presence of receptacles for proper disposal of sharps Document review ER Wards ICU Laboratory Document review ER Wards ICU Laboratory Document review
1 4
1 4
__ __ __
1 2 3 4 1 4
1 2 3 4 1 4
Document review ER Wards ICU Document review ER Wards ICU
__
__
__ 6.3.2.b.2 core
__
1 4
1 4
__
__
__ 6.3.2.b.3 core
__
1 4
1 4
__
__
__
__
6.3.3.a.1 core
1 4
1 4
__ __
__ __
__
__
Scoring: 1: 2: 3: 4:
__
__
0% compliance to the indicator 1 - 49% compliance to the indicator 50 - 99% compliance to the indicator 100% compliance to the indicator
21 of 23
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Score Sheet
CODE 6.3.3.b.1 core
HOSP PHIC
EVIDENCE DOCUMENT REVIEW 1. Infection control procedures on isolation and universal precaution 2. Program for the protection of healthcare workers e.g. personal protective equipment (PPEs) 3. Policies on all patient admission/referral, isolation and timely case reporting of highly transmissible and notifiable infectious disease e.g. meningococcemia, SARS, avian flu, etc 4. Hand hygiene procedures 5. Environmental care and healthcare waste management 6. Procedures on recycling & reuse of equipment i.e. personal protective equipment INTERVIEW Validate hospital policies on infection control such as use of PPEs, isolation precautions and hand washing OBSERVATION 1. Observe for use of gloves, surgical masks 2. Look for sinks or lavatories or designated areas for hand washing or dispenser for sanitizers 3. Look for separate holding area/room for highly infectious cases 4. Ask a hospital staff to demonstrate hand washing technique
SECTION Document review ER Wards ICU Laboratory
SURVEYOR SCORE 1 4
REMARKS
__ __ __
__ __ __
__ __ __
__ __ __
__
__
__ __ __ __
__ __ __ __
6.3.4.x.1 core
__ __ __
__ __ __ __
Document review 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 Document review DOCUMENT REVIEW Policies and procedures on reporting of infections to personnel and public health agencies Document review Leadership meeting
1 4
1 4
6.3.5.x.1 core
1 4 1 2 3 4
1 4 1 2 3 4
__
6.4 EQUIPMENT AND SUPPLIES 6.4.1.a.1 DOCUMENT REVIEW Procurement policy and plan which considers the following: __ __ 1. intended use __ __ 2. cost benefits __ __ 3. infection control __ 4. safety __ __ __ 5. waste creation and disposal __ __ 6. storage Note : all elements must be present in the policies, if not - score is partial INTERVIEW Ask about the processes in selecting and acquiring equipment and supplies (especially for LGU hospitals because procurement is centralized at the provincial/municipal/ city level) DOCUMENT REVIEW 1. License if applicable 2. List of specialized equipment 3. Certificates of training, certificates of attendance, or equivalent experience (at least 1 year) under a trained personnel OBSERVATION Identify specialized equipment that need only trained staff to operate Example of specialized equipment: MRI, CT scan, ECG, 2d echo, x-ray, respirator, ultrasound, anesthesia machine, endoscopes, etc
__
__
6.4.2.x.1 __ __ __ __ __ __
Document review Imaging Laboratory Wards ICU OR/RR/DR Other areas
1 2 3 4
1 2 3 4
__
__
6.4.3.x.1 core
__
__
Document review Facilities and maintenance
1 4
1 4
__ __ __ __
__ __ __ __
6.5 ENERGY AND WASTE MANAGEMENT 6.5.1.x.1 DOCUMENT REVIEW __ __ Pertinent licenses/permits from regulatory agencies (LGU, DENR, etc.) core 6.5.2.x.1 __ __ __ 6.5.2.x.2 core __ __ __ __ __ __ __ __ __
Document review
1 4 1 2 3 4 1 4
1 4 1 2 3 4 1 4
Document review DOCUMENT REVIEW 1. Policies and procedures which involves reuse, reduction and recycling in compliance with RA 9003 and DOH guidelines 2. Waste management program 3. MOA/contract of outsourced services for waste management 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 INTERVIEW Ask staff regarding SOPs on actual procedure waste disposal Document review ER Wards ICU Pharmacy Imaging Laboratory Facilities and maintenance
__
__ OBSERVATION 1. Segregation of waste 2. Proper labeling of waste receptacles 3. Recyclable waste staging areas 4. Proper management of temporary storage areas prior to hauling for disposal
__ __ __ __
__ __ __ __
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Score Sheet
CODE
HOSP PHIC
EVIDENCE
SECTION
SURVEYOR SCORE 1 4
REMARKS
7. IMPROVING PERFORMANCE 7.1.x.1 DOCUMENT REVIEW __ __ 1. Policy creating the QI program core __ __ 2. Proof of meetings or similar documents of QA Committee activities __ __ 3. Policies and procedures on performance measurement and improvement INTERVIEW Validation of QI activities thru interview of pertinent staff including frontliners and Committee members DOCUMENT REVIEW Annual plan and budget showing funds allotted to CPG development or adoption and implementation INTERVIEW Ask staff for presence of person knowledgeable of CPG appraisal
__
__
7.2.a.1 __ __
1 3 4
1 3 4
__ 7.2.b.1 __
__ __
__ 7.2.b.2 __
__
Document review DOCUMENT REVIEW Documentation of dissemination of PhilHealth-adopted CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and ER OPD other issuances Wards OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics Document review DOCUMENT REVIEW Documentation of dissemination and monitoring of CPGs e.g. Conferences- topics, meetings - look at the minutes, agenda, memos and ER OPD other issuances Wards OBSERVATION CPGs or IEC materials available in the wards, nurses station, and emergency room, doctors' offices/clinics DOCUMENT REVIEW 1. Conduct of utilization review of drugs, procedures or diagnostic tests based on CPG 2. Use of clinical pathways based on CPG 3. Conduct of medical audits using CPG as standard DOCUMENT REVIEW 1. Memoranda/orders creating the QI team/Quality circle 2. Minutes of meetings/extracts of minutes relating to concerned topic, documentation of activities 3. Monitoring reports on CPG use or similar QI activities 4. Designation of a point person for the QA program INTERVIEW Validate the activities by asking the management team or officer involved in QA program DOCUMENT REVIEW 1. Policies or issuances on CQI Program 2. QA/CQI manual 3. Patient satisfaction survey results/ratings 4. Staff satisfaction survey INTERVIEW Validate the activities thru interview of any staff including the frontliners, patients, external clients DOCUMENT REVIEW 1. Minutes or extracts of minutes of the management or Executive Committee meetings 2. Memoranda, policies, orders emanating from the evaluation of QI programs/activities 3. Monitoring and evaluation reports DOCUMENT REVIEW 1. Patient satisfaction survey results 2. Patient satisfaction survey questionnaire (may check on the domains and items) Document review Document review ER OPD Wards Document review
1 3 4
1 3 4
1 3 4
1 3 4
__
__
__
7.2.b.3 __ __ __ 7.3.x.1 __ __ __ __ __ __ __ __ __ __ __
1 2 3 4 1 2 3 4
1 2 3 4 1 2 3 4
__ 7.4.x.1 __ __ __ __
__
__ __ __ __
1 2 3 4
1 2 3 4
__ 7.5.x.1 __ __ __ 7.6.x.1 core __ __
__
__ __ __ __ __
1 2 3 4
1 2 3 4
Document review
1 4 1
1 4 1
7.6.x.2 __ __
Document review DOCUMENT REVIEW Documentation of better outcomes for patients as a result of CQI activities e.g. declining trends of nosocomial infection, increase in patient satisfaction ratings, in OB - increase in trend of trial labor vs. CS, increase use of component blood vs. fresh whole blood, etc. Document review DOCUMENT REVIEW Documentation of better services e.g. reduction of turn-around-time for diagnostic tests, OPD and ER services; increase in patient satisfaction ratings, higher Benchbook assessment ratings for renewal application, etc. DOCUMENT REVIEW 1. Policies and procedures on confidentiality of records 2. QA/CQI manual 3. Reports related to QI activities INTERVIEW Ask also 1. How the staff protect /ensure confidentiality of patient's data especially in relation to audit or peer review and how they prevent staff from leaking data or information. 2. How they present a picture of a patient like in IEC materials. Note : The surveyor should look for any data that can be attributed to specific individuals Document review Leadership meeting
7.6.x.3 __ __
4 1 2 3 4
4 1 2 3 4
7.7.x.1 __ __ __ __ __ __
__
__
__
__
23 of 23
Page 217 of 218
BENCHBOOK SELF-ASSESSMENT BENCHBOOK SELF-ASSESSMENT SUMMARY SUMMARY

(This form must be accomplished by the hospital.)
Name of hospital DOH License No. Category Classification Address Province Region Accreditation status applied for Center of Safety Center of Quality Center of Excellence Primary Government Secondary Private Tertiary
Self-assessment scores per area Patient Rights and Organizational Ethics Patient Care Leadership and Management Human Resource Management Information Management Safe Practice and Environment Improving Performance
Compliance (%)
Compliance to core indicators
Number of core indicators complied with
Percentage of compliance
Page 218 of 218

Benchbook SelfAssessment

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Orientation of Hospitals on Benchbook Self-Assessment and Accreditation Process

PHILIPPINE HEALTH INSURANCE CORPORATION

Manual 2 Table of Contents

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

right to care right to consent freedom of choice rights of incompetent

DOCUMENT REVIEW Monitoring reports related to patient or family education program/policy

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BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

All patients are correctly identified by their patient charts

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

DOCUMENT REVIEW Policies and procedures on implementation/compliance to clinical pathways

Presence of policy on test or treatment refusal

DOCUMENT REVIEW Policy on refusal of test or treatment

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

2.5.3.a.2 Care is coordinated to ensure continuity and to avoid duplication.

Proof of provision of resources for patient educational programs

DOCUMENT REVIEW Policies and procedures on drug administration

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BENCHBOOK for HOSPITALS

SECTION 1 - DOCUMENT REVIEW

Self Assessment and Survey Tool

NOT FOR CIRCULATION

BENCHBOOK for HOSPITALS