Revised Licensing Assessment Tools for Hospitals

Republic of the Philippines

Department of Health

OFFICE OF THE OF THE SECRETARY SECRETARY

April 11, 2018

DEPARTMENTCIRCULAR No. 2018- QM] FOR

:

ALL DOH REGIONAL DIRECTORS, HEALTH AND FACILITIES SERV SE RVIC ICES ES REGU RE GULA LATO TORY RY BUREAU (HFSRB) DIVISION CHIEFS, REGULATORY LICENSING AND ENFORCEMENT DIVISION CHIEFS HFSRB AND RLE RLED D RE REGU GULA LATO TORY RY (RLED), HF OF HOSPITALS HOSPITALS AND HOSPITAL OFFICERS, CHIEFS OF

MEDICAL MEDICA L DIREC DIRECTORS TORS SUBJECT

:

Revised Licensing Assessment Tools for Hospitals Hospitals

Based from the the rev review iew of the the dr draf aftt hospital assessment tools and discus discussions sions during Technical Working Group meetings, Bimonthly Enforcement cement Bimonthly Regula Regulatory tory Licensing and Enfor Division Divisi on Chiefs Meetings, National Dialogue, and consultative meetings with HFSRB

2. The HFSRB-approved floor plan shall be shall be the basis for assessing compliance to the

licensing standards for physical physical plant during inspection or monitoring. monitoring. 3. The required quantity for each emergency medicine has bee been n removed from the Assessment Tool. Hence, the hospitals and infirmaries have the sole responsibility for ensuring the availability of the emergency medicines medicines based on their their clinica clinicall guidelines or practice guidelines practice protocol and frequency of usage. or protocol usage. 4. Additional licensing licensing requirements requirements include compliance to: Electronic Medical Records Records a. Implementation of the Electronic Medical b. Implementation of the Antimicrobial Stewardship National al laws and and DOH DOH issuances: issuances: c. Nation 1. RA. No. 10932: Anti-Hospital Anti-Hospital Deposit Deposit Law ii. EC No. 26 s. 2017: “Providing for the Establishment of Smoke-Free Smoke-Free Enclosed Places” Environments in Public and Enclosed Places” iii. A.O. A.O. No. 2007-0041: “Guidelines on the Mandatory Allocation of a a Certain Percentage of the the Authorized Authorized Bed Bed Capacity as Charity Beds Beds in in Private Hospitals” iv. RA. No. 9439: “A Detention on of Patients in “An n Ac Actt Prohibiting the Detenti Medical al Cli Clinic nicss on Grounds of Nonpayment of Hospitals and Medic Medical Expenses” Hospital Bills or Medical Individual al Person Personal al Inform Information ation in R.A. 10173: “An Act Protecting Individu Information and Communications and Communications Systems in the Government the Government and the Private Sector, Creating fo th this is National Privacy

the Philippines Republic of the Department of Health

REGULATORY TORY BURE BUREAU AU HEALTH FACILITIES AND SERVICES REGULA HOSPITAL ASSESSMENT TOOL 1.

HEALTH HEALTH FACIL FACILITY ITY INFORMATION

Name of Facility: Address:

Email Address: Email Address:

Tel. / Fax Nos.:

Name of Owner:

Tel.. / Fax Nos.: Tel

Hosp. Administrator:

Tel.. / Fax Tel Fax Nos.: Nos.:

Chiefof Hospital/Med. Director:

Tel.. / Fax Nos.: Tel

License To License To Operate:

Authorized Bed Capacity:

Classification:

General

Level

1

I: Level 2 |:] Level

3

El

PART I HOSPITAL HOSPI TAL MEDIC MEDICAL AL SERVICES DOH STANDARDS (Indicators) for HOSPITALS Instructions: 0

(\I) if the hospital is compliant In the appropriate X-mark if if not compliant. box, place compliant or appropriate box, place a check mark (\I) or X-mark

- Interview at least 0

10 patients and 10 hospital staff members.

Conduct document document review review of at least 10 sample documents.

CRITERIA

INDICATOR

EVIDENCE

AREAS ,

COMPLIED

REMARKS

I. PATIENTRIGHTS AND ORGANIZATIONALETHICS Standard: Organizational policies and procedures patients' rights to quality quality care procedures respect support patients' care and their respect and support responsibilities in that care. All patient charts Wards l. Informed consent is DOCUMENT obtained from patients have signed consent. REVIEW signed consent. Patients charts Patients charts to initiation of prior to care. Note: Informed consent Informed consent includes a patient-do patient-doctor ctor discussion of the nature of the deczszon or the . procedure; procedur e; alternatives [0 proposed intervention; the proposed uncertainties related to each alternative; assessment to patient understanding; and

““9”“

INTERVIEW Patients ASk patient/fam patient/family ily from

[Sks’ benefits, and r [Sks’

patientIS or refusal ofthe intervention.

the wards/ICU ifthey appropriately were appropriately were informed by authorized personnell (doctor or personne or nurse) about their disease, condition or disability, its severity, prognosis, prognos is, benefits and possible adverse effects

of

PART I

HOSPITAL HOSPI TAL MEDIC MEDICAL AL SERVI SERVICES CES CRITERIA

INDICATOR

EVIDENCE

AREAS

'COMPLIED

REMARKS

3. PNRI

certification (when applicable) (when applicable) OBSERVE The facilities, and if structure. Check if the service capability of the hospital is in accordance with the health facility level

ACCORDINGTO ACCORDING TO CLASSIFICATION CLASSIFICATIONOF OF HOSPITAL (Place a check on column, if complied) corresponding column, on the corresponding CRITERIA A. Clinical services Clinical services at least for: - Medicine

Pediatrics Obstetrics and Gynecology Surgery Anesthesia - Others (please (please specify) specify) -

—

—

DOCUMENT REVIEW

LEVEL 1

I

LEVEL 2

LEVEL 3

PART I

HOSPITAL MEDICAL SERVICES CRITERIA D. High Risk Pregnancy Pregnancy

Care DOCUMENT REVIEW Policies and procedures E. Neonatal Intensive Care Unit DOCUMENT REVIEW and procedures Policies and Policies F. Intensive Care Intensive Care Unit DOCUMENT REVIEW Policies and Policies and procedures G. Respiratory Unit DOCUMENT REVIEW Policies and procedures H. Physical Medicine Medicine and and Rehabilitation Unit Rehabilitation Unit DOCUMENT REVIEW Policies and procedures I. Ambulatory Surgical Ambulatory Surgical Clinic (ASC) to Assessment (Refer to Assessment Tool for Tool for Ambulatory Ambulatory Clinic) Surgical Clinic) Surgical

LEVEL 1

'

‘

LEVEL 2

LEVEL 3

REMARKS

PART I

HOSPIT HOS PITAL AL MED MEDICA ICAL L SER SERVIC VICES ES CRITERIA

INDICATOR 3. History and

Physical Examination . Doctor's order . Nurses Notes TPR Sheet . TPR . Laboratory report . Imaging reports Maternal Record . Maternal with Partograph warranted) (if warranted) 10. Newborn Newborn record and maturity rating (if warranted) 11. Medication Medication and/or treatment record 12. Operative and anesthesia record warranted) (if warranted) 13. Record of interdepartmental referral/consultati to other on to on physicians, physician s, including notes 14. Record of referral transfer of or transfer 000“me

EVIDENCE

AREAS

'

COMPLIED

REMARKS

PART I

HOSPIT HOS PITAL AL MED MEDICA ICAL L SER SERVIC VICES ES CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED REMARKS

adopted CPGs/protocols

Standard: Each patient's physical, psychological and social status is assessed. An appropriate comprehensive history and physical examination is performed on performed on every patient within 48 hours from admission. admiss ion. The history includes present illness, past medical, family, medical, family, social and personal history.

All patients have comprehensive and PE within PE within history and hours from 48 hours 48 admission.

DOCUMENT

Wards

REVIEW Patient chart from Patient chart Medical wards or Medical have Records have Records history complete history complete and RE. and RE.

Medical Records Office

Standard: Appropriate professionals perform coordinated and sequenced patient assessment to reduce waste and unnecessary repetition. Previously obtained information is reviewed at every stage of the assessment to guide to guide future assessments

All patient charts have progress notes doctors and and other by doctors health professionals.

DOCUMENT

REVIEW Patient chart from medical records/wards.

Medical records room Wards

PART I HOSPITAL HOSPI TAL MEDIC MEDICAL AL SERVICES CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED

'

REMARKS

C. EVALUATION OF CARE Standard: The discharge thee patient's discharge plan plan is part of th patient's care plan and is documented in the patients’ chart. care plan 10. Discharge plans Medical DOCUMENT Discharge plans for All charts have records to ensure discharge plans. REVIEW patients to patients discharge plans. charts Patients' charts Patients' of continuity care. room wards medical from medical from at records, look at the discharge orders. It should It should contain all of the following: 0 May go home

order 0 Home medications (if applicable) 0 Follow up visits/schedule 0 Home care/advise AND MANAGEMENT MANAGEMENT III. LEADERSHIP AND A. MANAGEMENT REVIEW Standard: The provider organization's management team provides leadership, acts according to the organization's its services services and its policies and has overall responsibility for the organization's operation, and the quality of its resources 11. Organizational Presence of OBSERVE Lobby

PART I

HOSPITAL HOSPI TAL MEDICA MEDICAL L SERVIC SERVICES ES CRITERIA

INDICATOR

EVIDENCE VVAREAS

1. Credentialing

and privileging 2. Blood

Transfusion 3. Healthcare Healthcare Waste Waste Management 4. Patient Safety 5. Infection and Prevention and Prevention Control 6. Antimicrobial Stewardship (functional in Level 3 Hospitals 2019, Level 2 by 2019, by 2020, and all by 2020, by levels by 2022) 7. Pharmacologic and Therapeutic 8. Emergency and Disaster Preparedness 9. CQI 10. Grievance 1 1.Information and Communication Technology

INTERVIEW Committee members

COMPLIED

REMARKS

PART I

HOSPITAL HOSPIT AL MEDIC MEDICAL AL SERVI SERVICES CES REQUIREMENTS

Level

1

Level 2

~

Level 1 and 2 Hospitals may opt for imaging Note: Level Note: facility service capability higher than Level imaging facility Imaging Facility, respectively. Facility, respectively. 1 1. Level Imaging Facility 2. Level 2 Imaging Facility 3. Level 3 Imaging Facility C. PHARM PHARMACY ACY Open 24/7, providing Open 24/7, providing affordable and safe, affordable and efficacious medicines efficacious medicines DOCUMENT REVIEW 0 Recommendation from Center for Letter from Center Regulation and Drug Regulation Drug Research (CDRR) for initial LTO for waived waived inspection. 0 Inspection Inspection Report Report from CDRR D. BLOOD SERVIC SERVICE E FACILITY blood service facility) to assessment tool for blood service (Refer to There shall be shall be 24 hours / 7 days a week provision provision of safe blood.

Level 3 1

REMARKS

Facility and Level 2 Imaging Facility Imaging

PART I


INDICATOR

EVIDENCE

Presence of policies policies and DOCUMENT orga or gani niza zati tion on proc pr oced edur ures es for hiring, REVIEW documents and documents and credentialing and follows policies privileging of staff Policies and and procedures procedures for for hiring, hiring, hiring, credentialing and credentialing, and privileging privileging of staff of its staff.

16. The

AREAS Personnel /Administrative office

INTERVIEW

17. Staff numbers

Human Resources Management Officer/Personnel Officer DOCUMENT REVIEW

Personnel/ Staff to to bed ratio for and skill mix licensed doctors, Adminis trative are based on registered nurses and actual clinical actual clinical midwives/nursing aides 0 List of licensed office needs. follows the the DOH DOH doctors and doctors and ratio. prescribed (Refer nurses based on Wards to Attachment of (Trainees, except records HR records Tool for Assessment Tool Assessment physicians 0 Payroll undergoing residency undergoing residency Personnel) 0 Schedule of training and the duties for duties for the volunteers not and previous included) current month

COMPLIED

REMARKS

PART I


INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

and

responsibilities

C. ST STAF AFF F TRAINING AND DEVELOPMENT

Standard: There are relevant orientation, training and development programs to meet the Standard: There educational needs of the educational management and staff. 20. New personnel,

new graduates and external contractors- are adequately supervised by qualified staff

Proof that new personnel new personnel oriented adequately are adequately are and supervised

Personnel/ AdminisDocumentation of trative office orientation conducted DOCUMENT

REVIEW

INTERVIEW Ask new new personnel about lines of the lines the authority and supervision and if the supervision is adequate

OBSERVE 21. Annual plan plan on on Presence of annual plan DOCUMENT activities REVIEW training training on training on

Personnel/ Adminis-

PART I

HOSPITAL HOSPI TAL MEDIC MEDICAL AL SERVI SERVICES CES CRITERIA who are involved in each stage

INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

0 Proof of of

participation or submission in submission in the OHFSRS (Online Health Facility Statistical Reporting System)

B. RE RECO CORD RDS S MANAGEMENT Standard: Clinical records are confidential tial and safe, and readily accessible to facilitate patient care, are are kept are readily kept confiden all codes with relevant of and comply practice. practice. requirements statutory requirements statutory 24. When patients Presence of policies Medical policies and OBSERVE Patient charts are Records are admitted or procedures on procedures on filing and Patient charts retrieval of charts retr trie ieva vabl blee Room Ro om// are seen for easily re within 10-15 Office ambulatory or ambulatory or minutes care, emergency care, emergency patient charts documenting any previous care can be quickly retrieved for review, updating and concurrent use. 25. The Presence of policies Medical policies and DOCUMENT

PART I HOSPITAL HOSPIT AL MEDIC MEDICAL AL SERVICES CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

injury, and confirmed cases of diagnosis (e.g. cancer, diabetes mellitus, cerebrovascular accident) VI. SAFE SAFE PRACTICE AND AND ENVIRONMENT ENVIRONMENT A. INFECTIONCONTROL Standard: All interdisciplinary infection control program ensures the prevention and control of infection in all services. 27. Infection Infection Presence of an Infection DOCUMENT Prevention an and d Prev Pr even enti tion on an and d Co Cont ntro roll REVIEW Control Control Committee (IPCC) with Committee o IPCC Committee defined roles and Office composition responsibilities 0 Full time Infection Control Nurse Control Nurse 100 (1: beds) 0 IPCC IPCC functions functions and activities 0 Minutes of meetings 28. Infection Presence of an infection DOCUMENT Nurse Preve Pre vent ntio ion n an and d cont co ntro roll program ensuring REVIEW Super— Control Visor’s and control 0 of Manual. prevention IPC Manual. IPC

PART I


INDICATOR

outbreaks of healthcare associated infections.

associated of hospital

infections Presence of a coordinated system-wide procedure for asepsis.

EVIDENCE

AREAS

control infection control infection such as use of PPEs, isolation precautions and hand washing.

INTERVIEW Ask staff in ER and wards the wards the procedures on isolation (Isolation - physical isolation of a

patient with infection and reverse isolation).

30. There are

for

staff from Ask staff and wards and ER, wards laboratory about the approaches for during asepsis during asepsis diagnostic and treatment procedures Presence of program DOCUMENT program on REVIEW prevention of

ER Wards

COMPLIED

REMARKS

PART I


INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

washing or washing or for dispenser for hand sanitizers 0 Separate holding Separate holding highly room for highly infectious cases. 0 Ask a staff to to

demonstrate hand washing technique

Standard: When needed, the organization reports information about infections to personnel and public health agencies. Presence of policies policies and DOCUMENT procedures in procedures in reporting REVIEW notifiable diseases reporting Copy of reports notifiable submitted to diseases (Refer Philippine to A0 No. Integrated Disease Surveillance and 2008—0009). Response (PIDSR) B. PATIENT AND STAFF SAFETY Standard: The organization environment nt of care consistent with its mission, services, organization plans plans a safe and effective environme with laws and regulations. and with and

31. Policies and

incident

of

Infection

PART I

MEDICAL AL SERVI SERVICES CES HOSPITAL MEDIC CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIED

"REMARKS

Standard: Management is primarily responsible for developing, developing, communicating, and implementing a comprehensive quality qualit y impro improvemen vementt program throughout the organization and delegating responsibilitiesto appropriate appropriate personnel personnel its day-to-dayimplementation for its 34. Comprehensive

quality improvement program throughout the organization and delegating responsibilities to appropriate personnel for its day-to-day implementation

Proof that the management is primarily responsible for developing, communicating and implementing a implementing a comprehensive quality improvement program implementation

DOCUMENT

REVIEW 0 Memoranda/or

ders creating the Q1 team/Quality circle 0 Minutes of meetings/ extracts of minutes relating to concerned topic, documentation of activities 0 Monitoring on reports on reports CPG use or use or similar QI QI activities 0 Designation of a point person for the CQI

Administrative Office


INDICATOR

EVIDENCE

AREAS

COMPLIED

REMARKS

VIII. NATIONAL LAWS AND DOH ISSUANCES INIPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES OB Ward 37. Newborn Proof of of implementation DOCUMENT Newborn Screening REVIEW of Newborn (Rooming Screening — in compliance to RA 9288 and its IRR

38. Universal

Newborn

Hearing

Screening — in compliance to 9709 RA 9709 RA (Universal Newborn

o Policies

and procedures on procedures on Universal Newborn Screening 0 Logbook of of Newborns who were tested and copies of waiver for those who those who were not screened 0 Availability of filter paper

Proof of of implementation DOCUMENT Newborn Hearing of Newborn REVIEW 0 Logbook of Screening of Newborns who Newborns who were tested on hearing 0 Proof of of referral if service is not

111)

Newborn hearing screening room

,

PART I

HOSPIT HOS PITAL AL MED MEDICA ICAL L SER SERVIC VICES ES '

CRITERIA

INDICATOR

of Act of Health Act

2012)

Proof that newborn 41. Immunization — in babies given BCG and BCG and first dose Hepatitis B compliance to first dose vaccine RA No. RA 306 No. 306

EVIDENCE services are not provided 0 Referral if Logbook if conscientious objector. DOCUMENT

AREAS

OB Ward

REVIEW Records of Newborns given BCG and first and first dose Hepa—B vaccine OBSERVE

INTERVIEW STAFF Proof 42. Anti-smoking of implementation DOCUMENT of in compliance of policies REVIEW policies and Policies and RA 9211 to RA to procedures on antiprocedures on smoking procedures on procedures on 26 s. 2017, No. 26 EC No. anti-smoking “Providing for the Establishment of OBSERVE Smoke-Free “No Smoking” Environments in signages posted in signages posted —

Hallways Toilets Wards Offices OPD

COMPLIED

REMARKS


45. National

Tuberculosis Program in compliance NTP — in with RA 10767 (ComprehensiveTB Elimination Plan Act)

INDICATOR

EVIDENCE

OBSERVE Exit plans posted plans posted all hallways in all in and rooms Proof of of implementation DOCUMENT National TB Program REVIEW of National TB 0 Presence of Hospital TB Referral Logbook 0 List of Diagnosed TB Notified Cases Notified Cases (with received remarks by

AREAS

OPD Wards

DOH—

Regional Office) 46. AD. No. No. 2007 of implementation DOCUMENT 2007- Proof of allocation 0041: of of charity REVIEW Policies and “Guidelines on beds to indigent patie patients nts the Mandatory in private hospitals private hospitals procedures on the procedures on allocation of Allocation of a a for beds for Certain charity beds confinement of Percentage of Authorized the Authorized the indigent patients indigent patients Bed Capacity patients or patients

Wards

COMPLIED

REMARKS

PART I

HOSPITAL MEDICAL SERVICES CRITERIA

INDICATOR

Clinics on Grounds of

Anti-Hospital Deposit Law

EVIDENCE

AREAS

with but with discharge but unpaid hospital bills are aligned are aligned with the with the provisions in R.A. 9439. No. 9439. No. Proof of of implementation DOCUMENT Adminis trative of R.A. 10932 REVIEW Office Policies and the procedures on implementation of ER RA 10932 rendering emergency care admission to and admission and indigent and poor indigent marginalized patients.

Nonpayment of Hospital Bills Medical or Medical Expenses” 48. R.A. 10932:

T

OBSERVE: A copy of the R.A. 10932 and its Implementing Rules and Regulations are posted in a conspicuous

COMPLIED

REMARKS

PART I HOSPITAL MEDICAL SERVICES CRITERIA

INDICATOR

thereafter”

and extending the Period of

Registration up to December 31, 1975.

EVIDENCE opt to file the births/deaths personally at personally at the local civil registry.

AREAS

COMPLIED

REMARKS

the Philippines Republic of the Health Department of Health

FACILITIES AND SERVICES REGULATORY BUREAU HEALTH FACILITIES HEALTH

Name of Health Facility: Date of Inspection:

RECOMMENDATIONS: A. For Licensing Licensing Process [

]

For Issuance License To Issuance of License To Operate as HOSPITAL Validity from

[

]

to

Issuance depends upon compliance to the recommendations given and submission of the following within to the days from the date of inspection

the Philippines Republic of the Department of Health

REGULATORY TORY BUREA BUREAU U HEALTH FACILITIES AND SERVICES REGULA

Name of Health Facility: Date of Monitoring:

RECOMMENDATIONS: B. For Monitoring Monitoring Process Issuance of Notice Notice of Violation [ ]

[

]

Non-issuance of Notice Notice of Violation

PART II

HOSPITAL NURSING SERVICE DOH STANDARDS (Indicators) for HOSPITALS Instructions: 0 0 0

(\l) if the hospital is compliant or X-mark X-mark if if not In the appropriate box, not compliant. box, place compliant. place a check mark (\l) Interview at least 10 patients and 10 hospital staff members. Conduct document review of at least 10 sample documents.

CRITERIA

INDICATOR

EVIDENCE

AREAS

COMPLIEVD’

REMARKS

I. PATIENT CARE A. ACCESS assessment nt to reduce waste and Standard: Appropriate professionals perform coordinated and sequenced patient assessme unnecessary repetition. Licensed and DOCUMENT appropriately trained REVIEW Valid license PRC Valid PRC nursing personnel nursing personnel assigned in special and Certificate of relevant critical areas training

NURSING SERVICES Moderate Nursing Care and Management 1.

2. Nurses make Nurses make use of

Process in Nursing Process in the care of patients patients

Charts have have nurses’ nurses’ notes Presence of Nursing Nursing manual and properly utilized Kardex

CHART REVIEW from Patients’ charts charts from ward rdss medical records or wa medical records have nurses’ notes have nurses’ notes DOCUMENTS charts Patients’ charts Patients’ Kardex

Wards, ER, OPD

Wards Medica Medi call Records Office

PART II

HOSPITAL NURSING SERVICE CRITERIA

.

.

Patients are properly identified before medicines are administered

Medicine administration is docume umente nted d properly doc in the patient chart

INDICATOR

EVIDENCE

the for medicines with medicines with the order. doctor’s order. doctor’s Proof that patients patients are are INTERVIEW identified from if patients correctly prior Verify to administration of correctly they were were correctly identified prior to medications to drug administration. OBSERVE the staff staff verifies verifies the if the identity of patient patient prior to administration of medications (patient should be the one to state his/her name.) name.) All charts All charts have proper CHART REVIEW documentation of Medication sheet sheet in in medici med icine ne adm admini inistr strati ation. on. patient chart from medical records or from the wards.

AREAS

COMP CO MPLI LIED ED

REMA RE MARK RKS S

Wards ER

Medical records office wards

II. SAFE PRACTICE AND ENVIRONMENT A. INFECTION CONTROL Standard: The organization uses a coordinated system-wide approach to redu risks of reduce ce the the risks of health healthcarecareassociated infections. .

There are programs for prevention prevention and treatment of needle stick injuries, injuries, and

Presence of policies policies and procedures on procedures on the and treatment prevention of needle stick injuries injuries

INTERVIEW Ask staff their policies policies needle stick injury injury on

ER Wards

PART III HOSPITAL PHYSICAL PLANT DOH STANDARDS DOH STANDARDS (Indicators) for HOSPITALS

Instructions: 0 0

In the appropriate box, place a chec check k mar mark k (\l) if the hospital is compliant or X-mark X-mark if not not compliant. compliant. 10 10 members. Interview at least patients and hospital staff

Conduct Condu ct docum document ent revie review w of at least 10 sample documents.

CRITERIA

INDICATOR IN

PATIEN PATI ENT T CA CARE RE A. ACCESS 1.A multi-level ramp of ramp Presence Presence of ramp or shall have a mi mini nimu mum m elev el evat ator or 1.22 clear width of 1.22 meters in one direction and slope is 1:12; an elevator eleva tor which can accommodate at least a patient bed, provided if there is no ramp; Ramp is provided at the entrance if it is not at the same level with the inside 2. Entrances and exits Presence of Presence of entrances entrances

EVIDENCE

AREAS

I.

OBSERVE

OBSERVE

ER

COMPLIED REMARKS

PART III HOSPITAL PHYSICAL PLANT CRITERIA

INDICATOR

7

EVIDENCE

AREAS

o Wheeled stretcher can

B.

have a 360 degree turning radius OUTSOURCED SERVICES THAT MAY BE SERVICES BE OUTSOURCED

6. Outsourced se all serv rvic ices es Pres Pr esen ence ce of all the within facility outsourced services are within the hospital

1.

DOCUMENT REVIEW 0 Contracts/MOA for outsourced services 0 Valid licenses of all providers 0 Check contracts / job orders

ADMINISTRATIVE SERVICES

A. Dietary

Linen/

There shall be provision DOCUMENT REVIEW/ of safe, quality and nutritious nutrit ious food to INTERVIEW 0 Check policies patients. policies and in the the procedures in Diet prescription or diet diet dietary. counselling is provided 0 Monthly menu for to patients to patients patients

If

Administrative Office

COMPLIED REMARKS


E. Proper Waste

Disposal

EVIDENCE

INDICATOR Policies and procedures on proper waste disposal.

AREAS

COMPLIED REMARKS

DOCUMENT REVIEW

Proof of implementation Proof implementation of policies policies and procedures on proper waste disposal. F. Maintenance Policies and procedures DOCUMENT Lobby / OPD ER / REVIEW on maintenance (Equipment and and Wards Building) the rest of OBSERVE Proof of implementation implementation the hospital SAFE PRACTICE AND ENVIRON ENVIRONMENT MENT II. SAFE PRACTICE A. PATIENT AND AND STAFF STAFF SAFETY Standard: The organization plans a safe and effective environment of care consistent with its mission, with laws laws and regulations services, and with 7. Hospital has a valid AdminisPresence of updated DOCUMENT trative office license DOH license to operate REVIEW 0 Updated DOH license 0 If facility has nuclear medicine, check certifica cert ificate te issue issued d by PNRI

PART III HOSPITAL PHYSI HOSPITAL PHYSICAL CAL PLAN PLANT T CRITERIA

INDICATOR OSecurity ODisposal and control

EVIDENCE of of Implementation

AREAS

,

1

ER

0 Proof

Wards

hazardous materials INTERVIEW and biologic wastes about the frequency OEmergency and disaster ASk about Of the the following: preparedness 0 Fire drill conducted in the past 12 months 0 Earthquake drill conducted in the past 12 months Presence of policies Presence ll.Policies and ER policies and DOCUMENT the the for: for OPD REVIEW procedures procedures safe and efficient use 0 Quality Control 0 Presence of operating operating Wards of medical equipment 0 Corrective and DR thee manuals of th according to medical equipment Laboratory Preventive specifications are Pharmacy Maintenance Program 0 Preventive and documented and Maintenance medical for medical corrective implemented. maintenance logbook Office equipment Other areas areas 0 Film reject analy analysis sis 0 Quality control tests results

COMPLIED REMARKS

PART III HOSPITAL PHYSI HOSPITAL PHYSICAL CAL PLAN PLANT T CRITERIA patients, staff and visitors.

INDICATOR

EVIDENCE

,

AREAS

COMPLIED REMARKS

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

OBSERVE Securitymeasures measures ' Security is CCTV provided ' B. MAINTENANCE OF THE THE ENVIRO ENVIRONMENT NMENT OF CARE Standard: Emergency light and/or power and ventilation systems are provided for, in keeping with are provided power supply, water and relevant statutory requirements and codes of practice. practice. 14. Generator, emergency Presence of generator, DOCUMENT Engineering/ Maintenance light, water system, REVIEW water light, system, emergency 0 Check adequate ventilation system, adequate result of water Other Check result air air ventilation air air last 6 Relevant conditioning the last or conditioning or analysis for the Areas months. conditioning. 0 Preventive and corrective maintenance logbooks OBSERVE


EVIDENCE

INDICATOR

AREAS

COMPLIED

REMARKS

Standard: Current information and scientific data from manufacturers concerning their products products are available for reference and gui dance in the operation and maintenance of plant plant and equipment. 17. Operating manuals of Presence of operating DOCUMENT Engineering/ operating equipment

manuals equipment

REVIEW Operating manual of Medical equipment, generators, air conditioners and other non-medical equipment.

Maintenance Office Imaging, Laboratory

C. EN ENER ERGY GY AND WASTE MANAGEMENT MANAGEMENT collection and disposal of waste waste conform with relevant statutory Standard: The handling, collection and requirements and code statutory requirements of practice practice 18. Licenses/permits/ AdminisPresence of DOCUMENT clearance clea rancess from trative trati ve office REVIEW licenses/permits/ clearances from pertinent 0 Valid pertinent regulatory agencies regulatory agencies, if licenses/permits from applicable regulatory agencies (LGU, DENR, etc.)

Proof of compliance compliance i.e., generator permit, permit, elevator permit, permit, etc. DOCUMENT 0

19. Policies and

Proof of of strict

PART IV - LEVEL 1 HOSPITAL (\/) if the hospital is compliant or X—mark if not not compliant. Instruction: In the appropriate box, compliant. box, place place a check mark (\/)

ATTACHMENT 1.A - PERSONNEL

TOP MANAGEMENT (Should be full-time) Chief of of Hospital/Medical Director

Chief Nurse /Director Nurse /Director 0f Nursing Nursing

0

.

Licensed physician Have completed at least twenty (20) units towards a Master’s Degree in Hospital Administration or related course (MPH, course (MPH, MPA, MHSA, MBA, MPA, MBA, etc.) O_R at least five (5) years hospital experience in a supervisory or supervisory or managerial po posi siti tion on

0 Licensed nurse

0 Master’s Degree in

fl

DOCUMENT

REVIEW a Diploma/Certificate of

earned units earned units 0 Updated Physician Updated Physician license PRC license PRC o Certificates of Trainings attended 0 Proof of of Employment/ Appointment (notarized) 0 Service Reco Re cord rd/C /Cer erti tific ficat atee of of Employment (proof of hospital supervisory/manageria 1 experience) DOCUMENT

REVIEW

exp

nce

ADMINISTRATIVE SERVICES Accountant Billing Officer .

Budget / Finance Officer

Bachelor’s Degree in Accountancy (may be outsourced) With Bachelor’s Degree relevant to the job

Cashier

Human Resources Management Officer/ Personnel Officer Book keeper keeper Supply Officer/ Storekeeper

Medical Records Medical Records officer

1

DOCUMENT

REVIEW

0f ' Diploma/Cgrtificate umts earne _

license PRC license Updated PRC (if applicable) o Certificates of Trainings attended PFOOf 0f Employment/ Appointment (notarized) 0

1

1

1

1

'

With appropriate training DOCUMENT and experience REVIEW 0 Certificates of Trainings attended 0 Proof of of Employment/ Appointment (notarized) DOCUMENT 0 Bachelor's Degree in ICD 0 Training in ICD 10 REVIEW 0 Diploma/Certificate of 0 Training in Medical units earned Records Management units earned

1

l

1

CLINICAL SERVICES Consultant Staff in Pediatrics, Ob-Gyn, Pediatrics, Ob-Gyn, Medicine, Surgery, Medicine, Surgery, and Anesthesia. *HOSPilal may have additional consultan additional consultants ts from other specialties.

Resident Physician not go (Shall not on Duty on Duty (Shall duty for more on duty on more than

A11 Licensed physician DOCUMENT consultants . Fellow/Diplomate REVIEW be at at must be 0 Certificate from ACLS certified (for . ACLS certified least board Specialty society, if Specialty society, Surgeons and eligible. applicable (for applicable (for AnestheSiologists) least one At least At Board Certified) consultant . Residency Training be must be must Certificate (for board Board Eligible) certified 0 Certificate of per specialty. Training/ Residency Training/ Residency Medical Specialists (*DOH Medical Specialist, last exam was in 1989) 0 Updated PRC license 0 Certificates of Trainings attended 0 Proof of of Employment] Appointment (notarized) Licensed physician Wards - 1:20 DOCUMENT beds at any REVIEW 0 Updated PRC given time 0

Head Nurse/Senior Nurse/ Senior Nurse

Staff Nurse Nurse

Apporntment (notarized) 0 Service Record/Certificate of Employment of general (Proof of nursing service administration experience) 1:15 staff DOCUMENT Licensed nurse . 0 With at least 2 years- REVIEW nurses 0 Diploma hospital experience hospital experience license 0 Updated PRC PRC license certified o BLS BLS certified 0 Certificate of trainings attended of employment 0 Proof of (notarized) o If nursing staffing is nursing staffing outsourced: Validity of the contract of 0 Licensed nurse employment should be Ward - 1:12 at least one (1) year Beds at any o BLS certified BLS certified within the the validity given time and within and period of the (plus 1 reliever for hospital’s LTO. CVCI'Y 3 0 Schedule of duty approved by approved by Chief RNS) Nurse

Emergency Room

Licensed nurse in Trauma Trauma Training in and ACLS and Nursing, ACLS other relevant training

approved by Chief Nurse

1:3 beds per

shift (plus 1 reliever for every 3 nurses)

Department Nurse

Licensed nurse in BLS BLS Training in

1

ATTACHMENT 1.B - PHYSICAL PLANT

2.

DOH Approved Floor Plan Plan

3.

Checklist for Review Review of Floor Plans (accomplished)

OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):

ATTACHMENT 1.C — EQUIPMENT/INSTRUMENT EQUIPMENT/INSTRUMENT (Functional)

QUANTITY

AREA

ADMINISTRATIVE SERVICE Ambulance o If owned by hospital, available 24/7 and h sic sicall all resent if not be bein in us used ed Sui/mg tithep of inspection/moiitoring

.

Parking

1

0 If outsourced, shall shall be be on call but able

within reasonable to respond within reasonable time. with Internet Access Computer with Internet

.

Emergency nght

1

'

.

.

.

F1re Extinguishers

with Automatic Transfer Generator set Automatic Transfer set with Switch (ATS)

1

Admgéglreatlve

Lobby, hallway, nurses' station, office/unit and stairways hallway, lobby, hallway, lobby, unit unit nurses' station, or P er office/unit and area stairways 1

Genset house

KITCHEN/DIETARY Exhaust fan Food Conveyor or or equivalent (closedtype) Food Scale

1

1

1

COMPLIED

REMARKS

EQUIPMENT/1N STRUMENT

(Functional)

Instrument/Mayo Table Minor Instrument Instrument Set (May be used for Tracheostomy, Closed Tube Cutdown, etc.) Thoracostomy, Cutdown, Thoracostomy, etc.) Nebulizer Negatoscope Neurologic Hammer OR Light (portable Light (portable or equivalent) or equivalent) Oxygen Unit Tank is is anchored/chained/ strapped strapped or or with tank holder if if not from pipeline Pulse Oximeter Sphygmomanometer, Non-mercurial - Adult Cuff Pediatric Cuff - Pediatric Cuff Stethoscope Suction Apparatus Suturing Set non-mercurial Thermometer, non-mercurial Thermometer, - Oral - Rectal Vaginal Speculum’ Different Sizes Wheelchair Wheeled Stretcher Wheeled Stretcher with guard/side rails wheel lock and wheel and lock or anchor. or anchor.

,

QUANTITY

AREA

1

2 sets 1 1 1 1

2 1

1 1 1

l 2 sets 1 1 .1 for each different Size 1

1

ER

COMPLIED

REMARKS

EQUIPMENT/INSTRUMENT (Functional)

.

QUANTITY

AREA

OPERATINGROOM Air conditioning conditioning Unit Anesthesia Machine Anesthesia Machine

l/OR

Cardiac Monitor Cardiac Monitor with Pulse Oximeter

l/OR

l/OR

Caesarian Section Instrument Caesarian Section Defibrillator with paddles

1

Electrocautery machine to Emergency Cart (for contents, contents, refer to separate list) Glucometer with strips Instrument / Mayo Table

1

pack (Linen pack) Laparotomy pack Laparotomy (Linen pack) Instrument Set Laparotomy / Major Instrument different sizes of Laryngoscopes with different sizes blades Operating room light Operating room light Operating room Operating room table Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder holder if if not not pipeline pipeline Rechargeable Emergency Light Light (in (in case case malfunction) malfunction) generator Sphygmomanometer, Non—mercurial - Adult cuff Pediatric cuff - Pediatric cuff

'

,

.

1

1

1 1 1

set per OR set per OR

OR

1

per OR 1 per OR 1

1

per OR

1

per OR OR

1 1

per OR per OR

COMPLIED

REMARKS


,

QUANTITY

Stethoscope

AREA

1 1

Thermometer, non-mercurial

ROOM LABOR ROOM Fetal Doppler Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder holder if if not not pipeline pipeline Patient Bed Pulse Oximeter

1

1

1

Labor Room Room

1

Sphygmomanometer, Non-mercurial

1

Stethoscope Thermometer, Non-mercurial

1 1

ROOM DELIVERYROOM DELIVERY Air-conditioning Unit unit (Adult and Bag valve mask unit pediatric) Bassinet Clinical Infant Weighing Scale

1

1

1 1

Defibrillator with paddles Delivery set, primigravid Delivery set, multigravida Delivery light

is DR is (if DR

561°32‘83“ Complex ) 1 set 2 sets 1

COMPLIED

REMARKS


QUANTITY

AREA

COMPLIED

REMARKS

provided that they they are are not 50 than meters more away from each from other. each other. to equivalent (refer to Emergency cart or equivalent the contents) separate list for the with EENT Diagnostic Set Set with ophthalmoscope and otoscope different sizes of Laryngoscope with different sizes blades Mechanical/Patient bed with lock, if side rails wheeled; with guard guard or or side Table Bedsxde Nebuhzer Neurologic Hammer Oxygen Unit is anchored/chained if not tank is not pipeline pipeline Non— Mercurial Sphygmomanometer, - Adult cuff Pediatric cuff —

Stethoscope Suction Apparatus Thermometer, non-mercurial - Oral - Rectal

1

1

1

ABC ABC 1

NURSING UNIT/WARD

1

1

1 1 1 1

1 1

CENTRAL STERILIZING & SUPPLY ROOM Autoclave/Steam Sterilizer Autoclave/Steam Sterilizer

1

CSSR

LEVEL L 1 HOSPITAL ATTACHMENT 1.D - EMERGENCY CART CONTENTS FOR LEVE EMERGENCYCART CONTENTS Adenosine 6 Amiodarone

Vial

0R

DR

NSl

st N83

N84 Nss N86 N57 N88 NS9

510

11

512 REMARKS

ule

mL

1

ER

Anti—tetanus serum (either equine-based serum (either

human antiserum antiserum or human antiserum let 325 irin USP ine

ml

1

nists i.e. Salbutamol 2 Benzodiazipine (Diazepam 10mg/2m1 ampule ' box alert box alert Midazolam in and/or Midazolam Calcium (usually calcium gluconate 10% in 10 mL solution in solution l 75 tablet Cl ' D5W 250 mL 250 mL D50W mL

0.5 '

'

henh

Dobutamine

5mL 5mL

200 hrine 1

ml

ule

Furosemide 2 Hal H

'dol '

e ule/Vial

mL

6

2

Lidocaine 10% in 50mL solution via] Lidocaine 2% Lidocaine 2% solution sulfate

vial 1

50ml

mL Mannitol 20% solution 20% solution in 500ml/bottle 1

DOH-HOS-LTO-AT—L1-PIV Revision:01

04/23/2018 Page 12 of 19

~

CONTENTS CART CONTENTS EMERGENCYCART

ER

OR DR N81 N82 N8 N83 3 N84 N85 N85 N8 N86 6 N8 N87 7 N8 N88 8 N8 N89 9 NS 10 NS 11 N8 12 REMARKS

Methylprednisolone 4mg/tablet Methylprednisolone 4mg/tablet 10mg/2mL ampule Metoclopramide 10mg/2mL Metoclopramide Morphine sulfate 10mg/mL ampule (in high alert box ) Nitroglycerin inj. 10 mg/ 10mL ampule or dinitrate 5mg SL tablet or 10 Isosorbide dinitrate Isosorbide mg/ 10mL ampule Noradrenaline 2mg/2mL ampule 2mg/2mL ampule Paracetamol 300mg/ampule (IV preparation) 300mg/ampule (IV Phenobarbital 120mg/m1 ampule IV or 30mg 30mg tablet (in high alert box ) (in high 100mg/capsule or 100 mg/ZmL Phenytoin 100mg/capsule Phenytoin ampule LRS 1L/bottle Plain LRS Plain Chloride Sodium Chloride Plain NSS Plain 0.9% Sodium NSS 1L/bottle — 0.9% Chloride 40mEq/20mL vial (in high Potassium Chloride Potassium alert box ) B1/6/12 vial vial (1g B1,1g B6, Vitamin B1/6/12 Vitamin B6, 0.01gB12 0.01gB12 in 10 mL vial) bicarbonate 50mEq/50mL ampule Sodium bicarbonate Sodium Verapamil 5 rug/2 ml ampule

EQUIPMENT/SUPPLIES Airway adjuncts Airway adjuncts Intubation Kit ( with stylet and bag / Intubation Airway / valve masks ) disinfectant Alcohol disinfectant Alcohol Aseptic bulb syringe Calculator Capillary Blood Glucose (CBG ) Kit Board Cardiac Board Cardiac Endotracheal Tubes, Endotracheal Tubes, all sizes

DOH—HOS—LTO-AT-L1-PIV

Revision:01

04/23/2018 Page 13 of19

E

2

CART CONTENTS EMERGENCYCART EMERGENCY

ER

OR DR N81 N52 N83 NS4 NS4 NS NSS S NS NS6 6 NS7 NS NS8 8 NS NS9 9 NS 10 NS 11 NS 12 REMARKS

Pen lights Flashlights or Pen Flashlights or Gloves, sterile Gloves, non-sterile blades Laryngoscope with different sizes of blades cannula Nasal cannula Nasal mask or face shield or mask Protective face Protective goggles or goggles Standard face mask Sterile gauze ( pre—folded and individually packed ) (different volumes) volumes) Syringes (different catheter Urethral catheter Urethral collection bag Urine collection Urine Waterproof aprons aprons

*Notes: — Emergency Room ER — — Operating Room OR — — Delivery Room DR — NS — Nurses’ Station Nurses’ Station

DOH-HOS-LTO-AT—L1-PIV Revision:01

04/23/2018 Page 14 of 19

ASSESSMENT TOOL FOR LEVEL LEVEL 1 HOSPITAL ATTACHMENT 1.E — ADD-ON SERVICES CHECKLIST the following add-on Level 1 hospitals applying for the add-on services services must comply first with the licensing the following: standards for the 1. Physical plant of the the desired add-on service by securing an approved DOH DOHPermit Permit to

Construct; and Licensing standards for the required ancillary and support units (e. g. tertiary clinical laboratory, Level 2 x-ray facility, board certified certified specialists, specialists, and respiratory therapy unit). level of hospital. Thus, it is still strongly recommended to upgrade to a higher level hospital. 2.

A. INTENSIVE CARE UNIT CARE UNIT (ICU)

7‘

Multidisciplinary Team composed of, but not limited to, board certified Cardiologist, Pulmonologist, Neurologist, Pulmonologist 0_R an an Intensivist Nurse

I

by

i

Licensed physrcian . Fellow/Diplomate

0 Licensed nurse

DOCUMENT REVIEW 0 Diploma/Certificate from Specialty society Specialty society 0 Updated PRC license o Certificates of Trainings attended 0 Proof of of Employment / (notarized) Appointment (notarized) Appointment DOCUMENT REVIEW

team composed of least 1 per at least at specialty (May be part time or visiting consultant/s) an intensivist 1:3 beds at

1‘

Air Conditioning Conditioning Unit Unit Bag-valve-mask Unit Adult - Pediatric Cardiac Monitor Cardiac Monitor with Pulse Oximeter Pulse Oximeter Defibrillator with with paddles EENT Diagnostic Set with Set with ophthalmoscope and otoscope to Emergency Cart (for contents, contents, refer to separate list).

1

1 1

1 1

1

1

Infusion pump

1

different sizes of Laryngoscope with different sizes blades Mechanical Bed

1

Depending on Depending on the number of of beds applied

Mechanical Ventilator (May Mechanical Ventilator (May be outsourced) Minor Instrument Instrument Set (May be used for used for Closed Tube Closed Tube Tracheostomy, Cutdown, etc.) Thoracostomy, Cutdown, Thoracostomy, etc.) Oxygen Unit is anchored/chained/ strapped Tank is

set

1

1

set

1

7».~>~:"?'l‘3>.-,.lni 1;.

7

Nurse

0 Licensed nurse 0 Certificate of

in Critical Critical Training in Care Nursing, ACLS

Nursing Attendants/ -

-

M1dw1fe

0 Highschool

graduate . 0 With relevant With relevant health-related

“'31;qu h ouse

32331;?

DOCUMENT REVIEW - Diploma license PRC license - Updated PRC Certificate of trainings attended - Proofof employment (notarized) - If nursing staffing is nursing staffing outsourced: Validity of the contract the contract of be should be employment should and least (1) at one year within the validity period of the hospital’s LTO. - Schedule of duty approved by Chief Nurse DOCUMENTS REVIEW o Certificates of Trainings attended 0 Proofof Employment ( notarized )

1:3 bassinets/

incubator/ warmer (1 reliever for every 3 RNs)

1.12 . b.assmets/

incubato r / warmer (1 reliever for every 3 NAs)

with neonatal blades blades of Laryngoscope with neonatal different sizes

1

Mechanical Ventilator (May Mechanical Ventilator (May be outsourced)

1

Neonatal Stethoscope

1

Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder if if not not pipeline pipeline

1

for Breast milk Breast milk storage Refrigerator for storage

1

Sphygmomanometer, Non-mercurial - Neonate

1

Suction Apparatus

1

Thermometer, Non-mercurial

l

Umbilical Cannulation Umbilical Cannulation set C.

1

set

PREGNANCY UNIT (HRPLD HIGH RIS RISK K PREGNANCY UNIT

period of the hospital’s LTO.

of duty approvedby Chief Nurse DOCUMENTS REVIEW 0 Certificates of Trainings attended 0 Schedule

Nursing Attendants/ MidWife

o Highschool

graduate 0 With relevant health-related training be in in house (may be training)

1:12 beds beds at at any

given time 1 reliever for every 3

(P1115

0 Proofof Employment NAS/MWS)

( notarized )

Cardiac Monitor with Pulse Cardiac Monitor with Pulse Oximeter

1

Cardiotocography (CTG) Machine Cardiotocography (CTG)

1

Fetal doppler

1

PART IV - LEVEL 2 HOSPITAL (\I) if the hospital is compliant Instruction: In the In the appropriate not compliant. box, place compliant. place a check mark (\I) compliant or or X—mark if not appropriate box,

ATTACHMENT 2.A - PERSONNEL

TOP MANAGEMENT (Should be full-time) Chief of of Hospital/Medical Director

I Licensed physician DOCUMENT REVIEW 0 Have completed at completed at o Diploma/Certificate of least twenty (20) units towards a Master’s Degree in Hospital Administration or related course (MPH, MBA’ MFA, MHSA, etc.) MHSA, etc.) at least five (5) years hospltal experience in a superv1sory or . . managerlal pos1tlon

fl];

Chief of of Clinics / Chief Medical Professional

1

earned units earned units 0 Updated Physician PRC license 0 Certificates of Trainings attended 0 Proof of of Employment/ (notarized) Appointment (notarized) Appointment

. SCI'VlCC

Record/Certificate of of Employment (proof of hospital supervisory/managerial experience) 0 Licensed physician DOCUMENT REVIEW 0 Fellow/diplomate of o Diploma/Certificate a specialty/ from Specialty society Specialty society

1

Appointment (notarized) Appointment (notarized) 0 Service Record/Certificate of of Employment (proof of supervisory/managerial experience in nursing) DOCUMENT REVIEW

superv1sory or managerial position managerial position in nursing (RA. No. 9173)

Chief Administrative Officer/Hospital Administrator

Have completed at least twenty (20) Units towards Master’s towards Master’s

0

.

Degree in Hospital Administration or related course (MPH, course (MPH,

o

0

MBA? MPA’ MHSA’

etc.) AND at least five (5) years hospital experience in a supervisory / managerial position. managerial position.

.

Diploma/Certificate 0f umts earned . Updated PRC hcense Certlficates of Trainings att en(1 e d Proof of of Employment/ (notarized) Appointment (notarized) Appointment Service Record/Certificate of of Employment (proof of Employment (proof hospital SLIpCI’VlSOI'y/ manager 1a1 experience) _

ADMINISTRATIVE SERVICES Certified Public Accountant (may be outsourced)

ACCOlll'l t ant

Billing Officer

-

W1th Bachelor , s

Degree relevant to the

DOCUMENT REVIEW 0 Diploma/ Certificate Of units earned units earned 0 Updated PRC license (if applicable)

Medica Medi call So Soci cial al Lice Li cens nsed ed So Soci cial al worker (Full Time) (Full Time) Worker

(notarized) DOCUMENT REVIEW 0 Diploma / Certificate of earned units earned units

1

license PRC license Updated PRC certificates 0f Trainings attended 0

NutritionistDietician (Full

Licensed Nutritionist Dietician

0

Time)

1

Proof of of Employment / Appointment (notarized)

Building Maintenance

May be outsourced.

Man/Utility Worker Security Guard

must be guard must Security guard licensed.

(llcensed)

DOCUMENT REVIEW 0 Relevant Training 0 License, if applicable 0 Proof of of Employment/

aifgfiggirii employed

1

per shift

1

per Shift

by hospital by hospital 0 Notarized MOA if outsourced

CLINICAL SERVICES Consultant Staff in in Ob-Gyn, Pediatrics, Medicme, Surgery, Medicme, Surgery,

DOCUMENT REVIEW Certificate from 0 Certificate from o Fellow/Diplomate 0 ACLS certified ACLS certified (for Specialty society, if Board applicable (for Board applicable (for Surgeons and 0 Licensed physician

50% of At least 50% At least the consultants specialty per specialty

s

i

__

pulmonologist O a neonatologist High RiSk Pregnancy Unit: General .

.

Obstetnc1ans, preferably Wlth a Perinatologist, and a referral team of IM specialists

DOCUMENT REVIEW

0 Licensed physician

.

0 Fellow/Diplomate

0

Resident Physician Licensed physician not (Shall not Duty (Shall on Duty on duty for on duty go on than 48 hours

.

Certrficate from . Specialty somety, 1f Board applicable (for Board applicable (for Certified) Residency Training Board Certificate (for Board Eligible)

’ certificate 0f

Residency Training / Residency Training Medical Specialists (*DOH Medical Specialist, last exam was in 1989) license PRC license Updated PRC Certificates of Trainings attended 0 Proof of of Employment/ Appointment (notarized)

General Obstetricians, preferably with a

Perinatologist, and a referral team of IM specialists (May be part time or visiting visiting consultant)

DOCUMENT REVIEW Wards - 1:20 0 Updated PRC license beds at any PRC license given time . certificates Of PLUS Trainings attended

QUALIFICATION

PQ§1TION Supervising Nurse/Nurse Managers

Head Nurse/ Senior Nurse

Staff Nurse Nurse

Staff Nurse Nurse in

EVIDENCE

DOCUMENT REVIEW Licensed nurse 0 With at least least nine nine I Diploma/Certificate of Units Earned Units Earned (9) units of Master's Updated PRC license Degree in Nursing least two (2) Certificates of 0 At At least years-experience in Trainings attended 0 Proof of general nursing general nursing of Employment/ service Appointment administration. (notarized) 0 Service Record/Certificate of of Employment (Proof of general nursing service administration experience) DOCUMENT REVIEW 0 Licensed nurse 0 With at least 2 Diploma years-hospital 0 experience Updated PRC license 0 BLS 0 Certificate of trainings certified BLS certified attended o Licensed nurse PFOOf 0f employment o BLS certified BLS certified (notarized) . o If nursmg staffingis outsourced: Validity of the contract of 0 Licensed employment should be 0

'

'

COMPLIED ., REMARKS

-

1

per Department — Office hours only (8am — only (8am 5pm)

per shift per clinical 1

department

Ward - 1:12 beds at any time (1 reliever for every 3 RNs) 1:3 beds at

e emp oymen s on emp oymen at least one (1) year and within the validity period of the hospital’s LTO. 0 Schedule of duty 0 Licensed nurse approved by Chief approved by Nurse 0 Training in in Trauma Trauma and ACLS and Nursing, ACLS other relevant training 0 Licensed nurse 0 Training in in BLS BLS

rammg 1n ssen 1a Integrated Newborn Care [EINC]) in BLS and 0 Training in BLS and ACLS

Emergency Room Nurse ‘

Outpatient Department Nurse

nurses

1:3 beds per Shift (P1115 1 reliever

for every 3 nurses) 1

hours Office hours Office only (8am — 5pm)

Dentist — MOA if outsourced but the dental service should be should be within the vicinity 0f hospital Respiratory Therapist

Licensed dentist

DOCUMENT REVIEW o

. . Licensed respiratory licensed therapist or licensed therapist or nurse with respiratory therapy training therapy training

Diploma license PRC license Updated PRC Certificates of

Trainings attended 0 Proof of of Employment/ Appointment (notarized) If outsourced: Validity of the contract of

1

Office hours

only (8am — 5pm)

1

per shift

ATTACHMENT 2.B - PHYSICAL PLANT

1.

DéH -Ap’prav'éd fife

2.

DOH Approved Floor Plan

3.

Checklist for Review Review of Floor Plans Plans (accomplished)

OBSERVATIONS/FINDINGS (may use separate additional sheets if needed):

ATTACHMENT 2.C —EQUIPMENT/INSTR —EQUIPMENT/INSTRUMENT UMENT EQUIPMENT/IFSTRUMENT (Functional)

QUANTITY

A REA AR

ADMINISTRATIVE SERVICE Ambulance Available 24/7 0 Available 24/7 not being being used - Physically present if not during time of inspection/monitoring . w1th Internet Access Computer w1th

.

Emergency nght

.

.

.

Fire Extlnguishers

1

Parking

Administrative Office lobby, hallway, nurses‘ station, and office/unit and office/unit stairways lobby, hallway, 1 nurses‘ station, unit or per office/unit and office/unit and area 1

Stairways

with Automatic Generator set Transfer Automatic Transfer set with Switch (ATS)

1

house Genset house Genset

KITCHEN/DIETARY fan Exhaust fan Exhaust Food Conveyor or equivalent (closed— or equivalent type) Food Scale

1

1

1

COMPLIED

REMARKS


QUANTITY

Examining table

1

OBExamining table (with (with Stirrups Stirrups for OBGyne)

1

AREA

Glucometer with with strips Gooseneck lamp/Examining Light lamp/Examining Light

1

Instrument/Mayo Table

1

Minor Instrument Instrument Set (May be used for Closed Tube Tube Tracheostomy, Closed Thoracostomy, Cutdown, etc.) Cutdown, etc.)

2 sets

Nebulizer

1

Negatoscope Neurologic Hammer OR Light (portable Light (portable or equivalent) or equivalent) Unit Oxygen is anchored/chained/ strapped Tank is strapped or or with tank holder if if not not pipeline pipeline

1 1 1

2

Pulse Oximeter Pulse Oximeter

1

Sphygmomanometer, Non-mercurial - Adult Cuff Pediatric Cuff

l

—

1

1

ER

COMPLIED

REMARKS

EQUIPMENT/INSTRUMENT .

(Functional)

QUANTITY

Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder if if not pipeline Peak flow meter - Adult Pediatric Sphygmomanometer, Non-mercurial Adult cuff - Pediatric cuff

AREA

1

1

—

l

—

1

Stethoscope Thermometer, non-mercurial - Oral - Rectal Removal Set Suture Removal Suture Set Wheelchair / / Wheeled Stretcher

OPD

1 1

1 1 1

set l

ROOM OPERATINGROOM OPERATING Air conditioning conditioning Unit Anesthesia Machine Anesthesia Machine

1

Cardiac Monitor with Pulse Cardiac Monitor with Pulse Oximeter Ceasarian Section Ceasarian Section Instrument Instrument Defibrillator with with paddles

l

Electrocautery machine to Emergency Cart (for contents, contents, refer to separate list) Glucometer with with strips

1

1

l 1

1

COMPLIED

REMARKS


QUANTITY

A REA AR

COMPLIED

UNIT / RECOVERYROOM POST ANESTHESIA ANESTHESIA CARE CARE UNIT / Air conditioning conditioning Unit Cardiac Monitor Cardiac Monitor

1 1

(if separate from the OR Complex ) 1 (if separate from the OR Complex ) 1

With paddles Defibrlllator With

imiregfenlciztfart p

to (for contents, contents, refer to

Mechanical / patient bed, with guard side patient bed, rails and wheel lock wheel lock or anchored or anchored Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder holder if if not not pipeline pipeline Sphygmomanometer, Non-mercurial Adult cuff - Adult cuff Pediatric cuff Stethoscope Thermometer, non-mercurial

P ACU /RR ACU/RR

1

1

1

P ACU /RR ACU/RR

1 1 1

LABORROOM Fetal Doppler Oxygen Unit is anchored/chained/ strapped Tank is strapped 0r 0r with tank holder if if not not pipeline pipeline Patient Bed

1

1

1

Labor Room

REMARKS


QUANTITY

Instrument/Mayo Table

1

Kelly Pad or equivalent equivalent

1

different sizes of Laryngoscope with different sizes blades Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder if if not not pipeline pipeline Rechargeable Emergency Rechargeable Light (In (In case Emergency Light case of generator malfunctions) malfunctions)

AREA

1

1

1

-Non-mercurial Sphygmomanometer -Non-mercurial

1

Stethoscope

1

Suction Apparatus

1

Wheeled Stretcher Wheeled Stretcher

1

DR

HIGH HIG H RIS RISK K PREGNANCY UNIT Cardiac Monitor with Pulse Oximeter

1

Cardiotocography (CTG) Machine Fetal doppler Oxygen Unit is anchored/chained/ strapped Tank is strapped or or with tank holder if if not not pipeline pipeline

1 1

1

HRPU

COMPLIED

REMARKS

EQUIPMENT/INSTRUMENT . (Functional) Sphygmomanometer, Non-mercurial for neonate neonate Suction apparatus Thermometer, Non-mercurial Umbilical Cannulation set

QUANTITY

.

AREA

COMPLIED

REMARKS

1

1 1 1

set

INTENSIVE CARE UNIT (ICU) — For all INTENSIVE all types of ICU (PICU, SICU, Medical ICU, etc.) U, SICU, 1 Air conditioning conditioning unit Unit Bag-valve-mask Unit 1 - Adult 1 - Pediatric 1 Cardiac Monitor Cardiac with Pulse Oximeter Pulse Oximeter Monitor with 1 Defibrillator with paddles to Emergency Cart (for contents, contents, refer to 1 list) separate with EENT Diagnostic Set Set with 1 set ophthalmoscope and otoscope 1 Infusion pump Laryngoscope with different sizes of 1 blades Depending on Depending on the number of Mechanical Bed Mechanical Bed of ICU beds declared Mechanical Ventilator Mechanical Ventilator / / Respirator (May (May 1 be outsourced) Minor Instrument Set Instrument Set (May be used for

EQUIPMENT/INSTRUMENT . (Functional)

QUANTITY

Mechanical/Patient bed with look, if Mechanical/Patient bed side rails wheeled; with guard guard or or side rails

ABC

Bedside Table

ABC

Nebulizer

1

Neurologic Hammer

1

Oxygen Unit is anchored/chained if not pipeline tank is Sphygmomanometer, Non— Mercurial - Adult cuff - Pediatric cuff

AREA

COMPLIED

1

1 1

Stethoscope

1

Suction Apparatus

l

Thermometer, non-mercurial - Oral - Rectal

1 1

RESPIRATORY/PULMONARYUNIT ABG Machine Function Test Peak Test (PFT) Pulmonary Function (PFT) or or Peak Flow Rate Rate (PEFR) Tube Expiratory Flow Spirometer

1

1

Respiratory / Pulmonary Unit

REMARKS

EQUIPMENT/INSTRUMENT (Functional) '

Surgical Malette

QUANTITY

AREA

COMPLIED

1

CENTRAL STERILIZING & SUPPLY ROOM Autoclave/Steam Sterilizer

Bed or stretcher stretcher for cadaver cadaver

1

CSSR

CADAVER HOLDINGAREA/ROOM HOLDING AREA/ROOM CADAVER l HOLDING AREA

REMARKS

ATTACHMENT 2.D - EMERGENCY CART CONTENTS FOR LEVEL 2 HOSPITAL CART CONTENTS EMERGENCY CART

ER

0R DR ICU

HRPU

N32 N8 N83 3 N8 N84 4 N5 N55 5 N8 N86 6 N8 N87 7 s1 N3

vial Adenosine 6 mL Amiodarone 1 e Anti-tetanusserum (either equine-based antiserum or human antiserum ' 325 let USP ml

e ml i.e. Salbutamol 2 (Diazepam 10mg/2ml ampule Benzodiazipine(Diazepam Benzodiazipine aler ertt box and/or Midazolam and/or Midazolam in hi al Calcium (usually calcium gluconate 10% solution in 10 mL e ' 75 tablet Cl 1

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Dobutamine2

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200

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10% in in 50mL Lidocaine 10% 2% Lidocaine solution vial l 50ml sulfate

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Mannitol 20% solution in 500ml/bottle Meth Metocl

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1 1

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6 6

in hi in hi

DOH-HOS-LTO-AT-LZ-PIV Revisionzo1

04/23/2018 Page 16 of 18

EMERGENCY CART CONTENTS

ER

0R DR ICU NIC NICU U HRPU N81 N82 NS3 NS3 NS NS4 4 NS NSS S N8 N86 6 N87 orrmzxs mums REMARKS

alert box ) Nitroglycerin inj. 10 mg/ 10mL ampule or Isosorbide dinitrate 5mg SL tablet or 10 mg/l OmL ampule Noradrenaline 2mg/2mLampule Paracetamol 300mg/ampule (IV prepa preparatio ration) n) 300mg/ampule(IV Phenobarbital 120mg/ml ampule IV or 30mg 30mg box ) tablet (in alert box (in high high alert Phenytoin lOOmg/capsule or 100 mg/2mL ampule Plain LRS lL/bottle SodiumChloridee PlainNSS lL/bo lL/bottle ttle — 0.9% SodiumChlorid Potassium Chloride 40mEq/20mL vial (in high alert box ) Vitamin Bl/6/12 vial (1g B1,1g B6, 001an in 10 mL vial)

bicarbonate 50mEq/50mL Sodium bicarbonate Sodium ampule 50mEq/50mLampule Verapamil 5 mg/2 ml ampule

misurrmas EQUIPMENT

-

Airway adjuncts Airway / IntubationKit ( with stylet and bag valvemasks ) Alcohol disinfectant Aseptic bulb syringe Calculator Capillary BloodGlucose (CBG ) Kit Cardiac Board sizes all sizes Endotracheal Tubes, all Flashlights or Pen lights Gloves , sterile Gloves, non—sterile

DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 17 of 18

EMERGENCY CART CONTENTS

OTHERS

arms REMARKS

blades Laryngoscope with different sizes of blades Nasal cannula mask or goggles Protective face shield shield or mask goggles Standard face mask Sterile gauze (pre-folded and individually packed ) Syringes (different volumes) Urethral catheter Urine collection bag Waterproof aprons

*Notes: ER — — Emergency Room — Operating Room OR — — Delivery Room DR — NS — Nurses’ Station Nurses’ Station

DOH-HOS-LTO-AT-LZ-PIV Revision:01 04/23/2018 Page 18 of 18

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