Doh Assessment Tool

Department of Health
Bureau Of Health Facilities And Services (BHFS)

ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS
OUTLINE OF CONTENTS
I.
II.
GENERAL INFORMATION(page 2)
HOSPITAL ADMINISTRATION
A. Services
1. Administrative Service(pages 3-9)
1.1. Human resource
1.2. Accounting
1.3. Budget and Finance
1.4. Billing and claims
1.5. Medical Records
1.6. Procurement
1.7. Property and Supply Management
1.8
Linen and Laundry
1.9
Housekeeping
1.8. Nutrition and Dietary
1.9. Security Services
1.10. Ambulance Services
1.11. Central Information Management
1.12. Medical Records
1.13. Medical Social Services
1.14. Nutrition and Dietetics
1.15. Pharmacy
2. Patients Rights and Organizational Ethics
(pages 13-15)
3. Patient care (pages15-22)
4. Leadership and Management (pages 23-24)
5. Human Resource Management (page 25)
6. Information Management (page26)
7 . Maintenance of Environment of Care (pages 37-40)
8. Patient Safety (page 41-49)
Assessment Tool for

Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 1 of 96
7. Safe Practice and Environment (pages 27-37)

8. Patient and Staff Safety
11.Waste Management (page 49-52)
12.Improving Performance (page 52)
13. Leadership and Management
A. Clinical Services(page 53)
1.Level 1
2.Level 2
3.Level 3
III. PERSONNEL
POSITION STAFFING REQUIREMENT(pages 54-57)
1. Top Management Personnel Qualification Standard
2. Administrative
3. Clinical
4. Nursing
5. Ancillary
IV. EQUIPMENT AND INSTRUMENTS ()
A. List of Equipment and Instrument Requirement
1. Administrative
2. Clinical
2.1. Emergency Room
2.2. Outpatient Care
2.3. Operating Room
2.4. Recovery Room
2.5. High Risk Pregnancy Unit
2.6. Delivery Room
2.7. Pathologic/ Premature Nursery

2.8. Intensive Care Unit
3. Nursing Unit/Ward
4. Isolation Room
5. Physical Medicine and Rehabilitation Unit
6. Central Sterilizing and Supply Room
7. Dialysis Clinic
8. Ambulatory Surgical Clinic
9. Dental Clinic
7. Dietary
V. PHYSICAL PLANT REQUIREMENT(67-71)
Required rooms/areas/offices
VI.HOSPITAL PROGRAMS(72-74)
1. Blood Services ( 72)
2. Newborn Screening(72)
3. Mother-Baby Friendly Hospital Initiative(73)
4. Health Promotion and Disease Prevention (73)
5. Generics Act (74)
6. Health Emergency Management Services74()
VII.HOSPITAL COMMITTEES (page 75)
VII. HOSPITAL OPERATIONS CRITERIA(page 76)
VIII. SIGNATURE PAGE (page 77)
I. GENERAL INSTRUCTIONS:
1. Check to make sure that you have the complete tool with a total
ofseven-eight(78) pages and copies of the SOE,SOM and NOV Forms.
2. Assign sections of the tool to corresponding team members.
3. To properly fill-out this tool, the Regulatory Officer shall make use of:
INTERVIEWS, REVIEW OF DOCUMENTS, OBSERVATION

and VALIDATION of findings.
4. If the corresponding items are present or available, place a on each
of the appropriate boxes alongside each corresponding item. If not,
put an Xinstead.
5. The REMARKS column shall document relevant observations both
positive and negative, including innovations and initiatives undertaken
by those responsible in the facility.
6. Make sure to fill-in the blanks with the needed information. Do not
leave any items blank; writeN.A.if not applicable.
7. (Sh shaded cell means that specific items are not applicable to the
hospital level.
8. means the service can be outsourced but must be inside hospital
premises.
9. The Team Leader shall at the end of the inspection or monitoring visit,
make sure that the team members complete their respective tool
section and proceed to accomplish the Summary of Evaluation (SOE)
or Summary of Monitoring (SOM) Form and if warranted, the Notice of
Violation (NOV) Form.
10. The Team Leader shall ensure that all team members write down their
printed names, designation and affix their signatures and indicate the
date of inspection or monitoring,all at the last page of the Assessment
Tool, on the SOE and SOM Forms and if warranted, also on the NOV
Form.
11. The Team Leader shall make sure that the Head of the facility or, when
not available, the next most senior or responsible officer affix his/her
signature on the same aforementioned pages and indicate the position,
to signify that inspection or monitoring results were discussed during
the exitconference and a copy of the SOE or SOM and, only if
warranted, that of the NOV, were received.
12. This shall also serve as self-assessment tool for facility owners and
monitoring tool.
GENERAL INFORMATION:
Name of Hospital:
Address:
(Number &Street)
(Barangay/District)
(Municipality/City)
(Province &Region)
Telephone No./ Fax No.

E-mail Address:
License No (for renewal):
Date IssuedExpiry Date:
Hospital Category:
Level 1 Level 2 Level 3
Philhealth Accreditation:Center of: Safety QualityExcellence

Classification According to Ownership: Government Private
No. of: Authorized Bed Capacity
Implementing Beds
Name of Owner or Governing Body (if corporation):

Name of Hospital Administrator, Medical Director or Chief of Hospital
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DOH MONITORING
DOH INSPECTION
SELF-ASSESSMENT
CRITERIA
INDICATOR
AREA
EVIDENCE
ON:
he requirements of quality health service delivery, health regulation, health financing andgood governance.
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REMARKS
TIVE AND
RVICE:
ensure
timely
irect
es to all
e Group:
urce
a
e human
agement
ludes
election,
paration,
enefits in
th
s.
Documented and
implementable policies and
procedures
Approved documented
policies, guidelines and
procedures on:
a) Staffing plan
b) Recruitment and
Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training
Approved documented
policies, guidelines and
procedures on
a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training
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Complete, updated
and
easily retrievable
individual personnel file
Evidence of
continuous
improvement
Verifier:
Documents
review, Observe
Interview staff,
Validate
List of personnel
check if
Current
:
f)
g)
h)
i)
&
j)
Performance Evaluation
Rotation/Transfer
Succession Plan
Merit, Promotion, Awards
Incentives
Resignation, Termination
and Retirement
k) Physical Examination
record of schedule of
duties
appointment/employment
contract, if valid
updated health certificate
(as required)
orientation plan/program of
new employees
implemented
record of schedule of duties
appointment/employment
contract, if valid
updated health certificate
(as required)
orientation plan/program of
new employees implemented
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Verifier:
Documents
review, Observe
Interview staff,
Validate
List of personnel
check if
Current
Group
a
documented and
implementable policies
and procedures
Documents are readily

available
Verifier:
Documents review,
Interview staff,
Validate
documented and
and procedures
Look for approved Work

and Financial Plan and
its implementation
Verifier:
Documents review,
Interview staff,
Validate
laims
a system
nts and
claims.
documented and
and procedures
Proof of transactions
Policies, guidelines and

procedures on requisition,
purchase, issuance and
inventory; disposal of non-
l financial
preparation
ments and
s, and
and
f Books of
a
and
the
sal, Work
ans
n and
the
oncerned
a
e plan of
nagement
t and
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Verifier:
Documents review,
Interview staff,
Validate
Verifier:
Documents
review, Observe
Interview
Supply
a
y of
e,
conduct of
documented and
procedures
Documents are readily

available
Verifier:
Documents review,
Interview staff,
Validate
Laundry
adequate
n linens for
ther
Sorting of soiled and

contaminatedlinens in
designatedareas
Systematic washing of
laundry with safeguard
against spread of infection
Disinfection of laundry
ping
provision
nce of
d sanitary
Adequate
housekeeping
supplies.
Policies, procedures
and guidelines in
cleaning and washing of
soiled linens
evidence of continuous
review of policies and
procedures
Verifier:
Documents review,
Interview staff,
Validate
Verifier:
Documents review,
Interview staff,
Validate
or hospital
ients and
order
pital
protection
rties and
ucture
arm and
Services
o A.O.
ational
Security check for internal

and external customers
including use of visitors pass
Documented and approved

policies and procedures on
patient transport to and from
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procedures
Verifier:
Documents review,
Interview staff,
Validate
mation
a
e plan of
nagement
search for
ent of
lization of
ts and
of human
erating
24 hour availability of
ambulance for ready use
Available contract/ MOA, if
contracted out
Logbook on transport of
patients/clients by ambulance
to and from the facility
documented and
procedures
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With appropriate
manpower, equipment
and supplies during
patient transport
If contracted out; note
specifications in contract
or MOA
Verifier:
Documents review,
Observe,
Interview
staff&Validate
Medical Records
There shall be an
organized system of
recording, processing,
analyzing, maintaining
and safekeeping of all
patients' records through
the written data in
sequence of events
covering the diagnosis,
treatment and discharge
of patients
Medical Social
Services
There shall be policies
and procedures in place
pertaining to social case
work,
multisectoralnetworking
and linkages in
understanding the sociobehavioral and economic
plight of patients and
their families for the
holisticapproach in
theirmanagement and
treatment
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Documented and
procedures
ICD-10 reference books and
with additional ICD-10
modification
Logbooks on:
Admission
OR
DR
ER
OPD
Verifier:
Documents review,
Interview staff,
Validate
Approved documented
policies and procedures and
records on:
a)Patient classification according
to their capacity to pay
b) Continuity of care
c) Counselling of patients/clients
and their families
d) Records of pre-admission
and pre- discharge assessment,
and discharge plan
Available contract or MOA

with DSWD or the LGU
whenever applicable
(for private hospitals)
Allocation of not less than
10% of its Authorized bed
capacity as charity beds.
Compliance to RA 9439, An
Act Prohibiting the Detention
of Patients in Hospitals and
Medical Clinics on Grounds of
Nonpayment of Hospital Bills
or Medical Expenses, (IRR,
Verifier:
Observe,
Interview staff,
Validate
Nutrition And
Dietetics
1.1,1.f
1.1.1.g
There shall be
maintenance and
provision of safe, high
quality and nutritious
food to patients and
personnel.
Pharmacy
There shall be 24 hours,
7 days a week provision
of safe, affordable and
efficacious drugs and
medicines in accordance
with the Generics Act,
PNDF and DOH policies,
rules and regulations.
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Actual implementation
and evidence of
continuous review of
policies and procedures
If contracted out; note
specifications in contract
or MOA
documented and
and procedures
documented and
implementable
policies and
procedures
Verifier:
Observe,
Interview staff,
Validate
Verifier:
Observe,
Interview staff,
Validate
DOH MONITORING
INSPECTION DOH
2.1
SELF-ASSESSMENT
CODE
EVIDENCE
STANDARDS
CRITERIA
INDICATOR
AREA
PATIENTS RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations
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REMARKS
2.1.1
2.1.2
1.Organizational policies
and procedures respect
and support patients'
right to
to quality care and their
responsibilities in that
care.
quality care and their
responsibilities in that
care.
Informed consent is
obtained from patients prior
to initiation of care.
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.
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All patient charts have

signed consent.
DOCUMENT
Patient charts sample
charts of patients
currently admitted. If
hospital is departmentalized, get samples
during tour of the
differentdepartments.
Note: *Informed consent includes a patient-doctor
discussion of the following
issues: the nature of the
decision or procedure;
reasonable alternatives to
the proposed intervention;
the relative risks, benefits,
and uncertainties related to
each alternative;
assessment to patient
understanding; and
patient's acceptance or
refusal of the intervention.
Presence of facilities
consistent with clinical
service capability
based on DOH license
in accordance with the
hospitals level (e.g.
level 1 surgical
capability, level 2
ICU, level 3 teaching
and training hospital).
DOCUMENT
REVIEW
List of services
available
OBSERVATION:
Look at the facilities,
structure, manpower,
equipment and
supply. Check if the
service capability of
the hospital is in
accordance with
the hospital level.
Wards
(sample
size-10
charts, if
department
-alized, get
two from
each
department; when
a chart is
found to
have no
consent
before you
reach 10,
you do not
have to go
further.)
ER
OPD
ICU
OR
RR
PACU
2.2
2.2.1
2.2.1.a
PATIENT CARE
ACCESS - Goal: The organization is accessible to the community that it aims to serve.
3.Physical Access
to the organization
and its services is
facilitated and is
appropriate to
patients' needs.
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Entrances and exits are

clearly and prominently
marked, free of any
obstruction and readily
accessible.
Presence of entrances
and exits that are
readily accessible and
free from obstruction.
OBSERVATION
Entrances and exits
are accessible and
free from any
obstruction.
Note: Exit signs
ER
OPD
Wards
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)
2.2.1.b
2.2x1.c
4.Physical access to
the organization and its
services is facilitated
and is appropriate to
patients' needs.
5.Physical access to
the organization and its
services is facilitated
and is appropriate to
patients' needs.
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Directional signs are

prominently posted to
help locate service
areas within the
organization.
Alternative
passageways for
patients with special
needs (e.g. ramps) are
available, clearly and
prominently marked and
free of any obstruction.
Presence of
directional signages to
locate service areas.
Directional signs are

prominently posted.
Check ER, OPD,
wards and lobby.
Presence of
alternative
passageways (ramps,
elevators) that are
prominently marked
and free from
obstruction for
needs
ICU
OR/RR/
DR/PACU
Imaging
Laborato
ry
ER
OPD
Wards
Other
Areas
Lobby
ER
OPD
2.2.2
2.2.2.a
OBSERVATION
1.There are
alternative
passageways for
needs. Check ER,
OPD, wards and
other areas
2. They are
prominently marked
and
3. They are free from
obstruction
Wards
Other
areas
ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment
6.The organization
uniquely identifies all
patients including
newborn infants, and
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All patients are correctly

identified by their patient
charts.
All patients are

correctly identified by
their charts.
DOCUMENT and
INTERVIEW
Patient chart from
ER, ward, OPD and
ER
OPD
2.2.3
2.2.3.a
2..2.3.b
ICU and verify with

patient if he/she
really is the person
indicated in the
chart.
creates a specific
patient chart for each
patient that is readily
accessible to
authorized personnel.
Wards
ICU
ASSESSMENT
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care .
7.Each patient's
physical, psychological
and social status is
assessed.
8.Appropriate
professionals perform
coordinated and
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An appropriately
comprehensive history
and physical
examination is
performed on very
patient within 24 hours
from admission. The
history includes present
illness, past medical,
family, social and
personal history.
All patients have

comprehensive history
and PE within 24
hours from admission.
Previously obtained
information is reviewed
at every stage of the
All patient charts have

progress notes by
doctors.
CHART REVIEW
Wards
ER
DOCUMENT
Patient chart from
wards or ER.
NOTE:
comprehensive
history includes
present illness,
review of systems,
past medical, family
and personal history.
CHART REVIEW
Medical
Records
Office
sequenced patient
assessment to reduce
waste and
unnecessary repetition.
assessment to guide
future assessments.
2.2.3.c
9.Assessments are
performed regularly
and are determined by
patient's evolving
response to care.
Qualified personnel give

patients for surgery preoperative physical and
pre-anesthetic
assessment.
2.3
IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients
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All patients for surgery

have undergone preoperative anesthetic
assessment.
Patient chart from

medical records
Note: The progress
notes should be done
regularly and
documented in the
patient chart either as
separate progress
notes sheet or side
notes in the doctors
order sheet.
CHART REVIEW
Note: Look for preoperative anesthetic
evaluation in the
patient chart. Preoperative
assessment should
be done for patients
requiring more than
DOCUMENT REVIEW
local
anesthesia.
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.)
2.3.1
10.Diagnosticexamination
s appropriate to the
provider organization's
service capability and
usual case mix are
available andare
performed by qualified
personnel.
Policies and procedures

for the standard
performance, monitoring
and quality control of
diagnostic examinations
are documented and
monitored.
Proof of monitoring of
the implementation of
the policies and
procedures on quality
control of diagnostic
examinations
2.3.2.a
11.Drugs are
administered in a
standardized and
systematic manner in
the provider
organization.
Drugs are administered

in a timely, safe,
appropriate and
controlled manner.
All drugs are

administered in a
timely, safe,
appropriate and
controlled manner to
the right patient
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X-ray
Laboratory
. For the timeliness of

drug administration,
check the hospital
policy. If hospital does
not have policy,
frequency of drug
administration in the
chart should be
checked and validate it
thru patient interview
Note: Surveyor may
also check for
administration of any of
the following:
antibiotics,
anticonvulsants,
MgSO4, KCl drip and
other drips, calcium
gluconate, sodium
bicarbonate, etc. For
oral medications, do
direct observation
Chart
Review
2.3.2.b
12.Drugs are
administered in a
standardized and
the provider
organization.
Only qualified personnel

order, prescribe,
prepare, dispense and
administer drugs.
All doctors,
dentists,nurses and
pharmacists have
updated licenses
13.Drugs are
administered in a
standardized and
the provider
organization
Prescriptions or orders
are verified and patients
are identified before
medications are
administered.
Proof that the

prescriptions or orders
are verified before
medications are
administered.
Randomly check the

licenses of
doctors,dentists,
nurses and
pharmacists.
DOCUMENT
Procedures on
verification of orders.
INTERVIEW
Observe if staff verifies
the prescriptions or
orders for drugs with
the doctor and the drug
against the doctor's
order
Note: This is on a case
to case basis; includes
the route of
administration (slow IV)
and other precautionary
measures/instruction
e.g.. ANST
2.3.2.c
14.Drugs are
administered in a
standardized and
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Prescriptions or orders
are verified and patients
are identified before
INTERVIEW
Verify from patients if
they were correctly
identified prior to
Wards
Pharmacy
OPD
ER
the provider
organization
2.3.2.d
15.Drugs are
administered in a
standardized and
the provider
organization
medications are
administered.
drug administration.
OBSERVATION
Observe if the staff
verifies the identity of
patient prior to
administration of
medications.
Drug administration is
properly documented in
the patient chart.
All charts have proper

documentation of drug
administration
CHART REVIEW
Medication sheet in
patient chart from the
medical records.
Medical
Records
Room
.
2.4EVALUATION OF CARE
Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the
needs of the patient are continuously met.
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2.4.1
16. The discharge

plan
is part of the patient's
careplan and is
documented in the
patient chart.
All charts have

discharge plans.
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
Note: Discharge
plan is not
synonymous with
dischargesummary.
2.5LEADERSHIP AND MANAGEMENT

2.5.1Management team
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Goal: The organization effectively and efficiently governed and managed according to its values and goals to
ensure that care produces the desired health outcomes, and is responsive to patient's and community needs.
17.
2.5.1.a
17.The organization
regularly reviews and
updates its policies,
guidelines and
procedures
Strategically Posted
Vision and Mission of all
the Services
OBSERVATION
Approved Manual of
Operations and/ or
Written Policies,
Guidelines and
Procedures on Clinical
Services Offered
Strategically Posted
Functional and
Organizational Chart
with Photos Showing
Names andRelationship
by Positions
2.5.1.b
18.Terms of reference,
membership and
procedures are defined
for the meetings of all
committees within the
organization. Minutes of
meetings are recorded
and approved.
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Proof of the creation

of all committees
within the organization
which includes the
terms of reference for
membership
DOCUMENT
REVIEW
2.5.1.c
19.The organization's
management team
regularly assesses its
own performance and
the performance of the
organization.
Presence of
evaluation and
monitoring activities
to assess
management and
organizational
performance
INTERVIEW
1. Ask the
management team
about priorities for
performance
improvement that
relate to hospital
wide activities and
patient outcomes
2. Ask
management
team how
targets are
set.
2.6External Services
Goal: The organization ensures that services provided by external contractors meet appropriate standards
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2.6.1
20.Documented
agreements and
contracts cover
external service
providers and specify
that the quality of
services provided
must be consistent
with appropriate set
standards.
Presence of
MOA/contract for all
outsourced services
(e.g. dialysis unit,
dietary, laboratory,
radiology).
(Outsourced are
services/ facilities
provided by third
party but are inside
the hospital)
DOCUMENT
REVIEW
1.Contracts/MOA
for outsourced
services.
2. Valid licenses of
all providers of the
outsourced
services.
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.
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Documen
t review
Imaging
Laboratory
Other
areas
3.1
3.1.1
3.1.1.a
Human Resource Management

Human Resource Planning
Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and
external customers and to achieve its goals.
DOCUMENT
21.Planning ensures
The organization
Presence of policies
that appropriately
documents and
and procedures for
REVIEW
trained and qualified follows policies and
credentialing and
(and where relevant,
procedures for hiring, privileging of staff.
credentialed) staff are credentialing, and
Policies and
available to
privileging of its staff
procedures for
undertake the type
credentialing and
and level of activity
privileging of staff
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22.performed by the
organization. This
includes those who
are consulted when
suitable expertise is
not available within
the organization.
3.1.1.b
23.Workload is
monitored and
appropriate guidelines
consulted to
ensure that
appropriate staff
numbers
and skill mix are
available to achieve
desired patient and
organizational
outcomes.
Staff numbers and

skill mix are based on
actual clinical needs.
24.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.
Policies and
procedures on
records storage,
retention and disposal
are documented and
monitored.
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Staff to bed ratio for

licensed doctors,
nurses and
midwives/Nursing
Aides follow the
DOH prescribe ratio.
DOCUMENT
REVIEW
1. List of total
number of licensed
doctors and dentists,
registered nurses
and midwives/
nursing aides based
on HR records and
2. The schedule of
duties for the
previous and current
month
3. Number of beds
applied for and the
actual being used.
Wards
OBSERVATION
Number of beds
Policy on records
storage, retention
and disposal.
documen
t review
DOCUMENT
REVIEW
Policies and
procedures on
record storage,
safekeeping and
maintenance,
retention and
disposal.
4.1
DATA COLLECTION, AGGREGATION AND USE
Goal: Collection and aggregation of data are done for patient care, management of services, education and research .
4.2
4.2.1
RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements aremet .
Medical Records
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4.2.1.a
25.There shall be an
organized
system of processing,
analyzing, maintaining
and safekeeping of all
patients' records
through the written
data in sequence of
events
covering the diagnosis,
treatment and discharge
of patients.
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When patients are

admitted or are seen
for ambulatory or
emergency care,
patient charts
documenting any
previous care can be
quickly retrieved for
review, updating and
concurrent use.
and procedures on
systematic filing,
retrieval, disposal
and management of
medical charts,
contents include the
following:
-Doctors Progress Notes
-Informed Consent
-Problem List
Clinical and Graphic
Record of Vital Signs
(TPR sheet)
-Personal History and
Physical Examination
records
-Newborn Record and
Physical Maturity Rating,
if warranted
Doctors Progress Notes
-Medication and
Treatment Record
-Laboratory and X-ray
Reports
-Dietary Assessment
-Nurses Progress Notes
-Records of
Transfer/Referral to
Another Physician or
Health Facility
-Inpatient
Referral/Consultation
Notes of Other
Physicians
DOCUMENT
REVIEW
(Note also the
following:
1. ICD-10Coding is
being used.
2. Medical
Records Officer is
trained on ICD-10
Coding.
-Final Diagnosis
Advance Directive, if any
4.2.1.b.
1
26.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.
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The organization has

policies and
procedures and
devotes resources
including
infrastructure to
protect records and
patients charts
against loss,
destruction, tampering
and unauthorized
access or use. Only
authorized individuals
make entries in the
patient chart.
Presence of
procedures to protect
records and patients
charts against loss,
destruction,
tampering and
unauthorizedaccess
or use.
DOCUMENT REVIEW
Polices and
procedures on records
management for the
entire hospital to
maintain privacy,
accuracy and prevent
loss and destruction.
OBSERVATION
Observe 20 nurses in
the wards and records
personnel on how they
protect patient chart
against loss,
tampering and
unauthorized use.
Document
review
6x1
SAFE PRACTICE AND ENVIRONMENT

PATIENT AND STAFF SAFETY
6x1.1
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective
environment of care.
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6x1.1.
a
6x1.1.
b
27.The organization
plans a safe and effective
environment of care
consistent with its
mission, services, and
with laws and
regulations.
The organizational
environment complies
with structural standards
and safety codes as
prescribed by law.
28.The organization
environment of care
consistent with its
with laws and
regulations.
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.
6x1.1.
c
29.The organization
environment of care
Assessment Tool for
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There are management

plans for the safe and
efficient use of medical
If facility has nuclear

medicine, ask for the
certificate issued by the
Philippine Nuclear
Research Institute (PNRI).
Presence of a
management plan
addressing safety,
security, disposal and
control of hazardous
materials and biologic
wastes, emergency
and disaster
preparedness, fire
and utility systems.
Presence of operating
manuals of the medical
equipment.
DOCUMENT REVIEW
Management plan which
includes polices,
procedures and programs,
risk assessment, hazards
surveillance among others
that address the following:
1. Safety
2. Security
3. Disposal and control of
hazardous
materials/biologic wastes
4. Emergency and
disaster preparedness
5. Fire safety
6. Radiation safety
7. Utility systems
Note: The hospital must
have plans for all the
elements enumerated in
the criteria. Plans should
have guiding policies and
specificprocedures.
Document review
ER
OPD
Wards ICU
6x1.1.
d
consistent with its

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

that address safety,
security, control of
hazardous materials
and biological wastes,
emergency and disaster
preparedness, fire
and utility systems are
documented and
implemented.
DOCUMENT
Operating manuals
for the medical
equipment
Proof of
implementation of the
policies, procedures
and safety programs
on
Document review
1. Water safety water analysis
results for the past
6 months.
1. electrical safety
2. medical device
safety
3. chemical safety
2. Fire and
emergency
preparedness check for exit
plans, plans for
earthquake and
other disasters.
4. radiation safety
5. mechanical safety
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OR/DR/RR
Facilities
and
maintenan
ce Imaging
Laboratory
Others
ER
OPD
Wards
Imaging
6. water safety
7. combustible material
safety
8. waste management
9. hospital safety
program (fire,
emergency and
disaster preparedness)
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3. Control of
hazardous
materials MOA/Contract of
outsourced
services for waste
management
INTERVIEW
1. Ask staff from
ER, Wards, OPD,
Laboratory,
Pharmacy, and
facilities and
maintenance on
the manner of
waste segregation
and disposal
(general waste,
liquid & solid
waste, infectious
waste; noninfectious,
hazardous and
non-hazardous
2. Hospital safety
program
3. Mechanical
safety program of
the hospital
OBSERVATION
Laboratory
Pharmacy
Facilities
and
maintenan
ce
Other
areas
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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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
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6x1.1.
e
6x1.1.f 31.The organization
provides a safe and

and with laws and
regulations.
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Ask staff about their

role in the hospital
waste management
program particularly
manner of radiologic
waste disposal.
OBSERVATION
DOCUMENT
REVIEW
and procedures for
the safe and efficient
use of medical
equipment
(including the
implementation of
DOH AO# 20080021on the
gradual phase-out
of mercury)

for the safe and efficient
use of medical
equipment according to
specifications are
documented and
implemented
Document
review
ER
Proof of the
policies and
procedures for the safe
and efficient use of
medical equipment.
DOCUMENT
1. Operating manual
2. Preventive and
corrective
maintenance
Wards
OR/RR/DR
Facilities
and
maintenan
logbook
ce
3. Qualifications of
staff handling medical Imaging
Laborator
equipment
y
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 phaseAssessment Tool for
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Other
areas
out of mercury.
6x1.1.
g
32.The organization
provides a safe and
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.
ER
Presence of adequate
space, lighting and
ventilation in
compliance with
structural requirements
(for patient safety and
privacy).
OBSERVATION
1. Adequate space
2. Adequate lighting
(lights are working,
lighting is adequate
enough for conduct
of
general activities)
3. Adequate
ventilation
OPD
Wards
ICU
OR/RR/DR
Imaging
Laborator
y
Pharmacy
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6x1.1.
h
33.The organization
provides a safe and
and with laws and
regulations.
6x1.1.i 34.The organization
provides a safe and

and with laws and
regulations.
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Risks are identified,

assessed and
appropriately controlled.
Where elimination or
substitution is not
possible, adequate
warning and protection
devices are used.
and procedures on risk
identification,
assessment and
control.
A coordinated security
arrangements in the
organization assures
protection of patients,
staff and visitors
Presence of an
appointed personnel in
charge of security.
Document
review
DOCUMENT
REVIEW
Policies and
procedures on risk
identification,
assessment and
control, security
risks, use of
personal
protective
equipment, etc.
Hospital order or
memo DOCUMENT
REVIEW
Contract of
security agency or
appointment of inhouse security
or Appointment of
person in charge of
security
INTERVIEW
Ask the personnel in
charge of security
what the policies on
Document
review
Other
areas
security of the
hospital are
OBSERVATION
Presence of security
guard/s or personnel in
charge of security
7x1
MAINTENANCE OF THE ENVIRONMENT OF CARE
Goal: A comprehensive maintenance program ensures a clean and safe environment.
DOCUMENT
35.The organization An incident reporting Presence of incident
7x1.1
routinely collects
and evaluates
information to
improve the safety
and adequacy of
the environment of
care
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system identifies
potential harms,
evaluates causal
and contributing
factors for the
necessary corrective
and preventive
action.
reporting
system/sentinel
event monitoring
system (which may
include nosocomial
infections,
unexpected deaths,
adverse drug
reactions, flood
transfusion
reactions, falls, etc).
REVIEW
Minutes of
Leadership
meeting
Incident/senti
nel event
reports or
communication
s/
memoranda/ord
ers or
proceedings on
sentinel events
"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.
7x1.2
36. Emergency light

and / or power
supply, water and
ventilation systems
are provided for, in
keeping with
relevant statutory
requirements and
codes of practice.
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INTERVIEW
Ask readers
and staff from
wards and ER
how the
incident
reporting
system works.
Presence of
generator/emergenc
y light, water system,
adequate ventilation
or air conditioning.
Wards
ER
ICU
OR
Facilities
and
maintena
nce
DOCUMENT
Preventive and
corrective
maintenance
logbooks for
Other
areas
generator/
emergency light/
water tanks/
aircons
OBSERVATION
1. Presence of
generator/emerg
ency light, water
tanks, adequate
ventilation or air
conditioning
2. Test if faucets
and water
closets are
working
7x1.3
37.Equipment is
serviced only by
people trained in
the maintenance of
that equipment.
Registers and
records of
equipment and
related
maintenance are
kept.
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Proof of training of
the staff who is in
charge of the
maintenance of the
equipment.
DOCUMENT
REVIEW
Proof of
training of
service
personnel if inhouse or
Certificate of
Training,
attendance
sheet, Certificate
Facilities
and
mainten
ance
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.
7x1.4
38.Current
information and
scientific data from
manufacturers
concerning their
products are
available for
reference and
guidance in the
operation and
maintenance of
plant and
equipment.
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Presence of
operating
manuals
equipment
Facilities
and
maintena
nce
DOCUMENT
Operating
manual of
generators, air
conditioners and
other nonmedical
equipment.
Imaging
Laborato
ry
Other
areas
8x1
INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other
personnel,
visitors and trainees are identified and
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8x1.1.
a
39.An
interdisciplinary
infection control
program ensures
the prevention and
control of infection
in all services.
Presence of an
Infection Control
Committee (ICC)
with defined goals,
objectives, strategies
and priorities or for a
primary hospital - a
designated doctor
and nurse in-charge
of infection control.
DOCUMENT
REVIEW
DOCUMENT
REVIEW
1. ICC
composition
(for a primary
hospital - proof
of designation
of a doctor and
nurse in-charge
of = in2. ICC
functions and
activities
fection control)
3. Minutes of
meeting, at
least
quarterly activit
ies
4. Statistics on
nosocomial
infections
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INTERVIEW
Ask a member
of the ICC
regarding
infection control
program of the
hospital.
8x1.1.
b
40.An
interdisciplinary
infection 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.
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
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Pharmacy
Therapeutics
Committee
3. Reports of
infection control
activities e.g.
training,outbrea
kinvestigation,
preventive
programs
8x1.2.
a
41.The organization
uses a coordinated
system-wide
approach to reduce
the risks of
nosocomial
infections.
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The organization
takes steps to
prevent and control
outbreaks of
nosocomial
infections.
Presence of
coordinated systemwide procedure for
isolation of
nosocomial
infections.
Document
review
DOCUMENT
REVIEW
Procedures on
isolation of
nosocomial
infections
INTERVIEW
Ask= staff in
ER, wards and
ICU the
procedures on
isolation
ER
Wards
ICU
8x1.2.
b
42.The organization
uses a 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
case containment of
nosocomial
infections.
isolation physical
isolation of a
patient with
infection
DOCUMENT
REVIEW Proced
ures on case
containment of
nosocomial
infections
Document
review
ER
Note: case
containment means
prevention of
spread of
infection
examples:
reverse isolation,
prophylaxis for
exposed
personnel,
vaccination,
immunization
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INTERVIEW
Validate from staff
in ER, wards and
ICU the
procedures on
Wards
ICU
case containment
8x1.2.c 43.The organization

uses a 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
asepsis.
DOCUMENT
REVIEW
Procedures on
asepsis
INTERVIEW
Ask staff from
ER, wards,
laboratory and
ICU about the
approaches for
asepsis during
diagnostic and
treatment
procedures.
ER
Wards
ICU
Laborator
y
8x1.3.
a
44.The organization
uses a coordinated
system-wide
approach to reduce
the risks of infection
the staff are
exposed to in the
performance of their
Assessment Tool for
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There are programs

for prevention and
treatment of needle
stick injuries, and
policies and
procedures for the
safe disposal of
used needles are
and procedures on
the prevention and
treatment of needle
stick injuries and
safe disposal of
needles.
DOCUMENT
duties.
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documented and
monitored.
REVIEW
1. Policies and
procedures for
prevention
and treatment
of needle stick
injuries
ER
2. Policies and
procedures on
proper
handling and
safe disposal
of
Wards
sharps/needle
sticks
INTERVIEW
ICU
Laborator
Interview
y
hospital staff
on how they
handle and
dispose
needles
OBSERVATIO
N
Presence of
receptacles for
proper
disposal of
sharps.
8x1.3.
b
45.The
organization uses
a 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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There are
programs for the
prevention of
transmission of
airborne infections,
and risks from
patients with signs
and symptoms
suggestive of
tuberculosis or
other
communicable
diseases are
managed
according to
established
protocols.
Presence of
program on
prevention of
transmission of
airborne infections
and risks from
patients with signs
and symptoms
suggestive of
tuberculosis or
other
communicable
diseases .
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)
ER
Wards
3. Policies on
all patient
admission/refe
rral, isolation
and timely
case reporting
of highly
transmissible
and notifiable
infectious
disease e.g.
meningococce
mia, 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
Assessment Tool for
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ICU
Laboratory
INTERVIEW
Validate
hospital
policies on
infection
control such
as use of
PPEs, isolation
precautions
and hand
washing.
OBSERVATIO
N
1. Observe for
use of gloves,
surgical
masks.
3. Look for
separate
holding
area/room for
highly
infectious
cases.
4. Ask a
hospital staff
to
Assessment Tool for
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OR/DR
Ward
ER
demonstrate
hand washing
technique.
8x1.4
46.Cleaning,
disinfecting, drying,
packaging and
sterilizing of
equipment, and
maintenance of
associated
environment,
conform to relevant
statutory
requirements and
codes of practice.
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and procedures on
cleaning,
disinfecting, drying,
packaging and
sterilizing of
equipment,
instruments and
supplies. (Refer to
Annex__ Sterilization
Guidelines in
Hospital Setting)
DOCUMENT
REVIEW
1. Policies and
procedures on
cleaning,
disinfecting,
drying,
packaging and
sterilizing of
equipment,
instruments
andsupplies.
2. Policies on
decontaminatio
n, disinfection,
sterilization,
disinfectants for
specific medical
equipment/item
s and area.
3.
Housekeeping
procedures in
specific patient
areas.
OR/DR
8x1.5
47.When needed,
the organization
reports information
about infections to
personnel and
public health
agencies.
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and procedures on
reporting of
infections to
personnel and public
health agencies.
DOCUMENT
REVIEW
Presence of policies,
procedures and
guidelines for safe
reuse of items which
comply with relevant
statutory
requirements.
DOCUMENT
REVIEW
INTERVIEW
Ask heads and
staff about the
following:
1. Policy on
reuse of items
2. SOPs on reuse
3. Reporting
4. Personnel in
charge
9x1
9x1.1
ENERGY AND WASTE MANAGEMENT
Goal: The organization demonstrates its commitment to environmental issues by considering and implementing
strategies
to achieve environmental sustainability
48.The handling,
collection, and
disposal of waste
conform to relevant
statutory
requirements and
codes of practice.
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Presence of
licenses/permits/
clearances from
pertinent regulatory
agencies implementing
among others the
following: RA 9003, RA
6969, RA 275, PD 1586
DOCUMENT
REVIEW
Pertinent
licenses/permits
from regulatory
agencies (LGU,
DENR, etc.)
DOH Hospital Waste

Management Manual,
RA 8749 (Clean Air Act
9x1.2
49.The organization
implements a waste
disposal program
which involves
reuse, reduction and
recycling.
Proof of
implementation of
policies and
procedures on waste
disposal.
DOCUMENT
REVIEW
1. Issuances memos,
guidelines on
waste disposal
2. Contracts
with waste
handlers or
disposal
contractors, (if
applicable)
3. Hospital
policy that
conforms to the
joint DOH-DENR
circular on
waste
management for
LGUs
INTERVIEW
Ask staff
regarding SOPs
on actual
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ER
Wards
ICU
procedure waste
disposal.
OBSERVATION
1. Waste
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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Imaging
Laboratory
Facilities and
maintenance
9x1 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 nee
9x1.1
50.The organization
has a planned
systematic
organization- wide
approach to process
design and
performance
measurement,
assessment and
improvement
51.The organization
provides better care
service as a result of
continuous quality
improvement
activities.
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Presence of Quality
Improvement Program
Presence of patient
satisfaction survey
DOCUMENT
REVIEW
1. Policy
creating the
QI program
2. Proof of
meetings or
similar
documents of
QA Committee
activities
3. Policies
and
procedures on
a performance
measurement
and
improvement
INTERVIEW
Validation of alI
activities thru
interview of
pertinent staff
including
frontliners and
Committee
members.
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CRITERIA
INDICATOR
MONITORINGDOH
POSITION STAFFING
REQUIREMENT I:
(Top Management
Positions)
INSPECTIONDOH
CODE
ASSESSMENTSELF-
DOCUMENT
REVIEW
1. Patient
satisfaction
survey results
2.Patient
satisfaction
survey
questionnaire(
may check on
the domains
and items)
EVIDENCE
AREA
REMARKS
10x1
10x2
Hospital Administrator
Medical Director/ Chief
of Hospital or Medical
CenterChief
Assessment Tool for

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For level 1, must

have completed at
least 20 units
towards a Masters
Degree in Hospital
Administration or
Related
CourseANDat least
3 years experience
in a supervisory/
managerial position
For levels 2 and

3,must have
completed a
Masters Degree in
Hospital
Administration or
Related Course OR
at least 5 years
experience in a
supervisory
managerial position
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/
Certificate of
units earned
Proof of
employment/appointment
10x4
Chief of Clinics/Chief
Medical Professional
Services
10x4
Department Head
For levels 2 and 3, must

be a Diplomate/ Fellow
in a Specialty Society of
the Specialty
Department he/she
heads
Assessment Tool for

Revision: 00
Page 62 of 96
For levels 2 and

3,must be a
Diplomate/ Fellow in
a Specialty area
AND at least 5 years
experience in a
supervisory/manage
rial position
Verifier:
Documents review,
Interview staff,
Validate:
Diploma
Proof of
employment/appointme
nt
Verifier:
Documents review,
Interview staff,
Validate:
Diploma
Proof of
nt
10x5
Chief Nurse/Director
of Nursing/Deputy
Director for Nursing
For level 1, must

have completed at
least 9 units towards a
Masters Degree in
Nursing AND at least 2
years experience in
nursing
supervisory/managerial
position
For levels 2 and 3,
must have a Masters
Degree in Nursing AND
at least 5 years
experience in a nursing
supervisory position
10x6
3.5 Administrative
Officer
For level I, must have

completed at least 20
units towards a Masters
Degree in Hospital
Administration or
Related Course AND at
least 3 years experience
in a supervisory
/managerial position.
For levels 2 and 3, must
have completed a
Masters Degree in
Hospital Administration
or Related Course AND
at least 5 years
experience in a
supervisory managerial
position.
Assessment Tool for

Revision: 00
Page 63 of 96
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/ Certificate
of
units earned
Proof of
nt
Verifier:
Documents review,
Interview staff,
Validate:
Diploma/ Certificate
of
units earned
Proof of
nt
11x1
POSITION STAFFING
REQUIREMENT II
ADMINISTRATIVE
1.1 Chief of Hospital /Medical
Director/Medical Center Chief
1.2 Administrative Officer
1.3 Clerk:
- Pool
- Accounting
- Medical Records
- Cash Clerk
1.4 Accountant
1.5 Budget /Finance Officer
1.6 Bookkeeper
1.7 Billing Officer
1.8 Cashier
1.9 Human Resource Mgt. Officer
1.10 Training Officer
1.11 Medical Records Officer (ICD
trained)
1.12 Supply Officer
Assessment Tool for

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LEVEL 1
LEVEL 2
LEVEL 3
1
1:50 beds
1
1:50 beds
1
1:50 beds
1
1:50 beds
1
1
1
1(designate)
1(designate)
1
1
1:50 beds
0
1
1
1
1
1
1
1
1
1
1:50 beds
1
1
1
1
1
1
1
1
1
DOH MONITORING
DOH INSPECTION
ASSESSMENTSELF
CODE
REMARKS
1.13 Storekeeper/ Linen Custodian

1.14 Laundry Worker
1.15 Utility Worker
1
1
1/Shift
1
1:50 beds
1:50 beds/shift
1
1:50 beds
1:50 beds/shift
1.16 Security Guard
1/shift
1/entrance/exi
t per shift
1
1/entrance/exit
per shift
1
1/shift
1/shift
0
1(sharing is
allowed e.g.
hospital and
municipal/city
government)
1
0
0
.1
0
1:100 beds
1
1:100 beds
1:100 beds
1:100 beds
1:50 beds
1
1
1:50 beds
1
1
1.17 Engineer
1.18 Medical
Equipment/Biomedical Technician
1.19 Maintenance Personnel
1.20 Mechanic
1.21 Nutritionist-Dietitian (for level
2 and in case of sharing, must
be residing within the locality)
1.22 Cook
1.23 Food Service Worker
1.24 Food Service Supervisor
1.25 Medical Social Worker (For
level 1, If there is MOA with DSWDLGU, the Medical Social Worker
should be physically present in the
hospital)
Assessment Tool for

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11X2
CLINICAL:
2.1 Chief of Clinics/Chief Medical
Professional Services
2.2 Department Head
2.3 Consultant Physician
(Diplomate/
Fellow of a Specialty/ SubSpecialty Society after a formal
residency training program)
Assessment Tool for

Revision: 00
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1/
department
1/
department
(number not prescribed)
11X3
100 beds =
8
Every
additional 50
beds =
additional 3
( For
Departments
with accredited
residency
training
program,
number will
depend on the
requirement of
specialty
board
concerned).
1:20 beds at any

time plus 1
reliever
50 beds = 6
3.2 Asst. Chief Nurse (maybe

designated as
Training Officer)
100 beds and

above=1
100 beds and

above=1
3.3 Supervising Nurse
1:50 beds
50 beds and
1 per
2.4 Physician (must not go on duty

more than forty-eight (48) hours
continuous duty)
NURSING:
3.1 Chief Nurse/Director of Nursing
Assessment Tool for

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Every additional
50 beds =
additional 2
below = 1,
51-100 beds =
2,
101-150 beds
= 3,
151 beds and
above = 4
3.4 Supervising Nurse (Critical Care

Units)
-CCUs include all types of ICUs,
including Post-Anesthesia Care
Unit
(PACU) and RR
3.5 Head Nurse
3.6 Staff Nurse
-For every three (3) RNs, there
must be one (1) reliever)
3.7 Staff Nurse (CCUs)
-Base the ratio on the actual
number
of occupied CCU beds at the
time of
inspection
1:15 RNs
1:12 beds at any
time
3.8 Nursing Attendant/ Midwife

-Optional if the Authorized Bed
Capacity (ABC) is less than
twentyfour (24) beds. If the ABC is 24
beds and above, the ratio will
apply.
3.9 Nursing Attendant/ Midwife
(CCUs)
-For every three (3) Nursing
Attendants/Midwives, there
must be
one (1) reliever
1:24 beds at any

time
Assessment Tool for

Revision: 00
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department
/special area
1 per critical
care unit
1 per critical care

unit
1:15 RNs
1:12 beds at
any time
1:15 RNs
1:12 beds at any
time
1:3 beds at any

time
1:3 beds at any

time
1:24 beds at
any time plus 1
reliever
1:24 beds at any

time plus 1
reliever
1:15 beds at
any time
1:15 beds at any

time
11x4
3.10Operating Room Nurse
1/shift
3.12 Emergency Room Nurse

3.13 Out-Patient Department Nurse
1/ shift
1
1/shift( may
increase
depending on
the average
number of
OR cases
per day)
1/shift( may
increase
depending on
the average
number of
deliveries per
day)
1 shift
1
3.1
1 per/shift
.ALLIED MEDICAL PERSONNEL

4.1Pharmacist (full-time,registered);
must be physically present while
Adequate
Adequate
Delivery Room Nurse
Assessment Tool for

Revision: 00
Page 69 of 96
1/OR/shift( may
increase
depending on
the average
number of OR
cases per day)
Adequate
1/DR/shift( may
increase
depending on
the average
number of
deliveries per
day)
1/Dept/shift
1/Dept.
the retail outlet is open for

business)
4.2. Pathologist
4.3 Med. Technologist (full-time,
registered)
4.4 Other Lab. Personnel (specify)
4 5Dentist
4.6Dental Aide
4.7Radiologist
4.8Radiology Technologist
4.9 Radiation Safety officer
4.10 Physical Therapist
4.11 Respiratory Therapist( may be
on call for level 2)
Assessment Tool for

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1
Adequate
Adequate
Adequate
1
1
1
Adequate
1
1
1
Adequate
1(designate)
Adequate
Adequate
1(designate)
Adequate
2
2
2
Adequate
1
1
EQUIPMENT/INSTRUMENT REQUIREMENT
1.ADMINISTRATIVE
1. Computer/Typewriter
Level 1
Level 2
Level 3
1( may depend
on the need)
2. Ambulance (Available 24 hours, 7 days

a week and physically present)
(Refer to A.O. 2010-0003- National Policy on
Ambulance Use and Services)
1 ( may
depend on
the need)
1
3. Standby Generator with Automatic Transfer

Switch (ATS) (KVA may depend on the load)
4. Emergency Light
1/station/
lobby/
stairways
1/room/unit
1
1/station/lobby/
stairways
1/station
/lobby/
stairways
1/room/unit
1
5. Fire Extinguisher
6. Overhead Projector/ LCD
Assessment Tool for

Revision: 00
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1/room/unit
1
MONITORINGDOH
12x1
STANDARD REQUIREMENT
INSPECTIONDOH
CODE
ASSESSMENTSELF
REQUIRED NUMBER
FINDINGS
(Indicateactual
no. equipment
& instruments)
REMARKS
13x1
CLINICAL
EMERGENCY ROOM
1. Ambu Bag
Adult
Pediatric
2. Clinical Weighing Scale
3.Defibrillator
4. ECG Machine
1
1
1
1
1
1
1
1
1
1
1
1
5. EENT Diagnostic Set

6. Emergency Cart (complete with ER
Medicines.) See ann3ex for the list and
quantity.
9. Examining Table
10. Examining Table with stirrup
11. Gooseneck Lamp/Examining Light
12. Instrument Table
13. Laryngoscope with Different sizes of Blades
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
14. Medicine Cabinet

15. Minor Surgery Instrument Set
16. Nebulizer
1
1
1
1
1
1
1
1
1
17. Neurological Hammer

18. Oxygen Unit (anchored)
19. Pulse oximeter
20. Sphygmomanometer (non-mercurial)
1
1
1
1
1
1
Adult Cuff
Pediatric Cuff
21. Stethoscope
1
1
1
1
1
1
1
1
1
Assessment Tool for

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22. Suction Apparatus

23. Suturing Set
24. Thermometer (non-mercurial)
25. Tracheostomy Set
26. Vaginal Speculum Set
27. Wheelchair
28. Wheeled Stretchers with guard and wheel lock
or anchor
14x1OUTPATIENT CARE
1. Clinical Weighing Scale
2. ECG Machine
3. EENT Diagnostic Set
4. Gooseneck Lamp/Examining Light
5. Examining Table with wheel lock or anchor
6. Instrument Table
7. Minor Surgery Instrument Set
8. Neurological Hammer
9. Oxygen Unit
10.Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
11. Stethoscope
12. Suture Removal Set
13. Thermometer, non-mercurial
13. Vaginal Speculum Set
14. Wheelchair
2.3OPERATING ROOM
1. Air-conditioning Unit
2. Anesthesia Machine
3. Cardiac Monitor with pulse oximeter
Assessment Tool for
Revision: 00
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1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
PulseOximeter
15x1
4. C/S Set
5. Instrument Table
6. Laparotomy Set
7. Laryngoscope with Blades
8. Major Surgical Instrument Set
9. OR Light
10.OR Table
11. Ortho Instrument Set
Adult Cuff
Pediatric Cuff
14. Spinal Set
15. Stethoscope
17. Thermometer, non-mercurial
17. Wheeled Stretcher
RECOVERY ROOM
2. Bed with Guard Rail and wheel lock or anchor
Adult Cuff
Pediatric Cuff
5. Pulse Oximeter
6. Stethoscope
LABOR ROOM
1.CTG Machine
2. Amniotome
Assessment Tool for

Revision: 00
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1
1
1
1 set
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1/OR
1/OR
1 set/OR
1/OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
1
1
1/OR
1/OR
1 set/OR
1OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
4. Stethoscope
16x1DELIVERY ROOM ( IF APPLICABLE)
17X1
3. D/C Set
4. Delivery Set
5. DR Light
6. DR Table with Stirrup
7. Foetoscope (Doppler)
8. Instrument Table
9. Kelly Pad
10.Oxygen Unit, Anchored
11.Sphygmomanometer (non-mercurial)
12.Stethoscope
13.Suction Apparatus
14.Wheeled Stretcher
15.Bassinet
16.Infant Weighing Scale
HIGH RISK PREGNANCY UNIT
(NOT REQUIRED IN LEVEL 1)
1. Cardiac Monitor
2. Fetal Monitor (CTG Machine)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
xxxxxxxxxxx
xxxxxxxxxxx
xxxxxxxxxxx
1/DR
1/DR
1/DR
1/DR
1/DR
1
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1
1
1
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1
1
1
xxxxxxxxxx
4. Oxygen Unit, Anchored
xxxxxxxxxx
1
1
1
1
1
1
1
1
18X1 NEONATAL INTENSIVE CARE UNIT

1.
2.
3.
4.
Bassinet
Bili Light
Cardiac Monitor
Emergency Cart
Assessment Tool for

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5. Umbilical Cannulation Set

1
6. Laryngoscope with Neonatal Blades
1
7. Examining Light
1
8. Incubator
1
9. Infant Ambu Bag
1
10.Infant Weighing Scale
11.Oxygen Unit
1
12.Respirator/Mechanical Ventilator
13.Radiant Warmer
14. Infusion Pump/Syringe Pump
15. Glucometer
16. Nebulizer
17. Pulse Oximeter
18. Neonatal Stethoscope
2.7 19X1
INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1
2. Ambu Bag
Adult (in adult units)
Pediatric (in pediatric units)
3. Bed with Guard Rail
4. Cardiac Monitor
5. Defibrillator
6. ECG Machine
7. Emergency Cart with emergency
Medicines(Refer to annex for medicines and
supplies)
8. Endotracheal Tube
9. Laryngoscope with Blades
10. Oxygen Unit
Adult Cuff (in adult units
Pediatric Cuff Set (in pediatric units)
12. Stethoscope
Assessment Tool for
Revision: 00
Page 76 of 96
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

14. Tracheostomy Set
16. Pulse Oximeter
17. Mechanical Ventilator
18. Infusion Pump
2.8
20x1
NURSING UNIT OR WARD

1. Ambu Bag
Adult (if Adult ward)
Pediatric ( if Pediatric ward)
1
1
1
1
1
1
1
1
1
1
1
2. Clinical Weighing Scale (per nursing unit)
3. ECG Machine
4. Emergency Cart or its equivalent(per
nursing unit)
5. Mechanical Bed/Patient Bed with Side Rails
(According to Authorized Bed Capacity)
1
1
1
1
1
1
Actual count
Actual count
Actual count
6. Bedside Table corresponds to total beds

2.Laryngoscope with different Sizes of Blades
7. Nebulizer
Neurological Hammer
8. Oxygen Unit, Anchored

(may increase depending on the need)
Adult Cuff
Pediatric Cuff
10.Stethoscope
13.Suction Apparatus
Assessment Tool for

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1/Medical/
Pediaward
1
1
1/Medical/
Pedia ward
1
1
1
1
1
1
1
1
1
1
1
11.Thermometer (non- mercurial)

CE
21X1
CENTRAL STERILIZING & SUPPLY ROOM

1. Autoclave ( may increase depending on
the need)
2.Steam Sterilizer ( may increase depending
on the need)
22X1
DENTAL CLINIC
1. Dental Chair
2. Operating Stool per Dental Chair
Assessment Tool for

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1
1
1
1
1
1
3. Autoclave
4. Air Compressor
5. Dental X-ray
6. Mouth Mirror Explorer
7. Explorer, double end
8. Scalerjacquettes set No. 1,2,3
9. Low speed hand piece (angled head)
10. Cotton pliers
11. High speed hand piece with
bur remover
12. No.150 forceps (maxillary universal
forceps)
13. No.151 forceps (lower universal
forceps)
14 .No.150 s forceps (primary teeth)
15. No. 8L and No18R forceps(upper molar)
16. No.151A forceps (mandibular premolar)
17. No.17 forceps
18. No.15 S forceps (lower primary teeth)
Rongeur forceps
19. Surgical chisel and mallet
20.. Bone file
21. Surgical Scissor
22. Root elevator
23. Periostal elevator No. 9 double end
24. Gum Separator double end
25.Cowhorn forceps
26. Bonefile Stainless end
A
2
DIALYSIS CLINIC- Not required for Levels 1
and 2.
Assessment Tool for
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1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Refer to AO 2012-0001 New Rules and

RegulationsGoverning the Licensure and
Regulation of Dialysis Facilities in the
Philippines
Use checklist for Dialysis facility
24
2
UN
I
AMBULATORY SURGICAL CLINIC

Use checklist for Ambulatory Surgical Clinic
PHYSICAL MEDICINE and REHABILITATION
UNIT
Bicycle Ergonometer
Electric Stimulator
Exercise plinth/bed
Overhead pulley
Exercise stair with rails
Paraffin wax
Parallel bars with postural mirrors
TENS
Ultrasound
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Ultrasound
Assessment Tool for

Revision: 00
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DIETARY
Exhaust Fan
Food Scale
Garbage Receptacle with Cover
Osterizer/ Blender
Oven
Push Cart
Refrigerator/Freezer
Stove
Utility Cart
Assessment Tool for

Revision: 00
Page 81 of 96
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PHYSICAL PLANTREQUIRED ROOMS AND AREAS:

Cx1
Level 1
Level 2
Level 3
27x1
Lobby
Waiting Area
Information and Reception
Communication Booth (Area for level 1)
Toilet
Admitting Office ( Area for level 1)
Med. Records Office/Room
Business Office(may be combined with
Admin Office for level 1)
Billing
Cashier
Budget and Finance
Personnel Office (may be combined with
Administrative Office for level 1)
Office of the Admin. Officer
Office of Chief of Hospital
Office of the Chief of Clinics/Chief
Medical Professional Services
Conference and Training Room
Library
Staff Toilet
Property/ Supply Office /Room for level
Laundry and Linen Room or Area
Assessment Tool for

Revision: 00
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May be
Receiving and
Releasing Area
Sorting and Washing
Area
Pressing and Ironing
Area
Storage Area
Not required if
contracted out
Engineering /Maintenance Office for Level 2
Maintenance Area
Motor Pool Area

Housekeeping
Area
28x1
29
29
WASTE HOLDING /STORAGE AREA (color

coded)
DIETARY
NUTRITIONIST-DIETITIAN OFFICE OR AREA
FOR LEVEL 2
Supply Receiving Area
Not required
Cold and Dry Storage Area
Food Preparation Area
30
Not required if
contracted out
Toilet
Cooking and Baking Area
Washing Area
Serving and Food Assembly
Dining Area
Garbage and Disposal Area
SOCIAL SERVICE OFFICE
Assessment Tool for

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if contracted
out
31
32
33
MORGUE for Level 3, Cadaver Holding Area

for Level 1 and 2
Pathologist Office
Autopsy Area
Shower Area
Toilet
CLINICAL SERVICE
EMERGENCY ROOM (MAY BE COMBINED WITH OPD FOR LEVEL 1)
29x1
Waiting Area
Toilet (adjacent or w/in ER)
Nurse Station
Examination& Treatment Area with
Lavatory
Observation Area
Equipment & Supply Storage Area
Wheeled Stretcher Area
Decontamination Area for level

and 3
Holding Area for Infectious Cases

Doctors Quarter (with toilet)
34
3
35
OUTPATIENT DEPARTMENT (MAY BE

COMBINED WITH ER FOR LEVEL 1)
Waiting Area
Toilet (accessible)
Admitting and Records Area
Consultation Area (required)
Examination & Treatment Area
With Lavatory
OFFICE OF THE DEPT. HEADS
Medicine
Pediatrics
Assessment Tool for

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36
OB-GYNE
Surgery
Anesthesia
Emergency Medicine
OPERATING ROOM (MAY BE
COMBINED WITH DELIVERY ROOM
I ONE COMPLEX FOR LEVEL 1)
Major OR
Minor OR
Recovery Room
Sub-Sterilizing/Work Areas
Sterile Instrument /Supply
Storage Area for sterile packs
Storage Area for supplies
Scrub-up Area
Clean-up Area
Male Dressing Room and Toilet
Female Dressing Room and Toilet
Nurse Station/Work Area
Wheeled Stretcher Area
37
33
x1
38
33
x1.
a
Janitors Closet
OBSTETRICS OPERATING ROOM
(MAY BE COMBINED WITH SURGICAL
OPERATING ROOM FOR LEVEL 1)
DELIVERY ROOM
Labor Room with Toilet
Equipment and Supply Storage
Area for level
Sub-Sterilizing/Work Area
Equipment and Supply Storage
Area for level
Assessment Tool for

Revision: 00
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May be
combined
3934x1
Scrub-up Area
Clean-up Area
Male Dressing Room with Toilet
Female Dressing Room with Toilet
Wheeled stretcher area
Janitors Closet
NEONATAL INTENSIVE CARE UNIT
Work Area with Sink
Newborn Care Area with Sink
Treatment Area
Viewing Area
Breastfeeding Area with lavatory
NURSING UNIT/WARD
Nurse Station
Toilet
Patient Area
Dressing Area
Equipment & Supply Storage Area
Patients Room (Separate Male from

Female)
Toilet ( Separate Male & Female)
Isolation Room with Toilet

Utility Area
Linen Area
Toilet
Treatment Area
Medication Area w/ lavatory
With Color-Coded Waste Bins
Janitors Closet
Nursing Office; Office of Chief
Nurse
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39
36
x1
Toilet
ISOLATION ROOM
Ante room with lavatory and PPE rack
Windows and doors including ante

room are closed and air tight or leak
proof
Handwashing Facility/Hand Disinfection
Toilet
40
37
X1
DIALYSIS CLINIC (not required in levels 1

and 2)
Refer to A.O. 2012-0001, Regulation

of Dialysis Facilities in the Philippines
41
38
X1
AMBULATORY SURGICAL CLINIC(not required

in level 1 AND 2)
Required rooms /areas depend on the
surgical procedures the clinic is
capable of performing
43
PHYSICAL MEDICINE /REHABILITATION
UNIT (not required in level 1)
40
X
40
40
X
3x
1
41
x1
44
DENTAL CLINIC
Consultation room
Toilet
45
CENTRAL SUPPLY ROOM

Receiving and Cleaning Area
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Inspection Area
Packaging Area
Sterilizing Area
Sterile Supply Storage Area
Releasing Area
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CRITERIA
INDICATORS
MONITORING
STANDARDS
INSPECTIONDOH
CODE
ASSESSMENTSELF
PRAYER ROOM, AREA FOR LEVEL 2
EVIDENCE
AREA
REMARKS
41
41x1
41x1.a
B.HOSPITAL/ HEALTH
PROGRAMS:
1.Blood Services
Compliance to RA 7719
and its IRR, AO 20080008 Levels 1 and 2,
should be at least a
Blood StationFacility and
level 3, Blood Bank
Facility
1.2Level 3 hospital
should be a Blood Bank
(BB) facility
Documented policies:
To ensure adequate
supply of safe blood
and blood products.
blood and blood
products obtained
from blood service
facilities licensed by
DOH
for BC, blood and
blood products
collected, obtained
from healthy
voluntary
blood donors only
Documented policies:
To ensure adequate
supply of safe blood
and blood products
Blood and blood
products
obtained
from blood service
facilities licensed by
DOH
For BC, blood and blood
products
collected,
obtained from healthy
voluntary blood donors
only
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Actual implementation and

procedures
41x2
41x2,a
2.Health Promotion
and Disease
Prevention
2.1 Newborn Screening
- Compliance to
RA9288and its
IRR
41x3
2.2 Mother-Baby
Friendly
Hospital Initiative
41x3.a
- Compliance to RA
7600 and its IRR
and R.A. 10028
and its IRR
- Milk Code (EO
No. 5
41x4
2.3Healthy Lifestyle
Advocacy
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Documented policies
regarding Newborn
Screening
Logbook of Newborns who
were tested and copies of
waiver for those who were
not screened
Documented policies
regarding Rooming-In and
practice of Breastfeeding
There should be no
nursery for normal
newborns
Breastfeeding area
should be provided at the
pathologic nursery
Certification as Mother
Baby Friendly Hospital
Certification as Mother
Baby Friendly
Workplace
Documented policies and
SOPs specific to the
program
41x5
41x6
41.7
2.4 Family Planning
Documented
implementation and
practices
2.5. Immunization
(Republic ActNo.
309)
2.6. Anti-Smoking
Program
(per RA 9211)
Documented
implementation and
practices
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Documented policies
No smoking signages posted
at conspicuous areas
41x8
3.Generics Act of
1988
(R.A.6675)
41x8.a
1. e-EDPMSR.A.7581Price Act
of 1992; R.A.
9502Universally
Accessible Cheaper
and Quality
Medicines Act of 2008
41x9
41X9.a
4. Health
Emergency
Management
Service(HEMS)
A.O. No. 2004-0168,
National
Policy on Health
Emergencies
and Disasters
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Documented policies
implementing the
EDPMS
in compliance with DOH
A.O. No.20080014Guidelines on the
Pilot Implementation of
the
e-EDPMS and A.O. No.
2011-0012
Implementing
Guidelines on Electronic
Drug Price Monitoring
System Version 2.0
Verifier:
Visit hospital pharmacy
and document review,
Validate
Actual implementation and

procedures; reports on
uploading of essential
drug prices, etc.
Document review
With designated HEMS

Coordinator
Documented Health
Emergency
Preparedness,
Response and Recovery
Plan
Hospital/Office order
designating one
Conduct of
drills/exercisesi.e, Fire,
Earthquake, etc.
(For fire, it should be
supervised by the
Bureau of Fire
Protection).
Documentation of
drills/exercises
conducted.
Proof of
plan.
Evacuation
Plan/Route posted in
every room/area
CODE
42
C.HOSPITAL COMMITTEES:
1.Credentials
42x1
2.Blood transfusion
42x2
3.HIV/AIDS Core Team
42x3
4.Waste Management
42x4
42x5
40x6
40x7
5.Patient Safety
6.Infection Control
7.Pharmacologic/Therapeutics
428
8.Health Emergency/
Crisis Management
42x9
42x10
9.CQI
10.Tissue
(for levels 2 and 3 only)
42x11
11.Ethics
(for levels 2,and 3only)
42x12
12.Grievance
(for levels 2, and 3only)
42x13
Other committees, please

specify
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Written
Designation of
Members and
their
roles/function
s
Written
Policies and
Procedure
Updated and
Relevant
Minutes of
Meeting
Reports/
Records of
Implementation
REMARKS
Verifier: Documents review and Interview staff
43x1
2.Recording, Reporting,
Records Keeping
43x2
43x3
43x4
3.Inter/Intra Departmental
Referrals
4.Disaster
Management/Crisis
Management
5.Infection Control
43x5
43x6
6.Drug Management and

Control
7.Blood Service
43x7
43x8
43x9
8.Pre-Operative and Post-Op

Care
9.Triaging (when applicable)
10.Referrals/ Transfer
43x10
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Rehab
Anesthesia
Surgery
OR
Pediatrics
Medicine
(DeliveryOB/ Gyne
1.Clinical Practice Guidelines

(CPG)
Emergency
43
D.HOSPITAL OPERATIONS:
(The following Criteria
Requirements are applicable
only to levels 2 and 3 ).
OPD
SERVICES (levels 1 & 2) / DEPARTMENT (level 3)

CODE
REMARKS
11.Others, please specify

43x11
ASSESSED BY:
_____________________________
__
Signature over Printed Name
_____________________________
__
_____________________________
__
______________________________
__
_____________________________
__
Position
_____________________________
__
Position
_____________________________
__
Position
______________________________
__
Position
______________________________
_____________________________
___
Signature over
Printed Name
Date
______________________________
_____________________________________________________________
_____________________________ _____________________________
_
__
___
__
Signature over
Printed Name
Signature over
Date
Date Printed Name
Date
______________________________
_
Position
______________________________
_
Position
_______________________________
_
Position
______________________________
_
Date
______________________________
_
Date
_______________________________
_
Date
CONCURRED BY:
_______________________________
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_______________________________
Position/Designation
_______________________________
Date
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What are the different levels of hospital services described in the document?

What are the different levels of hospital services described in the document?

What committees are hospitals required to have according to the document?

What committees are hospitals required to have according to the document?

Department of Health

Bureau Of Health Facilities And Services (BHFS)

Assessment Tool for

7. Safe Practice and Environment (pages 27-37)

2.7. Pathologic/ Premature Nursery

INTERVIEWS, REVIEW OF DOCUMENTS, OBSERVATION

Telephone No./ Fax No.

Level 1 Level 2 Level 3

Philhealth Accreditation:Center of: Safety QualityExcellence

Name of Owner or Governing Body (if corporation):

Assessment Tool for

Assessment Tool for

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Documents are readily

Look for approved Work

Policies, guidelines and

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Documents are readily

Sorting of soiled and

Security check for internal

Documented and approved

Assessment Tool for

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Available contract or MOA

Assessment Tool for

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Clinical services are

Assessment Tool for

All patient charts have

Entrances and exits are

Assessment Tool for

Directional signs are

Directional signs are

All patients are correctly

All patients are

ICU and verify with

Assessment Tool for

All patients have

All patient charts have

Qualified personnel give

Assessment Tool for

All patients for surgery

Patient chart from

Policies and procedures

Drugs are administered

All drugs are

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. For the timeliness of

Only qualified personnel

Proof that the

Randomly check the

All charts have proper

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16. The discharge