New Assessment Tool for Hospitals - DOH Central Luzon

Department of HealthBureau Of Health Facilities And Services (BHFS)ASSESSMENT TOOL FOR LICENSURE OF HOSPITALSOUTLINE OF CONTENTSI. GENERAL INFORMATION(page 2)II. HOSPITAL ADMINISTRATIONA. Services1. Administrative Service (pages 3-8)1.1. Human Resource1.2. Accounting1.3. Budget and Finance1.4. Billing and Claims1.5. Procurement1.6. Property and Supply Management1.8 Linen and Laundry1.9 Housekeeping1.7. Nutrition and Dietary1.8. Security Services1.9. Ambulance Services1.10. Central Information Management1.11. Medical Records (Including DentalRecords)1.12. Medical Social Services1.13. Nutrition and Dietetics1.14. Pharmacy2. Patients Rights and Organizational Ethics(pages 9-10)3. Patient Care (pages 10-13)4. Implementation of Care (pages 13-15)5. Evaluation of Care (page 16)6. Leadership and Management (pages 16-17)7. External Services (page 17)III. PERSONNEL8. Human Resource Management (page 18)9. Data Collection, Management and Use(pages18-19)10. Safe Practice and Environment includingPatient and Staff Safety (pages 20-25)11. Maintenance of Environment of Care (pages26-27)12. Infection Control (pages 28-32))13. Energy and Waste Management (page 33)14. Improving Performance (page 34)POSITION STAFFING REQUIREMENT(pages 35-43)1. Top Management Personnel QualificationStandard2. Administrative3. Clinical4. Nursing5. AncillaryIV. EQUIPMENT AND INSTRUMENTS (pages44-52)List of Equipment and Instrument Requirement1. Administrative2. Clinical2.1. Emergency Room2.2. Outpatient Care2.3. Operating Room2.4. Recovery Room2.5. High Risk Pregnancy Unit2.6. Delivery Room2.7. Neonatal Intensive care Unit2.8. Intensive Care Unit3. Nursing Unit/Ward4. Isolation Room5. Central Supply and Sterilization Unit/ Room6. Physical Medicine and Rehabilitation Unit7. Dialysis Clinic8. Ambulatory Surgical Clinic9. Dental Clinic10. DietaryV. PHYSICAL PLANT REQUIREMENT(53-57)Required rooms/areas/officesVI.HOSPITAL PROGRAMS (pages 58-60)1. Blood Services2. Newborn Screening3. Mother-Baby Friendly Hospital Initiative4. Health Promotion and Disease Prevention5. Generics Act6. Health Emergency Management ServicesVII. HOSPITAL COMMITTEES (page 61)VII. HOSPITAL OPERATIONS CRITERIA (page 62)VIII. SIGNATURE PAGE (page 63)Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 1 of 60

I. GENERAL INSTRUCTIONS:1. Check to make sure that you have the complete tool with a total ofsixty-three (63) pages and copies of the SOE,SOM and NOV Forms.2. Assign sections of the tool to corresponding team members.3. To properly fill-out this tool, the Regulatory Officer shall make use of:INTERVIEWS, REVIEW OF DOCUMENTS, OBSERVATIONand VALIDATION of findings.4. If the corresponding items are present or available, place a ✔on eachof the appropriate boxes alongside each corresponding item. If not,put an X instead.5. The REMARKS column shall document relevant observations bothpositive and negative, including innovations and initiatives undertakenby those responsible in the facility.6. Make sure to fill-in the blanks with the needed information. Do notleave any items blank; write N.A. if not applicable.7. (Sh shaded cell means that specific items are not applicable to thehospital level.8. means the service can be outsourced but must be inside hospitalpremises.9. The Team Leader shall at the end of the inspection or monitoring visit,make sure that the team members complete their respective toolsection and proceed to accomplish the Summary of Evaluation (SOE)or Summary of Monitoring (SOM) Form and if warranted, the Notice ofViolation (NOV) Form.10. The Team Leader shall ensure that all team members write down theirprinted names, designation and affix their signatures and indicate thedate of inspection or monitoring,all at the last page of the AssessmentTool, on the SOE and SOMForms and if warranted, also on the NOVForm.11. The Team Leader shall make sure that the Head of the facility or, whennot available, the next most senior or responsible officer affix his/hersignature on the same aforementioned pages and indicate the position,to signify that inspection or monitoring results were discussed duringthe exit conference and a copy of the SOE or SOM and, only ifwarranted, that of the NOV, were received.12. This shall also serve as self-assessment tool for facility owners andmonitoring tool.II. GENERAL INFORMATION:Name of Hospital:Address:(Number & Street)(Municipality/City)Telephone No../ Fax No.E-mail Address:License No (for renewal):Date IssuedExpiry Date:(Barangay/District)(Province & Region)Hospital Category: Level 1 Level 2 Level 3Philhealth Accreditation:Center of: Safety Quality ExcellenceClassification According to Ownership: GovernmentNo. of: Authorized Bed CapacityImplementing BedsName of Owner or Governing Body (if corporation): PrivateName of Hospital Administrator, Medical Director or Chief of HospitalAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 2 of 60

SELF-ASSESSMENTDOH INSPECTIONDOH MONITORINGCODE STANDARDS CRITERIA INDICATOREVIDENCE AREA REMARKSHOSPITAL ADMINISTRATION:Goal- To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.ADMINISTRATIVE ANDFINANCE SERVICE: TheAFS shall ensure adequate1.1.1and timely financial anddirect support services to allhospital units.1.1.1.a1.1.1.a.1Administrative Group:Human ResourceManagementThere shall be acomprehensive humanresource management planwhich includes recruitment,selection, promotion,separation, welfare andbenefits in accordance withapplicable laws.●Documented andimplementable policies andproceduresApproved documented policies,guidelines and procedures on:a) Staffing planb) Recruitment andSelectionc) Hiring/Appointmentd) Orientation & StaffDevelopmente) continuing education, andtrainingApproved documented policies,guidelines and procedures ona) Staffing planb) Recruitment and Selectionc) Hiring/Appointmentd) Orientation & StaffDevelopmente) continuing education, andtraining● Complete, updated andeasily retrievableindividual personnel file● Evidence of continuousimprovementAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 3 of 60

:f) Performance Evaluationg) Rotation/Transferh) Succession Plani) Merit, Promotion, Awards& Incentivesj) Resignation, Terminationand Retirementk) Physical Examination● record of schedule of duties● appointment/employmentcontract, if valid● updated health certificate (asrequired)● orientation plan/program ofnew employees implemented●record of schedule of duties●appointment/employmentcontract, if valid● updated health certificate (asrequired)● orientation plan/program ofnew employees implementedVerifier:Documents review,Observe Interview staff,Validate▪ List of personnel –check ifCurrent1.1.1.b1.1.1.b.11.1.1.b.2Financial ManagementGroupAccountingThere shall be a systematicrecording of all financialtransactions, preparation offinancial statements andrelevant reports, and maintenanceand safekeeping ofBooks of Accounts.BudgetThere shall be aconsolidation andpreparation of the BudgetProposal, Work andFinancial/ OperationalPlans including itsimplementation andmonitoring by the hospitalstaff concerned.• documented andimplementable policies andprocedures• documented andimplementable policies andproceduresVerifier:Documents review, Interview staff,ValidateVerifier:Documents review, Interview staff,ValidateBilling And ClaimsThere shall be a system ofbilling patients andprocessing of claims• documented andimplementable policies andAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 4 of 60

1.1.1.b.31.1.1.cBilling and Claimsthere shall be a system ofbilling of patients andprocessing of claimsProcurement:There shall be acomprehensive plan ofsystematic management ofprocurement andacquisition of supplies,materials,healthcare equipment,vehicles, services,infrastructure work andother required logistics forthe effective and efficientdelivery of quality servicesdocumented and implementablepolicies and procedures●Policies, guidelines andprocedures on requisition,purchase, issuance andinventory; disposal of nonfunctionalequipment,instruments, supplies, expireddrugs and medicines andreagents are in place.Documents are readilyavailableLook for approved Workand Financial Plan and itsimplementationVerifier:Documents review, Interview staff,ValidateVerifier:Documents review,Observe Interview staffValidate1.1.1.dProperty and SupplyManagement:There shall be a systematicway of receipt, storage,issuance and conduct ofinventory .documented and implementablepolicies and proceduresProof of transactionsDocuments are readilyAvailableVerifier:Documents review, Interview staff,Validate1.1.1.eLinen and LaundryThere shall be adequatesupply of clean linens forpatients and other hospitalunits.● Sorting of soiled andcontaminated linens indesignated areas● Systematic washing of laundrywith safeguard against spread ofinfection● Disinfection of laundryPolicies, procedures andguidelines in cleaning andwashing of soiled linensVerifier:Documents review, Interview staff,Validate1.1.1.f HousekeepingThere shall be provisionand maintenance of clean,safe and sanitary facilitiesand environment forhospital personnel, patientsand clients● Adequatehousekeepingsupplies.●evidence of continuousreview of policies andproceduresVerifier:Documents review, Interview staff,ValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 5 of 60

1.1.1.g. SecurityThere shall be order withinthe hospital premises andprotection of lives,properties and criticalinfrastructure from threats,harm and losses●Security check for internal andexternal customers including useof visitor’s pass●evidence of continuousreview of policies andproceduresVerifier:Documents review, Interview staff,Validate1.1.1.h Ambulance Services(Compliance to A.O. 2010-0003- National Policy onAmbulance Use andServices)●Documented and approvedpolicies and procedures onpatient transport to and from thefacility●24 hour availability ofambulance for ready use●Available contract/ MOA, ifcontracted out●Logbook on transport ofpatients/clients by ambulance toand from the facilityWith appropriatemanpower, equipment andsupplies during patienttransportIf contracted out; notespecifications in contract orMOAVerifier:Documents review,Observe, Interviewstaff&Validate1.1.1.iCentral InformationManagementThere shall be acomprehensive plan ofsystematic management ofdata and research for theimprovement of acquisition,utilization of finances,assets and development ofhuman resources,operating systems andprocedures.●documented andimplementable policies andproceduresVerifier:Documents review,Observe, Interviewstaff&ValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 6 of 60

1.1.1.i.aMedical Records(Including DentalRecords)There shall be an organizedsystem of recording,processing, analyzing,maintaining andsafekeeping of all patients'records through the writtendata in sequence of eventscovering the diagnosis,treatment and discharge ofpatients● Documented andimplementable policies andprocedures● ICD-10 reference books withadditional ICD-10 modification● Logbooks on:AdmissionORDREROPDVerifier:Documents review, Interview staff,ValidateVerifier:Documents review, Interview staff,Validate1.1.1.jMedical Social ServicesThere shall be policies andprocedures in placepertaining to social casework, multisectoralnetworking and linkages inunderstanding the sociobehavioraland economicplight of patients and theirfamilies for the holisticapproach in theirmanagement and treatment● Approved documentedpolicies and procedures andrecords on:a)Patient classification accordingto their capacity to payb) Continuity of carec) Counselling of patients/clientsand their familiesd) Records of pre-admission andpre- discharge assessment, anddischarge plan●Available contract or MOA withDSWD or the LGU wheneverapplicable● (for private hospitals)Allocation of not less than 10% ofits Authorized bed capacity ascharity beds.●Compliance to RA 9439, “AnAct Prohibiting the Detention ofPatients in Hospitals and MedicalClinics on Grounds ofNonpayment of Hospital Bills orMedical Expenses”, (IRR, AONo. 2008-0001)Verifier:Observe, Interviewstaff, ValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 7 of 60

1.1,1.k Nutrition And DieteticsThere shall be maintenanceand provision of safe, highquality and nutritious foodto patients and personnel.• Actual implementation andevidence of continuousreview of policies andprocedures• If contracted out; notespecifications in contract orMOA• documented andimplementable policiesand proceduresVerifier:Observe, Interviewstaff, Validate1.1.1.l PharmacyThere shall be 24 hours, 7days a week provision ofsafe, affordable andefficacious drugs andmedicines in accordancewith the Generics Act,PNDF and DOH policies,rules and regulations.• Actual implementation andevidence of continuousreview of policies andprocedures• documented andimplementable policiesand proceduresVerifier:Observe, Interviewstaff, ValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 8 of 60

2.1.2 2.The organization informsthe community about theservices it provides and thehours of their availability.Clinical services areappropriate to patients' needsand the former's availability isconsistent with theorganization's servicecapability and role in thecommunity.Presence of facilitiesconsistent with clinicalservice capability based onDOH license in accordancewith the hospital’s level (e.g.level 1 surgical capability,level 2 – ICU, level 3–teaching and traininghospital).DOCUMENT REVIEWList of services availableOBSERVATION:Look at the facilities,structure, manpower,equipment and supply.Check if the servicecapability of the hospital isin accordance withthe hospital level.EROPDICUORRRPACUAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 10 of 60

2.2 PATIENT CARE2.2.1 ACCESS - Goal: The organization is accessible to the community that it aims to serve.2.2.1.a2.2.1.b3.Physical Access tothe organization and itsservices is facilitatedand is appropriate topatients' needs.4.Physical access to theorganization and its servicesis facilitated and isappropriate to patients'needs.Entrances and exits areclearly and prominentlymarked, free of anyobstruction and readilyaccessible.Directional signs areprominently posted to helplocate service areas withinthe organization.Presence of entrances andexits that are readilyaccessible and free fromobstruction.Presence of directionalsignages to locate serviceareas.Directional signs areprominently posted. CheckER, OPD, wards and lobby.OBSERVATIONEntrances and exits areaccessible and free fromany obstruction.Note: Exit signs should beluminous or illuminatedand prominently marked.There should be exit signsin major areas of thehospital and all doorsleading to theoutside.(Reference: RA6541 Building Code of thePhilippines)EROPDWardsICUOR/RR/DR/PACUImagingLaboratoryEROPDWardsOther AreasLobby2.2.1.c5.Physical access to theorganization and its servicesis facilitated and isappropriate to patients'needs.Alternative passageways forpatients with specialneeds(e.g.ramps andelevators) are available,clearly and prominentlymarked and free of anyobstruction..Presence of alternativepassageways (ramps andelevators) that areprominently marked andfree from obstruction forpatients with special needs.OBSERVATION1.There are alternativepassageways for patientswith special needs. CheckER, OPD, wards andother areas2. They are prominentlymarked and3. They are free fromobstructionEROPDWardsOtherareasAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 11 of 60

2.2.2. ENTRYGoal: The entry process meet patient needs and are supported by effective systems and a suitable environment2.2.2.a6.The organization uniquelyidentifies all patientsincluding newborn infants,and creates a specificpatient chart for eachpatient that is readilyaccessible to authorizedpersonnel.All patients are correctlyidentified by their patientcharts.All patients are correctlyidentified by their charts.DOCUMENT andINTERVIEWPatient chart from ER,ward, OPD and ICU andverify with patient if he/shereally is the personindicated in the chart.EROPDWardsICU2.2.3ASSESSMENTGoal: Comprehensive assessment of every patient enables the planning and delivery of patient care.2.2.3.a7.Each patient's physical,psychological and socialstatus is assessed.An appropriatelycomprehensive history andphysical examination isperformed on very patientwithin 24 hours fromadmission. The historyincludes present illness, pastmedical, family, social andpersonal history.All patients havecomprehensive history andPE within 24 hours fromadmission.CHART REVIEWDOCUMENTPatient chart from wardsor ER.WardsERNOTE: comprehensivehistory includes presentillness, review of systems,past medical, family andpersonal history.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 12 of 60

2..2.3.b8.Appropriate professionalsperform coordinated andsequenced patientassessment to reducewaste and unnecessaryrepetition.Previously obtainedinformation is reviewed atevery stage of theassessment to guide futureassessments.All patient charts haveprogress notes by doctors.CHART REVIEWPatient chart from medicalrecordsNote: The progress notesshould be done regularlyand documented in thepatient chart either asseparate “progress notes”sheet or side notes in thedoctor’s order sheet.MedicalRecordsOffice2.2.3.c9.Assessments areperformed regularly andare determined by patient'sevolving response to care.Qualified personnel givepatients for surgery preoperativephysical and preanestheticassessment.All patients for surgery haveundergone pre-operativeanesthetic assessment.CHART REVIEWNote: Look for preoperativeanestheticevaluation in the patientchart. Pre-operativeassessment should bedone for patients requiringmore than localanesthesia.2.3 IMPLEMENTATION OF CAREGoal: Care is delivered to ensure the best possible outcomes for the patients2.3.1 10.Diagnostic examinationsappropriate to the providerorganization's servicecapability and usual casemix are available and areperformed by qualifiedpersonnel.Policies and procedures forthe standard performance,monitoring and quality controlof diagnostic examinationsare documented andmonitored.Proof of monitoring of theimplementation of thepolicies and procedures onquality control of diagnosticexaminationsDOCUMENT REVIEWMonitoring reports,e.g..utilization review ofdiagnostics exams done,audit reports, manual ofprocedures, or DOHmonitoring reports e.g..Quality control diagnosticreports (QC reports onsoftwares, calibration ofdiagnostic equipment, filmreject analysis, etc.)X-rayLaboratoryAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 13 of 60

2.3.2.a2.3.2.b11.Drugs are administeredin a standardized andsystematic manner in theprovider organization.12.Drugs are administeredin a standardized andsystematic manner in theprovider organization.Drugs are administered in atimely, safe, appropriate andcontrolled manner.Only qualified personnelorder, prescribe, prepare,dispense and administerdrugs.All drugs are administered ina timely, safe, appropriateand controlled manner to theright patientAll doctors, dentists, nursesand pharmacists haveupdated licenses. For the timeliness ofdrug administration, checkthe hospital policy. Ifhospital does not havepolicy, frequency of drugadministration in the chartshould be checked andvalidate it thru patientinterviewNote: Surveyor may alsocheck for administration ofany of the following:antibiotics,anticonvulsants, MgSO4,KCl drip and other drips,calcium gluconate, sodiumbicarbonate, etc. For oralmedications, do directobservationRandomly check thelicenses ofdoctors,dentists, nursesand pharmacists.ChartReviewWardsPharmacyOPDER2.3.2.c13.Drugs are administeredin a standardized andsystematic manner in theprovider organizationPrescriptions or orders areverified and patients areidentified before medicationsare administered.Proof that the prescriptionsor orders are verified beforemedications areadministered.DOCUMENTProcedures on verificationof orders. INTERVIEWObserve if staff verifiesthe prescriptions or ordersfor drugs with the doctorand the drug against thedoctor's orderNote: This is on a case tocase basis; includes theroute of administration(slow IV) and otherprecautionarymeasures/instruction e.g..ANSTAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 14 of 60

2.3.2.d14.Drugs are administeredin a standardized andsystematic manner in theprovider organizationPrescriptions or orders areverified and patients areidentified before medicationsare administered.INTERVIEWVerify from patients if theywere correctly identifiedprior to drugadministration.MedicalRecordsRoomOBSERVATIONObserve if the staffverifies the identity ofpatient prior toadministration ofmedications.2.3.2.e15.Drugs are administeredin a standardized andsystematic manner in theprovider organizationDrug administration isproperly documented in thepatient chart.All charts have properdocumentation of drugadministrationCHART REVIEWMedication sheet inpatient chart from themedical records..2. EVALUATION OF CAREGoal: Care is coordinated between the organization and other health care providers in the community to ensure that theneeds of the patient are continuously met.2.4.1 16. The discharge plan ispart of the patient's careplan and is documented inthe patient chart.All charts have dischargeplansCHART REVIEWPatient chart from medicalrecords room, thedischarge orders shouldcontain the ff.:1. May go home order2.Home medications (ifapplicable)3.Follow upvisits/schedule4. Home care/adviseNote: Discharge plan is notsynonymous with dischargesummary.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 15 of 60

2.5 LEADERSHIP AND MANAGEMENTManagement teamGoal: The organization effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired healthoutcomes, and is responsive to patient's and community needs.2.5.1.a2.5.1.b17.The organization regularlyreviews and updates itspolicies, guidelines andprocedures18.Terms of reference,membership and proceduresare defined for the meetingsof all committees within theorganization. Minutes ofmeetings are recorded andapproved.● Strategically Posted Visionand Mission of all theServices●Approved Manual ofOperations and/ or WrittenPolicies, Guidelines andProcedures on ClinicalServices Offered●Strategically PostedFunctional andOrganizational Chart withPhotos Showing Names andRelationship by PositionsProof of the creation of allcommittees within theorganization which includesthe terms of reference formembershipOBSERVATIONDOCUMENT REVIEW2.5.1.c19.The organization'smanagement team regularlyassesses its ownperformance and theperformance of theorganization.Presence of evaluation andmonitoring activities toassess management andorganizational performanceINTERVIEW1. Ask the managementteam about priorities forperformance improvementthat relate to hospital wideactivities and patientoutcomes2. Ask management teamhow targets are set.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 16 of 60

2.6.120. Documentedagreements and contractscover external serviceproviders and specify that thequality of services providedmust be consistent withappropriate set standards.Presence of MOA/ contractfor all out-sourced services(e.g. dialysis unit, dietary,laboratory, radiology).(Outsourced are services/facilities provided by thirdparty but are inside thehospital)DOCUMENT REVIEW1.Contracts/MOA foroutsourced services.2. Valid licenses of allproviders of theoutsourced services.Documentreview3.13.1.13.1.1.aOBSERVATIONActual presence of theoutsourced services withinthe hospital if applicableNote: The contracts/MOAshould be updated. MOAis sufficient for somehospitals where theoutsourced services arenot within the facility.Human Resource ManagementHuman Resource PlanningGoal: The organization provides the right number and mix of competent staff to meet the needs of its internal andexternal customers and to achieve its goals.The organizationdocuments and followspolicies and proceduresfor hiring, credentialing,and privileging of its staff.21. Planning ensures thatappropriately trained andqualified (and where relevant,credentialed) staff areavailable to undertake thetype and level of activityperformed by theorganization. This includesthose who are consultedwhen suitable expertise isnot available withinthe organizationPresence of policies andprocedures forcredentialing andprivileging of staffPolicies and proceduresfor credentialing andprivileging of staffImagingLaboratoryOther areasAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 17 of 60

3.1.1.b22.Workload is monitoredand appropriate guidelinesconsulted to ensure thatappropriate staff numbersand skill mix are available toachieve desired patient andorganizational outcomes.Staff numbers and skillmix are based on actualclinical needs.Staff to bed ratio forlicensed doctors,registered nurses andmidwives/nursing aidesfollow the DOHprescribed ratio.DOCUMENT REVIEW1. List of total numberof licensed doctors anddentists, registerednurses and midwives/nursing aides based onHR records and2. The schedule ofduties for the previousand current month3. Number of bedsapplied for and theactual being used.OBSERVATIONNumber of beds4.1 DATA COLLECTION, AGGREGATION AND USE4.2Goal: Collection and aggregation of data are done for patient care, management of services, education and research.RECORDS MANAGEMENTGoal: Integrity, safety, access and security of records are maintained and statutory requirements are met.4.2.1 Medical Record4.2.1.a 23.Clinical records arereadily accessible tofacilitate patient care, arekept confidential and safe,and comply with allrelevant statutoryrequirements and codesof practiceWhen patients are admittedor are seen for ambulatory oremergency care, patientcharts documenting anyprevious care can be quicklyretrieved for review, updatingand concurrent use.●Presence of policies andprocedures on systematicfiling, retrieval, retention,storage, disposal andmanagement of medicalrecords. Patient’s chartcontents include thefollowing:-Doctor’s Progress Notes-Informed Consent-Problem List-Medication and TreatmentRecord-Laboratory and X-ray Reports-Dietary Assessment Clinicaland Graphic Record of VitalSigns (TPR sheet)-Personal History andPhysical Examination records-Newborn Record andPhysical Maturity Rating, ifwarrantedDOCUMENT REVIEWPolicies andprocedures onsystematic record filing,retrieval. retention,storage, safekeepingand maintenance anddisposal.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 18 of 60

24.There shall be anorganizedsystem of processing,analyzing, maintaining andsafekeeping of all patients'records through the writtendata in sequence of eventscovering the diagnosis,treatment and discharge ofpatients.-Doctor’s Progress Notes-Medication and TreatmentRecord-Laboratory and X-ray Reports-Dietary Assessment NursesProgress Notes-Records of Transfer/Referral toanother Physician or HealthFacility-Inpatient Referral/ConsultationNotes of Other Physicians-Final Diagnosis-Advance Directive, if anyDOCUMENT REVIEWNote also the following:1. ICD-10Coding is beingused.2. Medical RecordsOfficer is trained on ICD-10 Coding and MedicalRecords Management25.Clinical records are readilyaccessible to facilitate patientcare, are kept confidentialand safe, and comply with allrelevant statutory requirementsand codes of practiceThe organization has policiesand procedures and devotesresources includinginfrastructure to protectrecords and patients chartsagainst loss, destruction,tampering and unauthorizedaccess or use. Onlyauthorized individuals makeentries in the patient chart.Presence of procedures toprotect records and patientscharts against loss,destruction, tampering andunauthorized access or useDOCUMENT REVIEWPolices and procedureson records managementfor the entire hospital tomaintain privacy,accuracy and preventloss and destruction.OBSERVATIONObserve 20 nurses in thewards and recordspersonnel on how theyprotect patient chartagainst loss, tamperingand unauthorized use.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 19 of 60

6.16x1.16.1.1.a6.1.1.bSAFE PRACTICE AND ENVIRONMENTPATIENT AND STAFF SAFETYGoal: Patients, staff and other individuals within the organization are provided a safe, functional and effectiveenvironment of care.26.The organization plans asafe and effective environmentof care consistent with itsmission, services, andwith laws and regulations.27.The organization plans asafe and effective environmentof care consistent with itsmission, services, and withlaws and regulations.The organizationalenvironment complies withstructural standards andsafety codes as prescribed bylaw.There are management planswhich address safety,security, disposal and controlof hazardous materials andbiological wastesEmergency and disasterpreparedness, fire safety,radiation safety and utilitysystems.Presence of a managementplan addressing safety,security, disposal andcontrol of hazardousmaterials and biologicwastes, emergency anddisaster preparedness, firesafety, radiation safety andutility systems.If facility has nuclearmedicine, ask for thecertificate issued by thePhilippine NuclearResearch Institute(PNRI).DOCUMENT REVIEWManagement plan whichincludes polices,procedures andprograms, riskassessment, hazardssurveillance amongothers that address thefollowing:1. Safety2. Security3. Disposal and control ofhazardousmaterials/biologic wastes4. Emergency anddisaster preparedness5. Fire safety6. Radiation safety7. Utility systemsNote: The hospital musthave plans for all theelements enumerated inthe criteria. Plans shouldhave guiding policies andspecific procedures.EROPDWards ICU OR/DR/RRFacilities andmaintenanceImagingLaboratoryOthersAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 20 of 60

6.1.1.c28.The organization plans asafe and effective environmentof care consistent with itsmission, services, and withlaws and regulations.There are management plansfor the safe and efficient useof medical equipmentaccording to specifications.Presence of operatingmanuals of the medicalequipment.DOCUMENT REVIEWDOCUMENTOperating manuals forthe medical equipment6.1.1.d29.The organization provides asafe and effective environmentof care consistent with itsmission and services, and withlaws and regulations.Policies and procedures thataddress safety, security,control of hazardousmaterials and biologicalwastes, emergency anddisaster preparedness, firesafety, radiation safety andutility systems aredocumented andimplemented.Proof of implementation ofthe policies, procedures andsafety programs onDocument review1. Water safety - wateranalysis results for the past6 months.1. electrical safety 2. Fire and emergency2. medical device safetypreparedness - check forexit plans, plans forER3. chemical safetyearthquake and otherdisasters.OPD4. radiation safety Wards5. mechanical safety3. Control of hazardousmaterials - MOA/ContractImaging6. water safetyof outsourced services forwaste managementINTERVIEWLaboratory7. combustible material1. Ask staff from ER, Wards,OPD, Laboratory,Pharmacysafety8. waste managementPharmacy, and facilitiesand maintenance on themanner of wasteFacilities andmaintenancesegregation and disposal(general waste, liquid &solid waste, infectiouswaste; non-infectious,9. hospital safety programhazardous and nonhazardousOther areas(fire, emergency anddisaster preparedness)2. Hospital safety program3. Mechanical safetyprogram of the hospitalAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 21 of 60

OBSERVATION1. Electrical safety - checkfor exposed wires andsockets, “octopusconnections"2. Emergencypreparedness - check forevacuation plans, presenceof fire extinguishers3. Control of hazardouswaste - waste disposalsystem, segregation ofwaste, proper labeling ofwaste receptacles4. Chemical safety - checksafe storage and disposal ofreagentsDOCUMENT1. Quality controlprograms and correctiveand preventivemaintenance programs2. Record of disposal ofradiologic wastes3. Preventive andcorrective maintenancelogbook4. Film reject analysistest resultsINTERVIEWAsk staff about their rolein the hospital wasteAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 22 of 60

6.1.1.e30.The organization provides asafe and effective environmentof care consistent with itsmission and services, and withlaws and regulations.Policies and procedures forthe safe and efficient use ofmedical equipment accordingto specifications aredocumented andimplementedProof of the implementationof the policies andprocedures for the safe andefficient use of medicalequipment.management programparticularly manner ofradiologic wastedisposal.OBSERVATIONDOCUMENT REVIEWPresence of policies andprocedures for the safe andefficient use of medicalequipment (including theimplementation of DOHAO#2008-0021on thegradual phase-out ofmercury)DOCUMENT1. Operating manual2. Preventive andcorrective maintenancelogbook3. Qualifications of staffhandling medicalequipmentINTERVIEW1. Ask staff in the ER,ICU, wards, OR/RR/DR,facilities andmaintenance, imagingand laboratory about thepolicies and proceduresfor use of medicalequipment and their rolein the implementation ofsuch policies andprocedures.2. Ask staff in the ER,wards, ICU andOR/RR/DR for thehospital's program on thegradual phase-out ofmercury.ERWardsOR/RR/DRFacilities andmaintenanceImagingLaboratoryOther areasAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 23 of 60

6.1.1.f31.The organization provides asafe and effective environmentof care consistent with itsmission and services, and withlaws and regulations.The design of patient areasprovides sufficient space forsafety, comfort and privacy ofthe patient and for emergencycare.Presence of adequatespace, lighting andventilation in compliancewith structural requirements(for patient safety andprivacy).OBSERVATION1. Adequate space2. Adequate lighting(lights are working,lighting is adequateenough for conduct ofgeneral activities)3. Adequate ventilationEROPDWardsICUOR/RR/DRImagingLaboratoryPharmacyOther areas6x1.1.g32.The organization provides asafe and effective environmentof care consistent with itsmission and services, and withlaws and regulations.Risks are identified, assessedand appropriately controlled.Where elimination orsubstitution is not possible,adequate warning andprotection devices are used.Presence of policies andprocedures on riskidentification, assessmentand control.DOCUMENT REVIEWpolicies and procedureson risk identification,assessment and control,security risks and use ofpersonal protectiveequipment, etc.Documentreview33. The organization providesa safe and effectiveenvironment of Care consistentwith its mission and services,and with laws and regulations.A coordinated securityarrangements in theorganization assuresprotection of patients, staffand visitors.Presence of an appointedpersonnel in charge ofsecurity.Hospital order or Memo.DOCUMENT REVIEWPolicies and procedures onrisk identification,assessment and control,security risks, use ofpersonal protectiveAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 24 of 60

6x1.1.hequipment, etc.or Appointment of personin charge of securityINTERVIEWAsk the personnel incharge of security whatthe policies on security ofthe hospital are .OBSERVATIONPresence of securityguard/s or personnel incharge of security.7.1 MAINTENANCE OF THE ENVIRONMENT OF CAREGoal: A comprehensive maintenance program ensures a clean and safe environment.7.1.1 34.The organization routinelycollects and evaluatesinformation to improve thesafety and adequacy of theenvironment of careAn incident reporting systemidentifies potential harms,evaluates causal andcontributing factors for thenecessary corrective andpreventive action.Presence of incidentreporting system/sentinelevent monitoring system(which may includenosocomial infections,unexpected deaths, adversedrug reactions, floodtransfusion reactions, falls,etc)."Sentinel event" refers toinjuries caused by medicalmanagement (not necessarilythe disease process) that eithercaused death, prolonged hospitalizationor produced a disabilityduring the time of confinementor by the time ofdischarge.7.1.2 35. Emergency light and / orpower supply, water andventilation systems areprovided for, in keeping withrelevant statutory requirementsPresence ofgenerator/emergency light,water system, adequateventilation or airconditioning.DOCUMENT REVIEW●Minutes of Leadershipmeeting●Incident/sentinel eventreports or communications/memoranda/orders or proceedings onsentinel eventsINTERVIEWAsk readers and staff fromwards and ER how theincident reporting systemworks.DOCUMENTPreventive and correctivemaintenance logbooksfor generator/ emergencylight/ water tanks/WardsERICUORFacilities andmaintenanceAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 25 of 60

and codes of practice. airconditioners .Other areas7.1.3 36.Equipment is serviced onlyby people trained in themaintenance of thatequipment. Registers andrecords of equipment andrelated maintenance are kept.Proof of training of the staffwho is in charge of themaintenance of theequipment.OBSERVATION1. Presence ofgenerator/emergencylight, water tanks,adequate ventilation orair conditioning2. Test if faucets andwater closets areworkingDOCUMENT REVIEWProof of training of servicepersonnel if in-house orCertificate of Training,attendance sheet,Certificate of Attendance,diploma, citation orMOA/Contract foroutsourced services(verify qualification oftechnicians).Facilities andmaintenanceFacilities andmaintenanceImagingLaboratoryOtherareasAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 26 of 60

7.1.4 37.Current information andscientific data frommanufacturers concerning theirproducts are available forreference and guidance in theoperation and maintenance ofplant and equipment.INTERVIEWAsk about howequipment (generator,airconditioner, medicaldevices and otherequipment etc.) aremaintained.Presence of operatingmanuals equipmentDOCUMENTOperating manual ofgenerators, airconditioners and othernon-medical equipment.8.1 INFECTION CONTROLGoal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel,visitors and trainees are identified andAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 27 of 60

8.1.1.a8.1.1.b38.An interdisciplinary infectioncontrol program ensures theprevention and control ofinfection in all services.39.An interdisciplinary infectioncontrol program ensures theprevention and control ofinfection in all services.Presence of an InfectionControlCommittee (ICC) withdefined goals, objectives,strategies and priorities orfor a primary hospital - adesignated doctor and nursein-charge of infectioncontrol.Presence of an infectioncontrol program ensuringprevention and control ofinfections on all services.DOCUMENTREVIEWDOCUMENT REVIEW1. ICC composition (for aprimary hospital - proof ofdesignation of a doctor andnurse in-charge of = in2.ICC functions and activitiesfection control)3. Minutes of meeting, atleast quarterly activities4. Statistics on nosocomialinfectionsINTERVIEWAsk a member of the ICCregarding infection controlprogram of the hospital.DOCUMENT REVIEW1. Policies and procedureson prevention and controlof nosocomial infection orInfection control manual8.1.2.a40.The organization uses acoordinated system-wideapproach to reduce the risks ofnosocomial infections.The organization takes stepsto prevent and controloutbreaks of nosocomialinfections.Presence of coordinatedsystem-wide procedure forisolation of nosocomialinfections.2. Policies on rational antimicrobialuse based on thehospital antibiogram incoordination withMicrobiology laboratoryand Pharmacy TherapeuticsCommittee3. Reports of infectioncontrol activities e.g.training,outbreakinvestigation,preventive programsDOCUMENT REVIEWDocumentreviewAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 28 of 60

Procedures on isolation ofnosocomial infectionsERINTERVIEWWardsAsk= staff in ER, wards andICU the procedures onisolationisolation - physical isolationof a patient with infectionICU8.1.2.b41.The organization uses acoordinated system-wideapproach to reduce the risks ofnosocomial infections.The organization takes stepsto prevent and controloutbreaks of nosocomialinfections.Presence of coordinatedsystem-wide procedure forcase containment ofnosocomial infections.DOCUMENTREVIEW Procedures oncase containment ofnosocomial infectionsNote: case containment- means prevention ofspread of infectionexamples: reverse isolation,prophylaxis for exposedpersonnel, vaccination,immunizationDocumentreviewERWardsICU.INTERVIEWValidate from staff in ER,wards and ICU theprocedures on casecontainment8.1.2.c8.1.3.a42.The organization uses acoordinated system-wideapproach to reduce the risks ofnosocomial infections.43.The organization uses acoordinated system-wideapproach to reduce the risks ofinfection the staff are exposedto in the performance of theirThe organization takes stepsto prevent and controloutbreaks of nosocomialinfections.There are programs forprevention and treatment ofneedle stick injuries, andpolicies and procedures forthe safe disposal of usedPresence of coordinatedsystem-wide procedure forasepsis.Presence of policies andprocedures on theprevention and treatment ofneedle stick injuries andsafe disposal of needles.DOCUMENT REVIEWProcedures on asepsisINTERVIEWAsk staff from ER, wards,laboratory and ICU aboutthe approaches for asepsisduring diagnostic andtreatment procedures.DOCUMENT REVIEW1. Policies and proceduresfor prevention andtreatment of needle stickinjuriesERWardsICULaboratoryAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 29 of 60

8.1.3.bduties.44.The organization uses acoordinated system-wideapproach to reduce the risks ofinfection the staff are exposedto in the performance of theirduties.needles are documented andmonitored.There are programs for theprevention of transmission ofairborne infections, and risksfrom patients with signs andsymptoms suggestive oftuberculosis or othercommunicable diseases aremanaged according toestablished protocols..Presence of program onprevention of transmission ofairborne infections and risksfrom patients with signs andsymptoms suggestive oftuberculosis or othercommunicable diseases .2. Policies and procedureson proper handling andsafe disposal ofsharps/needle sticksINTERVIEWInterview hospital staff onhow they handle anddispose needlesOBSERVATIONPresence of receptacles forproper disposal of sharps.DOCUMENT REVIEW1. Infection controlprocedures on isolationand universal precaution2. Program for theprotection of healthcareworkers e.g. personalprotective equipment(PPEs)3. Policies on all patientadmission/referral,isolation and timely casereporting of highlytransmissible and notifiableinfectious disease e.g.meningococcemia, SARS,avian flu, etc.4. Hand hygieneprocedures5. Environmental care andhealthcare wastemanagement6. Procedures on recycling& reuse of equipment i.e.personal protectiveequipmentERWardsICULaboratoryERWardsICULaboratoryINTERVIEWAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 30 of 60

Validate hospital policieson infection control such asuse of PPEs, isolationprecautions and handwashing.OBSERVATION1. Observe for use ofgloves, surgical masks.OR/DR3. Look for separateholding area/room forhighly infectious cases.4. Ask a hospital staff todemonstrate hand washingtechnique.WardEROR/DR8.1.4 45.Cleaning, disinfecting,drying, packaging andsterilizing of equipment, andmaintenance of associatedenvironment, conform torelevant statutory requirementsand codes of practice.8.1.5 46.When needed, theorganization reportsinformation about infections topersonnel and public healthagencies.Presence of policies andprocedures on cleaning,disinfecting, drying,packaging and sterilizing ofequipment, instruments andsupplies. (Refer to Annex__Sterilization Guidelines inHospital Setting)Presence of policies andprocedures on reporting ofinfections to personnel andpublic health agencies.DOCUMENT REVIEW1. Policies and procedureson cleaning, disinfecting,drying, packaging andsterilizing of equipment,instruments and supplies.2. Policies ondecontamination,disinfection, sterilization,disinfectants for specificmedical equipment/itemsand area.3. Housekeepingprocedures in specificpatient areas.DOCUMENT REVIEWAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 31 of 60

Presence of policies,procedures and guidelinesfor safe reuse of items whichcomply with relevantstatutory requirements.DOCUMENT REVIEWINTERVIEWAsk heads and staff aboutthe following:1. Policy on reuse of items2. SOPs on reuse3. Reporting4. Personnel in charge9.1 ENERGY AND WASTE MANAGEMENTGoal: The organization demonstrates its commitment to environmental issues by considering and implementingstrategies to achieve environmental sustainability9.1.1 47.The handling, Presence ofAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 32 of 60

collection, and disposalof waste conform torelevant statutoryrequirements and codesof practice.9.1.2 48.The organizationimplements a wastedisposal program whichinvolves reuse, reductionand recycling.licenses/permits/clearances frompertinent regulatoryagencies implementingamong others thefollowing: RA 9003, RA6969, RA 275, PD 1586DOH Hospital WasteManagement Manual,RA 8749 (Clean Air ActProof of implementation ofpolicies and procedureson waste disposal.DOCUMENTREVIEWPertinentlicenses/permitsfrom regulatoryagencies (LGU,DENR, etc.)DOCUMENTREVIEW1. Issuances - memos,guidelines on wastedisposal2. Contracts with wastehandlers or disposalcontractors, (ifapplicable)3. Hospital policy thatconforms to the jointDOH-DENR circular onwaste management forLGUs1. Waste Segregation2. Proper labeling ofwaste receptacles3. Recyclable wastestaging areas4. Proper managementof temporary storageareas prior to hauling fordisposal.ERWardsICUImagingLaboratoryFacilities andmaintenance10.1 IMPROVING PERFORMANCEGoal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time andmeeting the needs of internal and external clients.Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 33 of 60

10.1.149.The organization hasa planned systematicorganization- wideapproach to processdesign and performancemeasurement,assessment andimprovementPresence of QualityImprovement ProgramDOCUMENT REVIEW1. Policy creating the QIprogram2. Proof of meetings orsimilar documents of QACommittee activities3. Policies andprocedures on aperformancemeasurement andimprovement10.1.250.The organizationprovides better careservice as a result ofcontinuous qualityimprovement activities.Presence of patientsatisfaction surveyINTERVIEWValidation of alI activitiesthru interview ofpertinent staff includingfrontliners andCommittee members.DOCUMENT REVIEW1. Patient satisfactionsurvey results2.Patient satisfactionsurveyquestionnaire(may checkon the domains anditems)Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 34 of 60

SELF-ASSESSMENTDOHINSPECTIONDOHMONITORINGCODE10.1POSITION STAFFINGREQUIREMENT I:(Top ManagementPositions)CRITERIAINDICATOREVIDENCE AREA REMARKS10.1.1Hospital Administrator(Optional)10.1.2Medical Director/ Chief ofHospital or MedicalCenter ChiefFor level 1, must havecompleted at least 20units towards aMasters Degree inHospital Administrationor Related CourseAND at least 3 yearsexperience in asupervisory/managerial positionVerifier:Documents review, Interview staff,Validate: Diploma/ Certificateof units earned● Proof ofemployment/appointmentFor levels 2 and3,must havecompleted a MastersDegree in HospitalAdministration orRelated Course OR atleast 5 yearsexperience in asupervisorymanagerial positionAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 35 of 60

10.1.3Chief of Clinics/ChiefMedical ProfessionalServicesFor levels 2 and3,must be a Diplomate/Fellow in a Specialtyarea AND at least 5years experience in asupervisory/managerial positionVerifier:Documents review, Interview staff,Validate: Diploma● Proof ofemployment/appointment10.1.4Department HeadFor levels 2 and 3, must bea Diplomate/ Fellow in aSpecialty Society of theSpecialty Departmenthe/she headsVerifier:Documents review, Interview staff,Validate:●Diploma●Proof ofemployment/appointmentAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 36 of 60

10.1.5Chief Nurse/Directorof Nursing/DeputyDirector for Nursing●For level 1, musthave completed atleast 9 units towards aMasters Degree inNursing AND at least 2years experience innursingsupervisory/managerialposition●For levels 2 and 3, musthave a Masters Degree inNursing AND at least 5years experience in anursing supervisorypositionVerifier:Documents review, Interview staff,Validate:●Diploma/ Certificate ofunits earned●Proof ofemployment/appointment10.1.63.5 AdministrativeOfficerFor level I, must havecompleted at least 20 unitstowards a Masters Degreein Hospital Administrationor Related Course AND atleast 3 years experience ina supervisory /managerialposition.For levels 2 and 3, musthave completed a Master’sDegree in HospitalAdministration or RelatedCourse AND at least 5years experience in asupervisory managerialposition.Verifier:Documents review, Interview staff,Validate:●Diploma/ Certificate ofunits earned●Proof ofemployment/appointmentAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 37 of 60

SELF – ASSESSMENTDOH INSPECTIONDOH MONITORINGREMARKSCODEPOSITION STAFFING REQUIREMENTIILEVEL 1 LEVEL 2 LEVEL 311.1 ADMINISTRATIVEChief of Hospital /Medical1 1 111.1.1 Director/Medical Center Chief11.1.2 Administrative Officer 1 1 1Clerk:1:50 beds 1:50 beds 1:50 beds11.1.3.a - Pool11.1.3.b - Accounting 1 1 111.1.4 Medical Records Officer trained in ICD- 1:50 beds 1:50 beds 1:50 beds10 and Medical Records Management11.1.5 Cash Clerk 0 111.1.6 Accountant 1 1 111.1.7 Budget /Finance Officer 1 111.1.8 Bookkeeper 1 1 111.1.9 Billing Officer 1 1 111.1.10 Cashier 1 1 111.1.11 Human Resource Mgt. Officer 1(designate) 1 111.1.12 Training Officer 1(designate) 1 1Medical Records Officer (ICD- 10 and 1 1 111.1.13 Medical Records Management trained)11.1.14 Supply Officer 1 1 111.1.15 Storekeeper/ Linen Custodian 1 1 111.1.16 Laundry Worker 1 1:50 beds 1:50 beds11.1.17 Utility Worker 1/Shift 1:50 beds/shift 1:50 beds/shift11.1.18 Security Guard 1/shift 1/entrance/exit 1/entrance/exit perper shift shift11.1.19 Engineer 1 111.1.20 Medical Equipment/Biomedical1 1Technician11.1.1.21 Maintenance Personnel 1 1/shift 1/shiftAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 38 of 60

11.1.1.22 Mechanic 0 0 111.1.1.23 Nutritionist-Dietitian (for level 2 and incase of sharing, must be residing withinthe locality)1 (sharing isallowed e.g.hospital andmunicipal/citygovernment)1:100 beds 1:100 beds11.1.1.24 Cook 1 1:100 beds 1:100 beds11.1.1.25 Food Service Worker 0 1:50 beds 1:50 beds11.1.1.26 Food Service Supervisor 0 1 111.1 Medical Social Worker (For level 1, If 1 1 1there is MOA with DSWD-LGU, theMedical Social Worker should bephysically present in the hospital)11.2 CLINICAL:11.2.1 Chief of Clinics/Chief MedicalProfessional Services1 111.2.2 Department Head 1/department11.2.3 Consultant Physician (Diplomate/Fellow of a Specialty/ Sub-SpecialtySociety after a formal residency trainingprogram)11.2.4 Physician (must not go on duty more 1:20 beds at any 50 beds = 6than forty-eight (48) hours continuous time plus 1 Every additionalduty)reliever50 beds =additional 2(number not prescribed)1/department 100 beds = 8Every additional50 beds =additional 3( ForDepartments withaccreditedresidency trainingprogram, numberwill depend onthe requirementof specialty boardconcerned).Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 39 of 60

11.3 NURSING:11.3.1 Chief Nurse/Director of Nursing 1 1 111.3.2 Asst. Chief Nurse (maybedesignated asTraining Officer)0 100 beds andabove=1100 beds andabove=111.3.3 Supervising Nurse 1:50 beds 50 beds andbelow = 1,51-100 beds =2,101-150 beds =3,151 beds andabove = 411.3.4 Supervising Nurse (Critical CareUnits)-CCUs include all types of ICUs,including Post-Anesthesia CareUnit(PACU) and RR1 per criticalcare unit1 per department/special area1 per critical careunit11.3.5 Head Nurse 1:15 RNs 1:15 RNs 1:15 RNs11.3.6 Staff Nurse-For every three (3) RNs, theremust be one (1) reliever)1:12 beds at anytime1:12 beds atany time1:12 beds at anytime11.3.7Staff Nurse (CCUs)-Base the ratio on the actual numberof occupied CCU beds at the time ofinspection1:3 beds at anytime1:3 beds at anytimeNursing Attendant/ Midwife-Optional if the Authorized Bed11.3.8 Capacity (ABC) is less than twentyfour(24) beds. If the ABC is 24beds and above, the ratio will apply.11.3.9 Nursing Attendant/ Midwife (CCUs)-For every three (3) NursingAttendants/Midwives, there must be1:24 beds at anytime1:24 beds atany time plus 1reliever1:15 beds atany timeone (1) reliever11.3.10 Operating Room Nurse 1/shift 1/shift( mayincrease1:24 beds at anytime plus 1reliever1:15 beds at anytime1/OR/shift( mayincreaseAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 40 of 60

depending onthe averagenumber of ORcases per day)11.3.11 Delivery Room Nurse 1 per/shift 1/shift( mayincreasedepending onthe averagenumber ofdeliveries perdepending on theaverage numberof OR cases perday)1/DR/shift( mayincreasedepending on theaverage numberof deliveries perday)day)11.3.12 Emergency Room Nurse 1/ shift 1 shift 1/Dept/shift11.3.13 Out-Patient Department Nurse 1 1 1/Dept.11.4 ALLIED MEDICAL PERSONNEL11.4.1 Pharmacist (full-time,registered); Adequate Adequate Adequate11.4.2 Pathologist 1 1 111.4.3 Med. Technologist (full-time,registered)Adequate Adequate Adequate11.4.4 Other Lab. Personnel (specify) Adequate Adequate Adequate11.4.5 Dentist 1 1 211.4.6 Dental Aide 1 1 211.4.7 Radiologist 1 1 211.4.8 Radiology Technologist Adequate Adequate Adequate11.4.9 Radiation Safety officer 1(designate) 1(designate) 111.4.10 Physical Therapist 111.4.11 Respiratory Therapist( may be “on call”for level 2)Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 41 of 60

SELF –ASSESSMENTDOHINSPECTIONDOHMONITORINGREQUIRED NUMBERCODE STANDARD REQUIREMENT Level 1 Level 2 Level 3FINDINGS(Indicate actualno.equipment& instruments)REMARKS12.1 EQUIPMENT/INSTRUMENT REQUIREMENT12.1.11.ADMINISTRATIVE12.1.1.1 Computer with Internet Access 1 1 or moredepending on theneed1 or moredepending onthe need12.1.1.2 Ambulance (Available 24 hours, 7 days a week andphysically present) (Refer to A.O. 2010-0003-National Policy on Ambulance Use and Services)1 1 112.1.1.3 Standby Generator with Automatic Transfer1 1 1Switch (ATS) (KVA may depend on the load)12.1.1.4 Emergency Light 1/station/lobby/stairways1/station/lobby/stairways1/station/lobby/stairways12.1.1.5 Fire Extinguisher 1/room/unit 1/room/unit 1/room/unit12.1.1.6 Overhead Projector/ LCD 1 1 1DIETARYOvenRefrigerator/FreezerOsterizer/BlenderFood ConveyorFood ScaleExhaust FanUtility CartGarbage Receptacle with CoverAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 42 of 60

13.1 CLINICAL13.1.1 EMERGENCY ROOM13.1.1.1 Ambu Bag13.1.1.1.a Adult 1 1 113.1.1.1.b Pediatric 1 1 113.1.1.2 Clinical Weighing Scale13.1.1.3 Defibrillator 1 1 113.1.1.4 ECG Machine 1 1 113.1.1.5 EENT Diagnostic Set 1 1 113.1.1.6 Emergency Cart (complete with ERMedicines.) See annex for the list andquantity.1 1 113.1.1.7 Examining Table 1 1 113.1.1.8 Examining Table with stirrup 1 1 113.1.1.9 Gooseneck Lamp/Examining Light 1 1 113.1.1.10 Instrument Table 1 1 113.1.1.11 Laryngoscope with Different sizes of Blades 1 113.1.1.12 Medicine Cabinet 1 1 113.1.1.13 Minor Surgery Instrument Set 1 1 113.1.1.14 Nebulizer 1 1 113.1.1.15 Neurological Hammer 1 1 113.1.1.16 Oxygen Unit (anchored) 1 1 113.1.1.17 Pulse oximeter13.1.1.18 Sphygmomanometer (non-mercurial) 1 1 113.1.1.18a Adult Cuff 1 1 113.1.1.18b Pediatric Cuff 1 1 113.1.1.19 Stethoscope 1 1 113.1.1.20 Suction Apparatus 1 1 113.1.1.21 Suturing Set 1 1 113.1.1.22 Thermometer (non-mercurial)13.1.1.23 Tracheostomy Set 1 1 113.1.1.24 Vaginal Speculum Set 1 1 113.1.1.25 wheelchair 1 1 113.1.1.26 Wheeled Stretchers with guard and wheel lock 1 1 1Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 43 of 60

Or anchor.13.2.1OUTPATIENT CARE13.2.1.1 1. Clinical Weighing Scale 1 1 113.2.1.2 2. ECG Machine 1 1 113.2.1.3 3. EENT Diagnostic Set 1 1 113.2.1.4 4. Gooseneck Lamp/Examining Light 1 1 113.2.1 5 5. Examining Table with wheel lock or anchor 1 1 113.2.1.6 6. Instrument Table 1 1 113.2.1.7 7. Minor Surgery Instrument Set 1 1 113.2.1.8 8. Neurological Hammer 1 1 113.2.1.9 9. Oxygen Unit 1 1 113.2.1.10 10.Sphygmomanometer (non-mercurial) 1 1 1 Adult Cuff 1 1 1 Pediatric Cuff 1 1 113.2.1.11 11. Stethoscope 1 1 113.2.1.12 12. Suture Removal Set 1 1 113.2.1.13 13. Thermometer, non-mercurial13.2.1.14 13. Vaginal Speculum Set 1 1 113.2.1.15 14. Wheelchair 1 1 113.3.1 OPERATING ROOM13.3.1.1 1. Air-conditioning Unit 1 1/OR 1/OR13.3.1.2 2. Anesthesia Machine 1 1/OR 1/OR13.3.1.3 3. Cardiac Monitor with pulse oximeter Pulse 1/OR1/OROximeter13.3.1.4 4. C/S Set 1 1 113.3.1.5 5. Instrument Table 1 1/OR 1/OR13.3.1.6 6. Laparotomy Set 1 1/OR 1/OR13.3.1.7 7. Laryngoscope with Blades 1 set 1 set/OR 1 set/OR13.3.1.8 8. Major Surgical Instrument Set 1 1/OR 1OR13.3.1.9 9. OR Light 1 1/OR 1/OR13.3.1.10 10.OR Table 1 1/OR 1/OR13.3.1.11 11. Ortho Instrument Set 1 1 113.3.1.12 12. Oxygen Unit (anchored) 1 1/OR 1/OR13.3.1.13 13. Sphygmomanometer (non-mercurial) 1 1/OR 1/OR13.3.1.13a Adult Cuff 1 1/OR 1/OR13.3.1.1b Pediatric Cuff 1 1/OR 1/OR13.3.1.14 14. Spinal Set 1 1/OR 1/OR13.3.1.15 15. Stethoscope 1 1/OR 1/OR13.3.1.16 16. Suction Apparatus 1 1/OR 1/ORAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 44 of 60

13.3.1.17 17. Thermometer, non-mercurial 1 1 113.3.1.18 17. Wheeled Stretcher 1 1 113.4.1 RECOVERY ROOM13.4.1.1 1. Air-conditioning Unit 1 1 113.4.1.2 2. Bed with Guard Rail and wheel lock or anchor 1 1 113.4.1.3 3. Oxygen Unit (anchored) 1 1 113.4.1.4 4. Sphygmomanometer (non-mercurial) 1 1 113.4.1.4a Adult Cuff 1 1 113.4.1.4b Pediatric Cuff 1 1 113.4.1.5 5. Pulse Oximeter 1 1 113.4.1.6 6. Stethoscope 1 1 113.4.1.7 7. Suction Apparatus 1 1 113.5.1 LABOR ROOM13.5.1.1 1. CTG Machine 1 1 113.5.1.2 2. Amniotome 1 1 113.5.1.3 3. Sphygmomanometer (non-mercurial) 1 1 113.5.1.4 4. Stethoscope 1 1 113.6.1 DELIVERY ROOM ( IF APPLICABLE)13.6.1.1 1. Air-conditioning Unit 1 1/DR 1/DR13.6.1.2 3. D/C Set 1 1/DR 1/DR13.6.1.3 4. Delivery Set 1 1/DR 1/DR13.6.1.4 5. DR Light 1 1/DR 1/DR13.6.1.5 6. DR Table with Stirrup 1 1/DR 1/DR13.6.1.6 7. Foetoscope (Doppler) 1 1 1/DR13.6.1.7 8. Instrument Table 1 1/DR 1/DR13.6.1.8 9. Kelly Pad 1 1/DR 1/DR13.6.1.9 10.Oxygen Unit, Anchored 1 1/DR 1/DR13.6.1.10 11.Sphygmomanometer (non-mercurial) 1 1/DR 1/DR13.6.1.11 12.Stethoscope 1 1/DR 1/DR13.6.1.12 13.Suction Apparatus 1 1/DR 1/DR13.6.1.13 14.Wheeled Stretcher 1 1 113.6.1.14 15.Bassinet 1 1 113.6.1.15 16.Infant Weighing Scale 1 1 11.3.7.1 HIGH RISK PREGNANCY UNIT ( Not required in Level 1)13.7.1.1 1. Cardiac Monitor 1 113.7.1.2 2. Fetal Monitor (CTG Machine) 1 1Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 45 of 60

13.7.1.3 3. Suction Apparatus 1 113.7.1.4 4. Oxygen Unit, Anchored 1 113..8.1 NEONATAL INTENSIVE CARE UNIT13..8.1.1 1. Bassinet 1 113..8.1.2 2. Bili Light 1 113..8.1.3 3. Cardiac Monitor 1 113..8.1.4 4. Emergency Cart 1 113..8.1.5 5. Umbilical Cannulation Set 1 113..8.1.6 6. Laryngoscope with Neonatal Blades 1 113..8.1.7 7. Examining Light 1 113..8.1.8 8. Incubator 1 11 13..8.1.9 9. Infant Ambu Bag 1 113..8.1.10 10. Infant Weighing Scale13..8.1.11 Oxygen Unit13..8.1.12 Respirator/Mechanical Ventilator13..8.1.13 Radiant Warmer13..8.1.14 Infusion Pump/Syringe Pump13..8.1.15 Glucometer13..8.1.16 Nebulizer13..8.1.17 Pulse Oximeter13..8.1.18 Neonatal Stethoscope13..8.1.19 Suction ApparatusINTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1Air-conditioning UnitAmbu BagAdult (in adult units)Pediatric (in pediatric units)Bed with Guard RailCardiac MonitorDefibrillatorECG MachineEmergency Cart with emergencyMedicines(Refer to annex for medicines andsupplies)Laryngoscope with BladesEndotracheal TubeAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 46 of 60

Oxygen UnitSphygmomanometer (non-mercurialAdult Cuff (in adult unitsPediatric Cuff Set (in pediatric units)StethoscopeSuction ApparatusTracheostomy SetPulse OximeterMechanical VentilatorInfusion PumpNURSING UNIT OR WARDAmbu BagAdult (if Adult ward)Pediatric ( if Pediatric ward)Clinical Weighing Scale (per nursing unit)ECG MachineEmergency Cart or its equivalent (pernursing unit)Mechanical Bed/Patient Bed with Side Rails(Patient beds in ER, Labor Room, and CriticalAreas are not included in the count)Actual bedcount shouldcorrespond toABC appliedfor.Actual bed countshouldcorrespond toABC applied for.Bedside Table should correspond to total bedsLaryngoscope with different Sizes of BladesNebulizer 1 1/Medical/Pedia wardNeurological HammerActual bedcount shouldcorrespond toABC appliedfor.1/Medical/Pedia wardOxygen Unit, Anchored(may increase depending on the need)Sphygmomanometer (non-mercurial)Adult CuffPediatric CuffStethoscopeSuction ApparatusThermometer (non- mercurial)CENTRAL STERILIZING & SUPPLY ROOMAutoclave ( may increase depending onAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 47 of 60

the need)Steam Sterilizer ( may increase dependingon the need)0 1 1DENTAL CLINICDental ChairOperating Stool per Dental ChairAutoclaveAir CompressorDental X-rayMouth Mirror ExplorerExplorer, double endScaler jacquettes set No. 1,2,3Low speed hand piece (angled head)Cotton pliersHigh speed hand piece with bur removerNo.150 forceps (maxillary universal forceps)No.151 forceps (lower universal)No.150 S forceps (primary teeth)No. 8L and No18R forceps(upper molar)No.151A forceps (mandibular premolar)No.17 forcepsNo.15 S forceps (lower primary teeth)Rongeur forcepsSurgical chisel and mallet.. Bone fileSurgical Scissor. Root elevator. Periostal elevator No. 9 double endGum Separator double endCowhorn forcepsBonefile Stainless endDIALYSIS CLINIC- Not required for Levels 1 and 2.(Refer to AO 2012-0001 “ New Rules and RegulationsGoverning the Licensure and Regulation of DialysisFacilities in the Philippines”Use checklist for Dialysis facilityAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 48 of 60

AMBULATORY SURGICAL CLINICUse checklist for Ambulatory Surgical ClinicPHYSICAL MEDICINE AND REHABILITATION UNITUltrasoundTENSElectric StimulatorElectric StimulatorExercise plinth/bedOverhead pulleyExercise stair with railsParaffin waxParallel bars with postural mirrorsAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 49 of 60

PHYSICAL PLANT-REQUIRED ROOMS AND AREAS:LEVEL 1 LEVEL 2 LEVEL 3• Lobby• Waiting Area• Information and Reception• Communication Booth (Area for level 1)• Toilet• Admitting Office ( Area for level 1)• Medical Records Office/Room• Business Office with the following sections• Billing• Cashier• Budget and Finance• Personnel Office (may be combined withAdministrative Office for level 1)• Office of the Admin. Officer• Office of Chief of Hospital• Office of the Chief of Clinics/Chief MedicalProfessional Services• Conference and Training Room• Library• Staff Toilet• Property/ Supply Office /Room for level Laundry and Linen Room or Area• Receiving and Releasing Area not required• Sorting and Washing Area if contracted-• Pressing and Ironing Area out.• Storage Area Engineering /Maintenance Office for Level 2• Maintenance Area not required• Motor Pool Area if contracted-• Housekeeping Area out.WASTE HOLDING /STORAGE AREA (colorcoded)Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 50 of 60

NUTRITIONIST-DIETITIAN OFFICE ( AREA FORLEVEL 1) DIETARY• Supply Receiving Area not required• Cold and Dry Storage Area if contracted-• Food Preparation Area out.• Cooking and Baking Area• Washing Area• Serving and Food Assembly• Dining Area• Garbage and Disposal Area• ToiletSOCIAL WELFARE/SERVICE• Social Worker’s Office• Counselling AreaMORGUE for Level 3, Cadaver Holding Areafor Level 1 and 2• Pathologist Office• Autopsy Area• Shower Area• ToiletCLINICAL SERVICEEMERGENCY ROOM (MAY BE COMBINED WITHOPD FOR LEVEL 1)• Waiting Area• Toilet (adjacent or w/in ER)• Nurse Station• Examination & Treatment Area with Lavatory• Observation Area• Minor Operating Room• Resuscitation Area for Level 2 and 3• Equipment & Supply Storage Area• Wheeled Stretcher Area• Decontamination Area for level 3• Holding Area for Infectious Casesawaiting transfer to other hospital for level 1and 2• Doctor’s Quarter (with toilet)OUTPATIENT DEPARTMENT (MAY BEAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 51 of 60

COMBINED WITH ER FOR LEVEL 1)• Waiting Area• Toilet (accessible)• Admitting and Records Area• Consultation Area (required)• Examination & Treatment Area With LavatoryOFFICE OF THE DEPT. HEADS• Medicine• Pediatrics• OB-GYNE• Surgery• Anesthesia• Emergency MedicineOPERATING ROOM (MAY BECOMBINED IN ONE COMPLEX WITH DELIVERYROOM FOR LEVEL 1)• Major OR• Minor OR• Sub-Sterilizing/Work Areas• Storage Area for Sterile InstrumentsAnd 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• Janitor’s ClosetRECOVERY ROOMOBSTETRICS OPERATING ROOM(MAY BE COMBINED WITH SURGICALOPERATING ROOM FOR LEVEL 1)DELIVERY ROOM• Transvaginal Ultrasound Room for Level 3• Equipment and Supply Storage Area• Scrub-up Area• Clean-up Area• Male Dressing Room with Toilet• Female Dressing Room with Toilet• Wheeled stretcher areaMay becombinedAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 52 of 60

• ToiletDIALYSIS CLINIC (not required in levels 1 and 2)• Refer to A.O. 2012-0001, “ Regulation ofDialysis Facilities in the PhilippinesAMBULATORY SURGICAL CLINIC(not required inlevel 1 AND 2)• Required rooms /areas depend on the surgicalprocedures the clinic is authorized to perform.PHYSICAL MEDICINE /REHABILITATION UNIT (notrequired in level 1)DENTAL CLINIC• Consultation room• ToiletCENTRAL SUPPLY ROOM• Receiving and Cleaning Area• Inspection Area• Packaging Area• Sterilizing Area• Sterile Supply Storage Area• Releasing AreaPRAYER ROOM (AREA FOR LEVEL 1)Assessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 54 of 60

SELF –ASSESSMENTDOHINSPECTIONMONITORINGCODE STANDARDS CRITERIA INDICATORSEVIDENCE AREA REMARKS4141x1B.DOH ProgramsImplemented in theHospital>1.Blood ServicesCompliance to RA 7719and its IRR, AO 2008-0008 Levels 1 and 2,should be at least aBlood Station Facility andlevel 3, Blood Bank Facility• Documented policies:‣ To ensure adequatesupply of safe bloodand blood products.‣ blood and bloodproducts obtained fromblood service facilitieslicensed by DOH‣ for BC, blood andblood productscollected, obtainedfrom healthy voluntary‣ blood donors onlyActual implementation andevidence of continuousreview of policies andproceduresVerifier:Documents review,Observe Interview staffValidate41x1.a1.2 Level 3 hospital shouldbe a Blood Bank (BB)facility• Documented policies:‣ To ensure adequatesupply of safe bloodand blood products‣ Blood and bloodproducts obtained fromblood service facilitieslicensed by DOHFor BC, blood and bloodproducts collected,obtained from healthyvoluntary blood donors onlyVerifier:Documents review,Observe Interview staffValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 55 of 60

41x241x2,a2.Health Promotionand DiseasePrevention2.1 Newborn Screening- Compliance toRA9288 and it’sIRR• Documented policiesregarding NewbornScreening• Logbook of Newborns whowere tested and copies ofwaiver for those who were notscreenedVerifier:Documents review,Observe Interview staffValidate41x341x3.a2.2 Mother-Baby FriendlyHospital Initiative- Compliance to RA7600 and its IRRand R.A. 10028and its IRR- Milk Code (EONo. 5• Documented policiesregarding Rooming-In andpractice of Breastfeeding• There should be no nurseryfor normal newborns• Breastfeeding area shouldbe provided at the pathologicnursery• Certification as “Mother –Baby Friendly Hospital”• Certification as “Mother –Baby FriendlyWorkplace”Verifier:Documents review,Observe Interview staffValidate41x42.3 Healthy LifestyleAdvocacy• Documented policies andSOPs specific to the programVerifier:Documents review,Observe Interview staffValidate41x52.4 Family Planning2.5. Immunization(Republic Act No.309)2.6. Anti-SmokingProgram(per RA 9211)• Documented policies andSOPs specific to the program• Documented policies• No smoking signages postedat conspicuous areasVerifier:Documents review,Observe Interview staffValidateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 56 of 60

41x841x8.a3.Generics Act of1988(R.A.6675)1. e-EDPMS-R.A.7581”Price Actof 1992; R.A.9502”UniversallyAccessible Cheaper andQualityMedicines Act of 2008”• Documented policiesimplementing the EDPMSin compliance with DOHA.O. No.2008-0014”Guidelineson thePilot Implementation of thee-EDPMS and A.O. No.2011-0012 “ImplementingGuidelines on ElectronicDrug Price MonitoringSystem Version 2.0”Verifier:Visit hospital pharmacy anddocument review, ValidateActual implementation andevidence of continuousreview of policies andprocedures; reports onuploading of essential drugprices, etc.Verifier:Documents review,Observe Interview staffValidate41x94. Health EmergencyManagementService(HEMS)A.O. No. 2004-0168, “NationalPolicy on HealthEmergenciesand Disasters”• With designated HEMSCoordinator• Documented HealthEmergency Preparedness,Response and Recovery Plan●Hospital/Office orderdesignating one●Proof of implementation ofthe plan.Verifier:Documents review,Observe Interview staffValidate41X9.a• Conduct of drills/exercisesi.e, Fire,Earthquake, etc. (Forfire, it should be supervised bythe Bureau of Fire Protection).● Documentation ofdrills/exercises conducted.● Evacuation Plan/Routeposted in every room/areaAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 57 of 60

CODE42 C.HOSPITAL COMMITTEES:WrittenDesignation ofMembers andtheirroles/functionsWritten Policiesand ProcedureUpdated andRelevant Minutesof MeetingReports/ Recordsof ImplementationREMARKS42x142x242x342x442x540x640x742842x942x1042x1142x1242x131.Credentials2.Blood transfusion3.HIV/AIDS Core Team4.Waste Management5.Patient Safety6.Infection Control7.Pharmacologic/Therapeutics8.Health Emergency/Crisis Management9.CQI10.Tissue(for levels 2 and 3 only)11.Ethics(for levels 2,and 3 only)12.GrievanceOther committees, pleasespecifyVerifier: Documents review and Interview staffAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 58 of 60

OPDEmergencyMedicineOB/ Gyne(DeliveryRoom)PediatricsORSurgeryAnesthesiaRehabCODE43D.HOSPITAL OPERATIONS:(The following CriteriaRequirements are applicableonly to level 3 ).SERVICES (levels 1 & 2) / DEPARTMENT (level 3)REMARKS43x143x243x343x443x543x643x743x843x943x1043x111.Clinical Practice Guidelines(CPG)2.Recording, Reporting,Records Keeping3.Inter/Intra DepartmentalReferrals4.DisasterManagement/CrisisManagement5.Infection Control6.Drug Management andControl7.Blood Service8.Pre-Operative and Post-OpCare9.Triaging (when applicable)10.Referrals/ Transfer11.Others, please specifyAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 59 of 60

ASSESSED BY:_______________________________ _______________________________ _______________________________ ________________________________Signature over Printed Name Signature over Printed Name Signature over Printed Name Signature over Printed Name_______________________________ _______________________________ _______________________________ ________________________________Position Position Position Position_______________________________ _______________________________ _______________________________ ________________________________Date Date Date Date_______________________________ _______________________________ ________________________________Signature over Printed Name Signature over Printed Name Signature over Printed Name_______________________________ _______________________________ ________________________________Position Position Position_______________________________ _______________________________ ________________________________Date Date DateCONCURRED BY:_______________________________Signature over Printed Name_______________________________Position/Designation_______________________________DateAssessment Tool forLicensure of HospitalsRevision: 00Effectivity date: 10/01/12Page 60 of 60