Form HOS-LTO-AT/L2-2007 Republic of the Philippines Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179 URL: http://www.doh.gov.ph/

ASSESSMENT TOOL FOR LICENSING OF LEVEL 2 HOSPITAL Name of Hospital Address of the Hospital : :

This tool serves as a guide for self-assessment of the health facility in preparation for inspection/ monitoring visits. 1. GENERAL INFORMATION Owner Chief of Hospital/Medical Director Classification : : : General Special Government [ [ ] ]

Private

[ ] National Local Others, please specify [ ] Single Proprietorship Partnership Corporation Civic Organization Religious Foundation Others, please specify

[ [

] ]

[ [ [ [ [ [

] ] ] ] ] ]

Chairman of the Board (If Corporation) Authorized Bed Capacity Implementing Bed Capacity

: :

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2. SERVICE CAPABILITY 2.1. Service Capability of a Level 2 Hospital: 2.1.1. Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care Clinical services provided in the Level 1 Hospital, as well as specialty clinical care Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) Nursing care provided in the Level 1 Hospital, as well as total and intensive skilled care

2.1.2. 2.1.3. 2.1.4.

2.2.

The hospital shall render quality health services appropriate to the level of care being provided:

SERVICE

AVAILABILITY
( if Available)

Manual of Operations/ Written Policies and Procedures

Duties and Responsibilities

Master Staffing Plan

Organizational Chart

Written Vision and Mission

REMARKS

Administrative Service Personnel Accounting Bookkeeping Cashiering Billing Collection Medical Records Supply Housekeeping (May be contracted out) Laundry and Linen (Laundry service may be contracted out but is subject to infection control mechanisms.) Maintenance (May be contracted out) Patient Transport Service ((May be contracted out; available for 24 hours) Security (May be contracted out) Dietary (May be contracted out) Social Service Clinical Service General Clinical Care
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Form HOS-LTO-AT/L2-2007
Manual of Operations/ Written Policies and Procedures Duties and Responsibilities Master Staffing Plan Organizational Chart Written Vision and Mission

SERVICE Medicine Pediatrics Obstetrics and Gynecology Surgery and Anesthesia Emergency Service Outpatient Service Nursing Service Intermediate Care and Management Health Education and Counseling Others, please specify

AVAILABILITY
( if Available)

REMARKS

As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the intermediate, moderate or partial care category, the patient can feed, bathe, dress and go to the toilet by himself without help, but requires some assistance from the nursing staff for special treatment of certain aspects of personal care.

SERVICE Ancillary Service Secondary Clinical Laboratory Radiology 2nd Level Pharmacy

AVAILABILITY
( if Available)

LICENSE NUMBER

DATE ISSUED

VALIDITY

REMARKS

A primary clinical laboratory may be considered; provided that a contract of service or memorandum of agreement with a secondary clinical laboratory located within the locality must be secured, and results for emergency cases must be transmitted within one hour.
May be contracted out but located within the premises of the hospital.

2.3.

Hospital Operations 2.3.1. Administrative Service The performance of each personnel is monitored and evaluated. [ ] Yes [ ] No New personnel receive an orientation program that covers the essential components of the service being provided. [ ] Yes [ ] No
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An exit interview is conducted for personnel who resign or retire from the service. [ ] Yes [ ] No 2.3.2. Emergency Room Personnel to deliver emergency care are available for 24 hours. [ ] Yes [ ] No All equipment, medicines and supplies necessary to provide emergency care are available. [ ] Yes [ ] No 2.3.3. Obstetrical Service Proper identification of newborns is ensured before they leave the delivery room and until discharge. [ ] Yes [ ] No 2.3.4. Nursing Service Nursing care is provided at all times. [ ] Yes [ ] No

Written policies for all nursing service areas within the hospital are available and reviewed annually. [ ] Yes [ ] No A Nursing Procedure Manual and a properly utilized Kardex are available in all patient care units. Nursing Procedure Manual [ ] Yes [ ] No Properly Utilized Kardex [ ] Yes [ ] No The delivery of nursing care utilizes the nursing process. [ ] Yes [ ] No 2.3.5. Medical Records Medical records contain patient information that is uniquely identifiable, accurately recorded, current, confidential and accessible when required. [ ] Yes [ ] No Medical diagnoses, procedures and/or operations performed on patients are recorded using ICD 10. [ ] Yes [ ] No ICD 10 reference books are available. [ ] Yes [ ] No

The Medical Records Officer is trained in ICD 10. [ ] Yes [

] No

A Patient Logbook is properly filled up in the following areas: Admitting Office [ ] Yes [ ] No Emergency Room [ ] Yes [ ] No Outpatient Department [ ] Yes [ ] No Operating Room [ ] Yes [ ] No Delivery Room [ ] Yes [ ] No
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Patient Charts are properly and completely filled up and contain up-to-date information on the following: In-Patient Out-Patient Contents of Medical Chart ( if ( if
available) Available)

Identification Data Chief Complaint History of Present Illness Physical Examination Diagnosis/Admitting Diagnosis Admitting/Attending Physician Clinical Laboratory Report X-ray Report Consultation/Referral Notes Medication/Treatment Progress Notes Final Diagnosis Nursing Record Discharge Summary Obstetrical Record (if applicable) Consent Doctors Order Sheet Records of newborns are properly and completely filled up. [ ] Yes [ ] No Records of medico legal cases are properly and completely filled up. [ ] Yes [ ] No Birth certificate forms are properly and completely filled up. [ ] Yes [ ] No Death certificate forms are properly and completely filled up. [ ] Yes [ ] No Confidentiality of patient information is maintained at all times. [ ] Yes [ ] No 2.3.6. Blood Services The hospital ensures that its supply of blood and blood products is safe. [ ] Yes [ ] No The hospital obtains blood and blood products only from blood service facilities licensed/authorized by the Department of Health (as required by R.A. 7719 National Blood Services Act of 1994 and Its Implementing Rules and Regulations). [ ] Yes [ ] No

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The hospital obtains blood and blood products collected from healthy voluntary blood donors only (as required by R.A. 7719 National Blood Services Act of 1994 and Its Implementing Rules and Regulations). [ ] Yes [ ] No 2.4. Programs 2.4.1. Health Promotion and Disease Prevention The hospital has a health promotion and disease prevention program that shall include the following: Breastfeeding (as required by R.A. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] No Family Planning [ ] Yes [ ] No Immunization [ ] Yes [ ] No Newborn Screening (as required by R.A. 9288 Newborn Screening Act of 2004 and Its Implementing Rules and Regulations) [ ] Yes [ ] No Rooming-In (as required by R.A. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] No 2.4.2. Disaster Management The hospital has a documented emergency and disaster management plan. [ ] Yes [ ] No 2.4.3. Human Resource Development The hospital implements a human resource development program that identifies, plan, facilitate and record training and education for all personnel. [ ] Yes [ ] No An appraisal system identifies and reviews the effectiveness and appropriateness of the training provided. [ ] Yes [ ] No 2.4.4. Quality Management The hospital has an established, documented and maintained quality management program that reflects continuous quality improvement principles. [ ] Yes [ ] No The program identifies the organizations quality goals, objectives and scope; quality responsibility, authority and resources; and quality activities and review processes. [ ] Yes [ ] No There is an exception reporting system that includes the recording, reporting, investigation, analysis, corrective action and review process for adverse, unplanned, or untoward events such as: Accidents, incidents, near misses, and adverse clinical events [ ] Yes [ ] No
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Complaints and suggestions Infectious / Notifiable diseases Service shortfalls

[ [ [

] Yes ] Yes ] Yes

[ [ [

] No ] No ] No

2.5.

Hospital Committees
Availability of Documentation on Committee Membership ( if Available) Availability of Written Policies and Procedures ( if Available)

Committee

Availability of Minutes of Meetings ( if Available)

Availability of Monitoring and Evaluation Reports ( if Available)

Blood Transfusion Credentials Fire Safety HIV/AIDS (as required by R.A. 8504 Philippine AIDS Prevention and Control Act of 1998) Infection Control Medical Audit Quality Assurance Therapeutics Waste Management Others, please specify

3. PERSONNEL 3.1. The health facility appoints and allocates personnel who are suitably qualified, skilled and/or experienced to provide the service and meet patient needs. 3.1.1. Each personnel is qualified, skilled and/or experienced to assume the responsibilities, authority, accountability and functions of the position. [ ] Yes [ ] No Professional qualifications are validated, including evidence of professional registration/license, where applicable, prior to employment. [ ] Yes [ ] No

3.1.2.

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3.1.3.

An organized medical and nursing staff shall be responsible for the quality of patient care and for the ethical conduct and professional practices of its members. [ ] Yes [ ] No

POSITION Administrative Service Chief of Hospital / Administrative Officer Clerk (Pool) Clerk (Accounting; designation can be flexible as long as function is present) Medical Records Clerk Storekeeper/Linen Custodian Utility Worker (May be contracted out) Driver (May be contracted out) Nutritionist/Dietitian (May be contracted out. In case of shared service, nutritionist/dietitian should be residing within the locality.) Cook/Food Service Worker Medical Social Worker

REQUIREMENT

COMPLIANCE
( if Compliant)

STATUS
(FT if Full Time) (PT if Part Time)

REMARKS

1 1:50 beds 1

1:50 beds 1 1/shift 1 1

1 1

In the absence of a Medical Social Worker, patients may be referred to the Municipal/City/Provincial Social Worker, provided there is a Memorandum of Agreement between the hospital and the local government.

Clinical Service Physician 1:20 beds at any time plus one (1) reliever 1

Physician (On call)

The physician must not go on continuous duty for more than forty-eight (48) hours.

Nursing Service Chief Nurse/ Supervising Nurse + 1

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POSITION Staff Nurse Nursing Attendant/ Midwife Others, please specify

REQUIREMENT 1:12 beds at any time 1:24 beds at any time

COMPLIANCE
( if Compliant)

STATUS
(FT if Full Time) (PT if Part Time)

REMARKS

The number of registered nurses supervised should not exceed fifteen (15). Otherwise, one (1) Chief Nurse and one (1) Supervising Nurse are required. For every three (3) Nurses, there must be one (1) reliever. The number of beds used in the ratio is the actual number of occupied Critical Care Unit beds at the time of inspection. Plantilla items are not required. Critical Care Units include all Intensive Care Units (ICUs) and Post-Anesthesia Care Unit (PACU)/Recovery Room (RR). For every three (3) Nurses or Nursing Attendants/Midwives, there must be one (1) reliever. Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four (24) beds. If the ABC is 24 beds and above, the ratio will apply. For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever.

3.2.

Hospital Organization 3.2.1. Administrative Service The Chief of Hospital has: Completed at least twenty (20) units towards a masters degree in hospital administration or related course. [ ] Yes [ ] No OR At least three (3) years of experience in a supervisory/managerial position. [ ] Yes [ ] No The Administrative Officer has: Completed at least twenty (20) units towards a masters degree in hospital administration or related course. [ ] Yes [ ] No OR At least three (3) years of experience in a supervisory/managerial position. [ ] Yes [ ] No 3.2.2. Nursing Service The Chief Nurse has: Completed at least nine (9) units towards a masters degree in nursing service administration or related course . [ ] Yes [ ] No AND
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At least two (2) years of experience in a nursing supervisory/managerial position. [ ] Yes

] No

4. EQUIPMENT/INSTRUMENT 4.1. All equipment and instruments necessary for the safe and effective provision of services are available and are properly maintained. 4.1.1. Records of equipment are maintained and updated regularly. [ ] Yes [ ] No A preventive maintenance program ensures that all equipment are maintained and/or calibrated to an appropriate standard or specification. [ ] Yes [ ] No There is a plan in place for essential equipment replacement. [ ] Yes [ ] No Personnel are competent when using equipment in line with manufacturers instruction/operational manual. [ ] Yes [ ] No Operational manuals of all equipment and instruments are available for reference and guidance. [ ] Yes [ ] No

4.1.2.

4.1.3.

4.1.4.

4.1.5.

ITEM Administrative Service Computer/Typewriter Fire Extinguisher Standby Generator Food Conveyor (closed type) Refrigerator/Freezer Stove Transport Vehicle (Available for 24 hours) Clinical Service Emergency Room Outpatient Department Ambu Bag - Adult - Pediatric Clinical Weighing Scale EENT Diagnostic Set (or its equivalent)

REQUIREMENT

COMPLIANCE
( if Compliant) (

CONDITION
if Serviceable)

REMARKS

1 2 1 1 1 1 1

1 1 1 1
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ITEM Emergency Cart (or its equivalent) Examining Table Gooseneck Lamp / Examining Light Instrument Table Medicine Cabinet Minor Surgery Instrument Set Nebulizer Neurological Hammer Oxygen Unit Sphygmomanometer - Adult Cuff - Pediatric Cuff Set Stethoscope Suction Apparatus Suturing Set Vaginal Speculum Set Wheelchair Wheeled Stretcher Surgical Service Obstetrical Service Air-conditioning Unit Anesthesia Machine Bassinet C/S Set D/C Set Delivery Set DR Light DR Table with Stirrup Infant Weighing Scale Instrument Table Kelly Pad Laparotomy Set Laryngoscope with Blades Major Surgical Instrument Set OR Light OR Table Oxygen Unit Sphygmomanometer - Adult Cuff - Pediatric Cuff Set Spinal Set

REQUIREMENT 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

COMPLIANCE
( if Compliant) (

CONDITION
if Serviceable)

REMARKS

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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ITEM Stethoscope Suction Apparatus Wheeled Stretcher Nursing Unit Ambu Bag - Adult Pediatric

REQUIREMENT 1 1 1

COMPLIANCE
( if Compliant) (

CONDITION
if Serviceable)

REMARKS

Bedside Table Clinical Weighing Scale Emergency Cart (or its equivalent) Patient Bed Nebulizer Oxygen Unit

1/Nursing Unit (in Adult Units) 1/Nursing Unit (in Pediatric Units) Depends on ABC* 1/Nursing Unit 1/Nursing Unit Depends on ABC* 1/Nursing Unit 1/Nursing Unit plus one (1) standby oxygen unit 1/Nursing Unit 1/Nursing Unit (in Adult Units) 1/Nursing Unit (in Pediatric Units) 1/Nursing Unit 1/Nursing Unit

Sphygmomanometer - Adult Cuff Pediatric Cuff Set

Stethoscope Suction Apparatus

* Authorized Bed Capacity

Central Sterilizing and Supply Room Autoclave Others, please specify

5. PHYSICAL PLANT 5.1. All physical facilities and utility systems necessary for the safe and effective provision of services are available and are properly maintained.

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AREA Administrative Service Lobby Waiting Area Information and Reception Area Toilet Business Office Medical Records Room Office of the Chief of Hospital/Administrative Officer Laundry and Linen Area Maintenance and Housekeeping Area Parking Area for Transport Vehicle Supply Room Waste Holding Room Dietary Dietitian Area Supply Receiving Area Cold and Dry Storage Area Food Preparation Area Cooking and Baking Area Serving and Food Assembly Area Washing Area Garbage Disposal Area Dining Area Toilet Cadaver Holding Room

COMPLIANCE
( if Compliant) (

LIGHTING
if Adequate)

VENTILATION
( if Adequate)

REMARKS

Not required if the service is contracted out.

Clinical Service Emergency Room Waiting Area Toilet (adjacent or within ER) Nurse Station
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AREA Examination and Treatment Area with Lavatory/Sink Observation Area Equipment and Supply Storage Area Wheeled Stretcher Area Outpatient Department Waiting Area Toilet (accessible) Admitting and Records Area Consultation Area Examination and Treatment Area with Lavatory/Sink

COMPLIANCE
( if Compliant) (

LIGHTING
if Adequate)

VENTILATION
( if Adequate)

REMARKS

OPD and ER departments may be combined in one complex. If OPD and ER are separate, all the areas specified under OPD are required. If OPD and ER are combined in one complex, only this area under OPD is required. The rest of the areas under OPD are not required.

Surgical and Obstetrical Service Major Operating Room Delivery Room Sub-sterilizing Area / Work Area Sterile Instrument, Supply and Storage Area Scrub-up Area Clean-up Area Dressing Room Toilet Nurse Station / Work Area Wheeled Stretcher Area. Janitors Closet Nursing Unit Patient Room (Male and Female) Toilet (Male and Female)
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AREA Isolation Room with Toilet Nurse Station Treatment and Medication Area with Lavatory/Sink Central Sterilizing and Supply Room Receiving and Releasing Area Work Area Sterilizing Area Sterile Supply Storage Area Nursing Service Office of the Chief Nurse

COMPLIANCE
( if Compliant) (

LIGHTING
if Adequate)

VENTILATION
( if Adequate)

REMARKS

5.2.

Environment The hospital is: Readily accessible to the community.

] Yes

] No

Free from undue noise, smoke, dust, foul odor, flood. [ ] Yes

] No

Not located adjacent to railroads, freight yards, childrens playgrounds, airports, industrial plants, and waste disposal plants. [ ] Yes [ ] No 5.3. Occupancy The location of the hospital complies with all local zoning ordinances. [ ] Yes [ ] No 5.4. Safety The hospital provides and maintains a safe environment for patients, personnel and public. [ ] Yes [ ] No Buildings pose no hazards to the life and safety of patients, personnel and public. [ ] Yes [ ] No Exits are restricted to the following types: door leading directly outside the building, interior stair, ramp, and exterior stair. [ ] Yes [ ] No A minimum of two (2) exits, remote from each other, are provided for each floor of the building. [ ] Yes [ ] No
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Exits terminate directly at an open space to the outside of the building. [ ] Yes [ ] No 5.5. Security The hospital ensures the security of person and property within the facility. [ ] Yes [ ] No 5.6. Lighting and Ventilation Areas used by patients and personnel are adequately lighted and ventilated. [ ] Yes [ ] No 5.7. Exposure to Environmental Tobacco Smoke Patients and personnel are not put at risk by exposure to environmental tobacco smoke. [ ] Yes [ ] No Smoking is absolutely prohibited throughout the hospital in accordance with R.A. 9211 Tobacco Regulation Act of 2003. [ ] Yes [ ] No 5.8. Patient Movement Adequate space is provided to allow patients and personnel to move safely around patient bed areas. [ ] Yes [ ] No Patients who use mobility aids are able to safely maneuver with the assistance of their aid within their bed area. [ ] Yes [ ] No Doorways, corridors, elevators and turning areas readily accommodate the bed, attached equipment and any escorts of patients who require to be transported or transferred between rooms or services in their beds. [ ] Yes [ ] No Corridors and ramps for access by patient and equipment are at least 2.44 Meters in width. [ ] Yes [ ] No Corridors in areas not commonly used for bed, stretcher and equipment transport are at least 1.83 Meters in width. [ ] Yes [ ] No A ramp or elevator is provided for ancillary, clinical and nursing services located on the upper floor. [ ] Yes [ ] No A ramp is provided as access to the entrance of the hospital or health facility that is not on the same level of the site. [ ] Yes [ ] No DOH licensed facilities shall be given until end of 2010 to comply.

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5.9.

Auditory and Visual Privacy Adequate privacy for patients is provided such that sensitive or private discussion, examination, and/or procedure are conducted in a manner or environment where these cannot be observed or the risk of being overheard by others is minimized. [ ] Yes [ ] No

5.10. Power Supply The hospital has an approved power supply system. [

] Yes

] No

Panel boards and feeders are properly coded and labeled. [ ] Yes 5.11. Water Supply The hospital has an approved water supply system. [

] No

] Yes

] No

The hospital has available water supply that is potable and safe for drinking. [ ] Yes [ ] No Records of water analysis (bacteriological examination) are available and updated regularly (at least annually). [ ] Yes [ ] No Frequency ..................................................... The water tank/water reservoir is flushed regularly. [ ] Yes [ ] No Frequency ..................................................... 5.12. Waste Management 5.12.1. The hospital has a waste management program. [ ] Yes Liquid Waste Liquid waste is discharged into a multi-chamber septic tank. [ ] Yes [ ] No OR Liquid waste is discharged into municipal/city sewers that are connected to a sewage treatment plant. [ ] Yes [ ] No 5.12.3. Solid Waste Solid waste is collected, treated and disposed of in accordance with the Health Care Waste Management Manual of the Department of Health, 2004. [ ] Yes [ ] No

] No

5.12.2.

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The hospital observes segregation, coding and labeling of waste. Black Trash Bag (General Non-Infectious Dry) [ ] Yes [ ] No Green Trash Bag (General Non-Infectious Wet) [ ] Yes [ ] No Yellow Trash Bag (Infectious Pathological) [ ] Yes [ ] No Sharp Container (Sharps) [ ] Yes [ ] No Logbook Available and Updated [ ] Yes [ ] No Frequency ..................................................... Protective equipment and clothing appropriate to the risks associated with the handling, storage, and disposal of wastes are provided to and used by personnel. [ ] Yes [ ] No 5.13. Sanitation The hospital observes pest and vermin control: In-House [ ] Yes [ ] No Contractor [ ] Yes [ ] No Company Name ..................................................... Memorandum of Agreement is available and updated. [ ] Yes [ ] No Frequency ..................................................... Records are available and updated. [ ] Yes [ ] No Frequency ..................................................... There are screen wires on doors, windows, and other openings. Ward [ ] Yes [ Dietary Service [ ] Yes [ 5.14. Maintenance A building maintenance program is in place to ensure that all buildings/facilities are kept in a state of good repair. [ ] Yes [ ] No A building/facility inventory is maintained and updated regularly. [ ] Yes [ ] No Frequency ..................................................... Written policies and procedures are available. 5.15. Material Specification Floors, walls and ceiling are made of sturdy materials that allow durability, ease of cleaning and fire resistance. [ ] Yes [ ] No
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] No ] No

] Yes

] No

Form HOS-LTO-AT/L2-2007

5.16. Segregation Wards observe segregation of sexes. [ ] Yes [ ] No

Separate toilets are available for patients and personnel, male and female. [ ] Yes [ ] No 5.17. Signage There are visual aids and devices for: Information and Orientation Direction Identification Prohibition and Warning Official Notice 5.18. Permits A Permit to Construct is available for: Construction of New Hospital (if applicable) [ ] Yes [ ] No Alteration/Expansion/Renovation of Existing Hospital (if applicable) [ ] Yes [ ] No Change in Classification (if applicable) [ ] Yes [ ] No Increase in Bed Capacity (if applicable) [ ] Yes [ ] No

[ [ [ [ [

] Yes ] Yes ] Yes ] Yes ] Yes

[ [ [ [ [

] No ] No ] No ] No ] No

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