YES NO Points Points REMARKS

5. MANAGEMENT RESPONSIBILITY
A. Management Responsibility
1 Management Commitment
1.1. Statutory and Regulatory Compliance Major
1.1..a Municipal and other business permit licenses Critical X 2 2

Ø SEC/DTI registration
Ø Mayor’s Permit
1.1..b Clinic Licenses Critical X 2 2
Ø License to operate Laboratory
Ø BRL accreditation for HIV Testing
Ø RHS X-ray License
2 Quality Policy, Mission and vision
1..2 Written Vision and Mission, Quality Policy Major
1..2.a Posting/Visibility of above documents in the Critical X 2 2
clinic
1.2b Awareness of all personnel on the above Critical x 2 2
5.2 Customer Focus ISO
Element
3. Customer Focus
1.3 Feedback system Major
1.3.a. Methods. Tools, forms of gathering customer Critical X 2 2
feedback
5.5. Responsibility, authority and communication
4 Administration
1.4 Organizational Structure Major
1.4..a. Copy of Organizational Chart Critical X 2 2
1.4.b Job Description and Responsibilities of Critical X 2 2
personnel
1.4 Medical Director or Medical Clinic Head Major
1.4.a Appointment Paper x 2 2
1.4.b Authority, Responsibility and Job description Critical x 2 2

1.4.c Copy of PTRC I.D/Licenses Critical x 2 2

1.4.d Previous employment records with min. 2 Critical x 2 2
years experience
1.4.e Training certificates on Maritime Info Non- x 2 2
Critical
5. Administration
1.5 Management Representative Major
1.5.a Appointment paper or contract Critical X 2 2
1.5.b. Job description; authority and responsibility Critical X 2 2

6. Administration
1.6 Internal Communication Major
1.6.a Methods of internal communications for Critical x 2 2
general information
1.6.b System form disseminating internal Non- x 1 1
communication such as memos, etc… Critical
1.6.c Filing systems of memos, announcements, Critical x 2 2
letters and other forms of communications

1.6.d Timely posting of communication- record of Critical x 2 2

transmittal
5.6 Management Review ISO
Element
7. Management Review
1.7 Management Review & Staff Meeting Major
1.7.a Minutes, attendance of management/staff Critical x 2 2
meeting
1.7.b Schedule of management review & Staff Critical x 2 2
meeting
1.7..c Review of the result Critical x 2 2
41 41
 YES NO Points Points REMARKS
4.1. QUALITY MANAGEMENT SYSTEM ISO
Element
1. Quality Standard System (QSS) manual Major

1.1.a Documented Quality Manual Critical X 2 2

1.1.e Proper distribution of quality manual, Critical 2 0
procedure and work instruction
4.2.3 Control of Documents ISO
Element
2. Quality documents
1.2 Control of Quality Records Major
1.2.a Identification of records Critical X 2 2
1.2.b. Filing System Critical X 2 2
1.2.c Person In Charge Critical X 2 2
1.2.d Revision Request Form Critical X 2 2
1.2.e Person with authority of approval, review Critical X 2 2
and re-approval of revision
4.2.4 Control of Records ISO
Element
3. Human Resource Development
1.3 HRD Records Major
1.3.a Directory of Medical staff & non-medical Critical 2 0
staff
1.3.b Employee 201 Files Critical 2 0
1.3.c Retention Policy Non- 1 0
Critical
1.3.d Confidentiality Agreement Critical 2 0 None
21 12
 YES NO Points Points REMARK
6. RESOURCE MANAGEMENT
1. Human Resource Development
1.2. Code of Discipline Major
1.2.a Policy for disciplinary practices or code of Critical 0
dicipline
2
1.2.b Awareness of staff on code of discipline Critical 0
2
3. Human Resource Development
1.3 Employees Benefit Programs Major
1.3.a Uniform and I.D. Critical x 2 2
1.3.b Complinace to minimum requiremetnt of Critical 0
Government agency such as DOLE, SSS, BIR, etc.
2
6.2.2 Training, Awareness and competence
4. Human Resource Development
1.4 Performance appraisal system for Major
employees
1.4.a Guideline for evaluation/appraisal Critical 2 0
1.4.b Performance appraisal form Critical 2 0
1.4.c Recorded evaluation/appraisal Critical 2 2
5. Human Resource Development
1.5. Staff development and training Major
program for competency
1.5.a Training Records for new employees Critial 2 0
1.5.b Record of In house training programs Critical 2 0
1.5.b Records of training certificates and Critical 0
attendance 2
6.3 Facilities ISO Element
6. Facilities
1.6 Government regulatory requirement Major
1.6.a Sufficient Lighting Critical 2 0
1.6.b Adequate ventilation Critical 2 0
1.6.c Good housekeeping Critical 2 2
1.6.d Availability of Health & safety equipments Critical 0
2
1.6.e Adequate potable water supply Critical 2 0
1.6.f Availability of clean comfort rooms Critical 2 2
1.6.g Sufficient functional rooms with privacy Critical 0
2
1.6.h Signage for information and direction Critical 0
available 2
1.6.i Waste disposal procedure Non- 0
Critical 1
1.6.j Provision on Emergency light Critical 0
2
1.6.k Security measures in place Critical 2 0
1.6.l Proper storage spaces for reagents and or Critical 0
medical supplies 2
1.6.m Adequate communication facilities Critical 2 0
7. Equipment
1.7. Complete functional equipments Major
1.7.a List of functional equipments Critical 2 0
1.7.b Inventory of equipment Critical 2 0
1.7.c Equipment In good condition Critical 2 0
1.7.e. Proper Labeling of equipment Critical 2 0
8. Equipment
1.8. Equipment Maintenance Major
1.8.a Person/Dept, responsible for maintenance Critical 0
2
1.8.b Maintenance program Critical 2 0
1.8.c Master list and calibration records of Critical 0
equipments 2
1.8.d Preventive Maintenance Program Critical 2 0
1.8.e Preventive Maintenance Plan Critical 2 0
1.8.d Preventive Maintenance Record Critical 2 0
1.8.e Record of Repair Critical 2 0
67 8
 YES NO Points Score REMARKS
7. Service Realization ISO Element

7.1 Planning of realization process

1. Management Commitment
1.1 Quality Planning Major
1.1.a Quality Plan (where necessary) Critical 2 0
1.1.b Awareness on Quality Plan Critical 2 0
2. Flow charting
1.2 Business Flow chart for Major
Administrative Unit
1.2..a. Flowchart of Accounting Dept. Critical 2 0
3. Flow Chart
1.3. Complete flowchart for medical Major
operations
1.3..a Physical Examination Critical 2 0
1.3.b Visual Test Unit Critical 2 0
1.3.c. Laboratory Unit Critical 2 0
1.3.d X-ray Unit Critical 2 0
1.3.e Pychological Unit Critical 2 0
1.3.f Auditometry Unit Critical 2 0
1.3.g Dental Unit Critical 2 0
1.3.h EKG Unit Critical 2 0
7.2. Customer related process ISO Element

4. Contract Review
1.4 Establishment of customer requirements Major
thru standard MOA with manning agency

1.4.a Memorandum of Agreement with Client Non-

and consultants Critical
1.4.b Assignment of person/s to review the MOA Critical

1.4..c Schedule, record and outcome of the Non-

review of MOA Critical
1.4.d Filing system of MOA documents Non-
Critical
1.4.e Complete copies of MOA documents Non-
Critical
5. Customer Requirements
1.5.a Files of referrals
6. Customer Requirements
1.6 Proposal Letter Major
1.6.a Copy of proposal letter Critical 2 0
1.6.b Range of service fee Critical 2 0
7. Staff orientation for requirement of new
clients
1.7. Record of staff orientation on client’s Major
expectations
1.7.a Minutes of the meeting Critical 2 0
7.2.3 Customer Communication ISO Element

8. Complaints
1.8 System for handling Complaints Major
1.8.a Person assigned to handle complaints and Critical 0
his/her responsibility and authority 2
1.8.b Report format or form of complaint Critical 2 0
1.8.c Records and report on the review of Critical 0
complaints 2
7.4 Purchasing
9, Equipment
1.9 Purchasing control and guidelines Major
1.9.a Policy on purchasing Critical 2 0
1.9.b Requisition form Critical 2 0
1.9.c Purchase Order or contract Critical 2 0
1.9.d Records of receipts Critical 2 0
10. Supplies
1.10 Complete major suppliers Major
1.10. a List of necessary/required medical Critical 0
supplies 2
1.10.b Requisition Forms od medical suppliers Critical 0
2
1.10.c Purchase order or contract of medical Critical 0
supplies 2
1.10.d Storage area of medical supplies and Critical 0
reagents 2
11. Supplies
1.11 Guidelines I the requision , purchase and Major
inventory of suppliers
1.11.a Writen guidelines in the requisition, Critical 0
purchase and inventory of supplies 2
1.11.b Inventory list Critical 2 0
1.11.c File Requisition forms and Purchase Critical 0
Orders 2
1.12.e Minimum stock requirements of re-agents Critical 0
and inventory status of medical supplies
2
12. Supplies
1.12 Adequate storage supplies Major
1.12.a Proper storage areas for reagenants Critical 2 0
1.12.b Proper storage for x-ray films Critical 2 0 NA
7.5 Operations Control ISO Element

13. Manual
1.13. Operations Manual Major
1.13..a Availability to point of use Critical 2 0
14. Manual
1.14 Work Instructions Manual Major
1.14.a Availability on place/person use Critical 2 0
66 0
 YES NO Points Score REMARK
8. MEASUREMENT, ANALYSIS AND IMPROVEMENT

1. Audit System
1. 1 Procedure for Internal Quality Audit Major
1.1.a. Procedure for internal Audit Critical 2 0
1.1.b Identification of Auditors Critical 2 0
1.1.c Audit plan showing schedule Critical 2 0
1.1.d Result of IQA Critical 2 0
1.1.e Forms used for auditing Critical 2 0
8.2.3 Monitoring and measurement of process
2. Quality Performance Monitoring
1.2. Quality performance monitoring indicator Major

1.2.a List of existing clients Critical 2 0

1.2.b Data on repatriation rate (not to exceed Critical 0
1.5% annually) 2
1.2.c Certificate of proficiency rating of Critical 0
Laboratory 2
1.2.d Rate of film spoilage (not to exceed 5% Critical 0
Monthly 2
1.2.e No record of suspension/penalty Critical 2 0
8.3 Control of Non-conforming products or Services ISO Element

E. Quality Improvement Activity

3. System for defecting deficiency/deviation
from QSS
1.3. Procedure/plan/guideline for detecting Major
clinic deficiencies
1.3.a Tools for detection of deficiencies Critical 2 0
1.3.b Report on deficiencies Critical 2 0
4. Systems for preventive & Corrective
Measures
1.4 Procedure for Corrective and Preventive Major
Actions
1.4.a Procedure for corrective action Critical 2 0
1.4.b Corrective Actions on non-conformities Critical 0
2
1.4.c Agenda on CA in management review Critical 2 0
1.4.d Objective or documentation evidence on Critical 0
the implementation of CA 2
1.4.e Time table for corrective action plan Critical 2 0
5. Systems for preventive & Corrective
Measures
1.5 Plan for Continuing CQI Major
1.5.a Written plan for CQI Critical 2 0
8.4 Analysis of Data
6. Management review
1.6 Management Information System Major
1.6.a Person responsible for Information Critical 0
System 2
1.6.b. Records on Statistical Data Critical 2 0
1.6.c Statistical reports to top management Critical 2 0
42 0
Evaluation Criteria on QSS Checklist

Numerical Rating 50% and below = No Recommendation

51% - 65% = For Follow-up Audit
66 % - 95 % = With Recommendation Requiring
Corrective Actions
\ 96% - 100% = Full Recommendation

RATING*

PART I: QUALITY MANAGEMENT SYSTEM

Total score (1-21) x 100 x 20% = 11.42857

21

PART II: MANAGEMENT RESPONSIBILITY

Total score (1-40) x 100 x 20% = 20

40

PART III: RESOURCE MANAGEMENT

Total score (1-67) x 100 x 20% = 2.38806

67

PART IV: SERVICE REALIZATION

Total score (1-74) x 100 x 20% = 0

74

PART V: MEASUREMENT ANALYSIS & IMPROVEMENT

Total score (1-42) x 100 x 20%

42 = 0

OVERALL RATING = 33.81663 %

Annex D

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