Annex A

Self Assessment Tool for the Proposed Expanded Primary Care Benefit Please √ if
INDICATORS available REMARKS
(EPCB) for Health facilities FOR ACCREDITATION STANDARDS Yes No
1.2.e. Fecal Occult Blood
Name of facility: ___________________Date of Assessment: (MM/DD/YY) 1.2.f. Pap smear
Address: _____________________________________________________ 1.2.g. Lipid profile (Total Cholesterol,
_____________________________________________________________ HDL and LDL, Triglycerides)
1.2.h. FBS
A. Instructions:
1.2.i. OGTT
 Indicate the type of provider being evaluated by placing a tick mark on 1.2.j. ECG
the appropriate box. 1.2.k. Creatinine
1.3 Has a current DOH Radiology license. Name of the facility:
 For each of the items in the indicators for accreditation standards Check for availability of the following test: __________________
please indicate your compliance by checking the appropriate box. 1.3.a. Chest x-ray Distance from the
 For services to be outsourced to another facility, please indicate in the referring facility (in km.)
__________________
remarks column the name of identified facility and its distance from the
1.4. Has a licensed pharmacy. Name of the Pharmacy:
referring facility (in km.). Check the availability of valid FDA license. __________________
B. Type of Health facilities (please √ type of facility) Distance from the
referring facility (in km.)
 OPD of PhilHealth accredited L1, L2, and L3 hospitals
__________________
 Infirmaries 1.5 Has a current Mayor’s Permit. If no, please indicate type
 Ambulatory surgical clinics of facility:_______
1.6 Availability of EPCB Plus medicines (see
 Rural Health Units/Health Centers Annex A)
 Medical outpatient clinics (e.g. HMO clinics) 1.6.a. Generic
1.6.b. Branded
C. Ownership of Health facility
1.7 Has a policy on providing services during If no, please indicate the
 Government Private weekends (at least 1 every week) and during proposed flexible
D. Average no. of patients seen in a day _________________________ the extended hours of the clinic until 8:00 pm operational hours (e.g. 12
on weekdays to accommodate patient needs. nn – 8 pm during
E. No. of physician stationed in OPD ___________________________
weekdays and half day
F. Accreditation Requirements during weekends)
__________________
Please √ if
INDICATORS available
1.8 Has a policy and procedures for referral of Please indicate name of
REMARKS
FOR ACCREDITATION STANDARDS Yes No patients to higher level of care, when needed. the referral facility.
1.1 Duly-licensed by the DOH. If no, please indicate type __________________
of facility 1.9 Has adequate and appropriate information
_________________ materials (e.g. flyers, brochures, posters, audio
1.2 Has a current DOH Laboratory license. Name of the facility: visual presentation) on health and wellness
Check for availability of the following tests: __________________ such as anti-smoking, and promotion of
1.2.a. CBC with platelet count proper diet, exercise, and immunization.
1.2.b. Urinalysis Distance from the 2.0 Well-placed signages to ensure ease of
1.2.c. Fecalysis referring facility (in km.) access of EPCB clients to the consultation area
1.2.d. Sputum microscopy __________________ and ancillary services.
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INDICATORS
FOR ACCREDITATION STANDARDS
2.1 The fixed co-payment rates are posted in a
conspicuous area in the consultation room/
area.
2.2 Has clearly posted information on the
extended hours of the clinic.
2.3 A clean, adequate, and safe area for EPCB
consultations and examinations that ensures
privacy and confidentiality.
2.3.a. Designated examination area, not
necessarily a separate room
2.3.b. With structures for assuring that
patients’ privacy is respected (e.g. partitions
or covers in consultation or examination
areas; there is reasonable distance between
patients for auditory and visual privacy).
2.4 Adequate lighting/ electric supply
2.5 Adequate clean water supply
2.6 Well ventilated waiting area with adequate
seats for patients
2.7 Has the basic equipment and supplies for
required services, including:
2.7.a. Non-mercurial BP apparatus
2.7.b. Non-mercurial thermometer
2.7.c. Stethoscope
2.7.d. Weighing scale (adult)
2.7.e. Weighing scale (infant)
2.7.f. Tape measure
2.7.g. Nebulizer
2.7.h. Lubricating jelly
2.7.i. Disposable needles and syringes
2.7.j. Sterile cotton balls/ swabs
2.7.k. Applicator stick
2.7.l. Disposable gloves
2.7.m. Specimen cups/ bottles
2.7.n. Sterilizer or its equivalent (auto
clave)
2.7.o. Vaginal speculum (big)
2.7.p. Vaginal speculum (small)
2.7.q. Decontamination solutions
2.7.r. 70% Isopropyl alcohol
2.7.s. 3% to 5% acetic acid
2.7.t. Glass slides
Please √ if Please √ if
INDICATORS
available REMARKS available REMARKS
Yes No FOR ACCREDITATION STANDARDS Yes No
2.7.u. Storage cabinet for sterile
instruments and supplies
2.8 A designated, secure and appropriate drug If the storage area is the
storage area for EPCB Plus medicines. same as the facility’s main
2.8.a. Storage rooms/shelves or cabinets pharmacy, the EPCB
where medicines and controlled drugs are facility should at least be
kept is properly secured. able to demonstrate that
2.8.b. If locked, ask who holds the key to there is a separate
the storage inventory of the drugs
2.8.c. There are visual discriminators such used for inpatient.
as signs or markers that are helpful to
differentiate medications from one If any ONE of the items
another; this is to avoid confusion is not complied with,
between strengths, similar-looking labels mark NO.
and names that sound or look familiar
2.8.d. Observe where expired medicines
are kept, if any
2.9 Has a clean and functional toilet with
adequate supply of water, and wash area.
If any ONE of the items 2.10There is adequate infection control and
is missing, mark NO. risk management, including:
2.10.a. Availability of a sink, with
adequate water and soap for
handwashing
2.10.b. Use of puncture proof receptacles
for disposed sharps and needles
2.10.c. Use of gloves, masks
2.10.d. Staff observes handwashing
techniques
2.10.e. Properly segregated and marked
waste bins
2.11 Has a designated area for sputum
collection. The area is provided with:
2.11.a. A sink with adequate water supply
and soap is located near the collection
area for handwashing.
2.12 PhilHealth certified Electronic Medical
Record (EMR) or its equivalent is installed and
operational in the consultation area of the
facility and is safe and accessible to all
members of the health care team.
2.13 Has a biometric kiosk.*
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 Please √ if
INDICATORS
available REMARKS
FOR ACCREDITATION STANDARDS Yes No
3.1 A PhilHealth accredited physician
(preferably General Practitioner or Family
Physician) is on site for the duration of clinic
hours.
3.2 A duly licensed nurse is on site for the
duration of clinic hours.
3.3 A microscopist trained in Direct Sputum 1. Ask for the DSSM
Smear Microscopy (DSSM) is on site on Certificate of the
designated schedules. microscopist. The
3.3.a. A Certificate of Training for DSSM requirements for a “Adopting the 2008 Revised List of Notifiable
is given separate for a microscopist, who trained medical
may not necessarily be a medical technologist and
technologist. radiology technician are
deemed complied with if
the facility has a DOH
license for laboratory,
and radiology,
respectively.
2. If the microscopist is a
shared resource across
several facilities, the
facility must be able to
show proof that the
microscopist has a 5.1.h. 5cc syringe with needle patient
regular schedule for
DSSM services.
3. If the sputum is
collected in other
laboratory, the facility
must be able to present a
Certificate of Service
Delivery Support.
4.1 Individual health profiles in EMR or Ask for print outs of an
equivalent individual health profile
from the EMR
4.2 Monthly and annual Report of EPCB Plus Ask for a sample report
services availed by PhilHealth members generated from the EMR
4.3 Record of EPCB Plus drugs inventory Electronic system
generated reports are
acceptable; logbook
Please √ if
INDICATORS
available REMARKS
FOR ACCREDITATION STANDARDS Yes No
4.4 Record of laboratory supplies inventory or Electronic System
attached valid DOH LTO of the service generated reports are
delivery provider (referral facility) acceptable; logbook
4.5 Record of radiology supplies inventory or Electronic system
attached valid DOH LTO of the service generated reports are
delivery provider (referral facility) acceptable; logbook
4.6 Record of submission of Notifiable Copy of report submitted
diseases (per DOH AO No. 2008-0009
Diseases, Syndromes, Health-Related Events
and Conditions”) for hospital and infirmaries
or Top 10 outpatient cases for other HCIs
5.1 Maternal health, nutrition, and
micronutrient supplementation
5.1.a. IEC Materials for Unang
Yakap/ENC and Breastfeeding
5.1.b. Weighing Scale
5.1.c. Measuring tape/height chart
5.1.d. Food table/pyramid
5.1.e. Iron/Folate 60 mg elemental
iron/400 ug folic acid tablet
5.1.f. Iodine 200mg elemental iodine
5.1.g. Iodized salt
registry
5.1.i. Mother and Child Book
5.2 Tetanus Toxoid Immunization
5.2.a. Tetanus Toxoid ampules
5.2.b. Syringes with needles
5.2.c. Patient registry
5.2.d. Vaccine Carrier
5.2.e. Vaccine refrigerator
5.3 Deworming
5.3.a. Mebendazole
5.3.b. Albendazole Tablets
5.4 Counseling on health caring and seeking
behaviour
5.4.a. IEC Materials
5.5 Early detection and management of
danger signs and complications of
pregnancy
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 Please √ if Please √ if
INDICATORS INDICATORS
available REMARKS available REMARKS
FOR ACCREDITATION STANDARDS Yes No FOR ACCREDITATION STANDARDS Yes No
5.5.a. Patient record 5.8.2.m. Syringes with/without
5.5.b. Possibly chart or checklist of danger needle
signs 5.8.2.n. Tourniquet
5.5.c. BP apparatus 5.8.2.o. Sterile Urine vials
5.5.d. Stethoscope 5.8.2.p. EDTA and plain test
5.5.e. Ambulance or transport utility tubes
5.6 Antenal administration of steroids in 5.8.2.q. Well-equiped laboratory
preterm labor that can run these tests
5.6.a. Syringes 5.9 Screening for adequacy of fetal growth,
5.6.b. Dexamethasone 5 mg/ampule assessment of fetal well-being and prediction
5.6.c. Dexamethasone 8 mg/ampule of fetal compromise
5.6.d. Betamethasone 5.9.a. Tape measure
5.7 Support Services 5.9.b. Stethoscope
5.7.a. Calendar 5.9.c. Lubricating jelly
5.7.b. Antenal registration card 5.9.d. Examining table
5.7.c.Patient record 5.9.e. Weighing scale
5.7.d. Pregnancy tracking forms 5.9.f. Sphygmomanometer (non-
5.7.e. Mother and child book mercurial)
5.7.f. Community health team 5.9.g. Thermometer (non-mercurial)
maternal death reporting form 5.9.h. Patient registry
5.8 Diagnostic/screening tests 5.10 Antenatal diagnosis of congenital
5.8.a. Blood typing anomalies
5.8.b. VDRL or RPR 5.10.a. Ultrasound machine
5.8.c. HBsAg 6.1 National TB Control Program – Directly
5.8.d. OGCT Observed Treatment Short Course (NTP
5.8.e. Pregnancy Test DOTS) Certification issued by the DOH
5.8.f. Cervical cancer screening using: 6.2 General Infrastructure
5.8.1. Pap smear 6.2.a. Large and clear sign bearing the
5.8.2. VIA Test name of the clinic
5.8.2.a. Light Source 6.2.b. Additional sign indicating it is a
5.8.2.b. Speculum PhilHealth accredited facility
5.8.2.c. Sterile cotton pledget 6.2.c. Directional Signage
5.8.2.d. Boiled water or nomal 6.2.d. Generally clean environment
saline solution 6.2.e. Sufficient seats for patients
5.8.2.e. Acetic acid 3-5% 6.2.f. Well ventilated waiting area,
5.8.2.f. Syringe without needle preferably with exhaust fan
5.8.2.g. Patient registry 6.2.g. Lighting adequate
5.8.2.h. Microscope 6.2.h. Adequate water supply for
5.8.2.i. Slides handwashing
5.8.2.j. Cover slips 6.2.i. Covered garbage containers
5.8.2.k. Stains with color-coded segregation
5.8.2.l. Centrifuge 6.2.j. Examination table with clean

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INDICATORS
FOR ACCREDITATION STANDARDS
linen
6.2.k. Secured storage area for
patients records and drugs
6.2.l. Sputum collection area with
appropriate ventilation
6.2.m. Concrete pit for disposing
sputum collecting cups
6.3 Diagnostics
6.3.a. Microscopy
6.3.b. Chest X-ray
6.4 Equipment and Supplies
6.4.a. TB Drugs with adequate buffer
stock for registered and targeted
patients
6.4.b. Microscope
6.4.c. AFB reagents
6.4.d. Glass slides
6.4.e. Cover slips
6.4.f. Cotton swabs
6.4.g. Stethoscope
6.4.h. Weighing scale
6.4.i. Disposable gloves in
examination room
6.4.j. Disposable needles and syringes
6.4.k. Sputum collecting cups with
cover
6.4.l. Decontamination solution
6.5 Forms and Documents
6.5.a. NTP treatment cards
completely filled-up and updated
6.5.b. NTP identification card
6.5.c. TB lab registry – updated and
properly filled-up
6.5.d. TB patient registry
6.5.e. Flow chart of patient
management
6.5.f. Referral forms
6.5.g. Written policy or procedures in
the DOTS Center
6.5.g.i. Infection Control
6.5.g.ii. Water and wastes
disposal
Please √ if Please √ if
INDICATORS
available REMARKS available REMARKS
Yes No FOR ACCREDITATION STANDARDS Yes No
6.5.g.iii. Selection and
assignment of treatment partner
6.5.g.iv. Patient and staff
protection
6.5.g.v. Referrals
6.5.g.vi. Defaulter Tracing
6.5.h. Quality control validation
results with feedback sheet from
external validators
6.5.i. Spot map of catchment area
including clinics/RHU/Hospital
6.5.j. Patient education materials for
TB
6.6 Staffing and Manpower
6.6.a. DOTS Center administrator
6.6.b. Accredited Physician
6.6.c. Medical
Technologist/Microscopist
6.6.d. Nurse
6.6.e. TB Diagnostic Committee
6.6.f. NTP Program Certificates
6.6.f.i. Sputum exam for
microscopist
6.6.f.ii. Fix dose combination
6.6.f.iii. DOTS training for DOTS
manpower
6.7 Quality Improvement Programs
6.7.a. Vision
6.7.b. Mission
6.7.c. Records Management
6.7.d. Policy Implementation Review
* Pending issuance on the guidelines on the use of biometrics and certification of the biometric utility
Prepared by: ___________________________________________
__________________________________________
(Designation)
Attested correct by: _______________________________________
_______________________________________
Head of Facility/ Medical Director/ Chief of Hospital
(Signature over printed name and date signed)
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