Annex C 

Accreditation Survey Tool / Self-Assessment Tool for the

Expanded Primary Care Benefit (EPCB)
Health Care Institution (HCI)

Name of Health Care Institution: _____________________________________________

Address: __________________________________________________________________

Date of Survey: _________________________

A. Eligible health facilities

1. PhilHealth accredited L1, L2, and L3 hospitals, infirmaries, ambulatory surgical clinics
2. Medical outpatient clinics (e.g. HMO clinics)

B. Accreditation Requirements

Instructions:

 Indicate the type of provider being evaluated by placing a tick mark on the selection.
 For each of the items in the (4) categories of standards, indicate compliance by writing YES or NO in the appropriate
column of the facility being evaluated.

PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

1.1 The EPCB HCI is duly-

Do not fill N/A
licensed by the DOH.
1.2 The EPCB HCI has a If none, Certification of
current DOH Laboratory service delivery support
license. issued by the referral
Check for availability of the facility (see Annex H of
following tests: the Circular)
 CBC ______ ______ ______
 Lipid profile ______ ______ ______
 FBS ______ ______ ______
 Urinalysis ______ ______ ______
______ ______ ______
 Fecalysis
______ ______ ______
 Sputum microscopy
______ ______ ______
 ECG
______ ______ ______
 Paps smear
______ ______ ______
 Oral Glucose
Tolerance Test
1.3 The EPCB HCI has a If none, Certification of
current DOH Radiology service delivery support
license. issued by the nearest
Check for availability of the qualified referral facility
following test: _____ _____ _____ (see Annex H of the
 Chest x-ray Circular)

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PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

1.4. The EPCB HCI has a If none, Certification of

licensed pharmacy. service delivery support
Check the availability of valid issued by the nearest
_____ _____ _____
FDA license qualified referral facility
(see Annex H of the
Circular)
1.5 The EPCB HCI has a
current Mayor’s / business Do not fill
Permit.
1.6 The EPCB HCI has a
policy indicating it provides the
following services as required
by PhilHealth Circular No.
2018-0017:
 Health screening and _____ _____ _____
assessment, consultation
and treatment of
uncomplicated upper
respiratory infections,
low-risk pneumonia,
acute gastroenteritis,
urinary tract infection,
asthma.
 Cervical cancer
assessment using visual ______ ______ ______
acetic acid and/or Paps
smear
 Breast examination
______ ______ ______
 Digital rectal exam (for
______ ______ ______
males)
 Diabetes screening ______ ______ ______
1.7 The EPCB HCI has a
policy on providing services
during weekends (at least 1 ______ ______ ______
day every week) and during
the extended hours of the clinic
until 8:00 pm on weekdays to
accommodate patient needs.
1.8 The EPCB HCI has a
policy and procedures for ______ ______ ______
referral of patients to higher
level of care, when needed.
1.9 The EPCB HCI has
adequate and appropriate
information materials (e.g.
flyers, brochures, posters, ______ ______ ______
audio visual presentation) on
health and wellness such as
anti-smoking, and promotion
of proper diet, exercise, and
immunization.
2.0 Well-placed signages to
ensure ease of access of EPCB ______ ______ ______
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PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

clients to the consultation area

and ancillary services.
2.1 The fixed co-payment rates
are posted in a conspicuous ______ ______ ______
area in the consultation room/
area.
2.2 The EPCB HCI has clearly Signage indicating
posted information on the ______ ______ ______ hours of operation
extended hours of the clinic. clearly posted.
2.3 A clean, adequate, and safe
area for EPCB consultations
and examinations that ensures
privacy and confidentiality.
 Designated examination
area, not necessarily a ______ ______ ______
separate room
 With structures for assuring
that patients’ privacy is
respected (eg. 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 The EPCB HCI has the If any ONE of the
basic equipment and supplies items is missing, mark
for required services, including: NO.
 Non-mercurial BP ______ ______ ______
apparatus
 Non-mercurial ______ ______ ______
thermometer
 Stethoscope ______ ______ ______
 Weighing scale (adult) ______ ______ ______
 Weighing scale (infant) ______ ______ ______
 Tape measure ______ ______ ______
 Nebulizer ______ ______ ______
 Lubricating jelly ______ ______ ______
 Disposable needles and ______ ______ ______
syringes
 Sterile cotton balls/ ______ ______ ______
swabs
 Applicator stick ______ ______ ______
______ ______ ______
 Disposable gloves
______ ______ ______
 Specimen cups/ bottles
______ ______ ______
 Sterilizer or its equivalent
______ ______ ______
(auto clave)
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PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

 Vaginal speculum (big)

 Vaginal speculum (small) ______ ______ ______
 Decontamination ______ ______ ______
solutions ______ ______ ______
 70% Isopropyl alcohol
______ ______ ______
 3% to 5% acetic acid
______ ______ ______
 Glass slides
______ ______ ______
 Storage cabinet for sterile
instruments and supplies ______ ______ ______

2.8 Availability of EPCB

medicines:
 Generic ______ ______ ______
 Branded ______ ______ ______
2.9 A designated, secure and If the storage area is
appropriate drug storage area the same as the
for EPCB medicines. facility’s main
 Storage rooms/shelves or pharmacy, the EPCB
cabinets where medicines HCI should at least be
and controlled drugs are ______ ______ ______ able to demonstrate
kept is properly secured. that there is a separate
 If locked, ask who holds ______ ______ ______ inventory of the drugs
the key to the storage used for EPCB.
 There are visual
discriminators such as ______ ______ ______ If any ONE of the
signs or markers that are items is not complied
helpful to differentiate with, mark NO.
medications from one
another; this is to avoid
confusion between
strengths, similar-looking
labels and names that
sound or look familiar
 Observe where expired
______ ______ ______
medicines are kept, if any
2.10 The EPCB HCI has a
clean and functional toilet with
Do not fill
adequate supply of water, and
wash area.
2.11 There is adequate
infection control and risk
management, including:
 Availability of a sink, with _____ _____
adequate water and soap
for handwashing
 Use of puncture proof Do not fill
receptacles for disposed ______ ______
sharps and needles
 Use of gloves, masks
______ ______
 Staff observes
handwashing techniques
______ ______
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PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

 Properly segregated and

marked waste bins
2.12 The EPCB HCI has a
designated area for sputum
collection. The area is
provided with:
 A sink with adequate ______ ______ ______
water supply and soap is
located near the
collection area for
handwashing.
2.13 Electronic Medical Record
(EMR) or its equivalent, is
installed and operational in the
EPCB consultation area of the ______ ______ ______
facility and is safe and
accessible to all members of
the health care team.
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 1. Ask for the DSSM
Direct Sputum Smear Certificate of the
Microscopy (DSSM) is on site microscopist. The
on designated schedules. requirements for a
 A Certificate of Training trained medical
for DSSM is given technologist, and
separate for a radiology technician
microscopist, who may are deemed complied
not necessarily be a with if the facility has
medical technologist. 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
regular schedule for
DSSM services.

3. If the sputum is
collected in other
laboratory, the facility
must be able to
present a Certificate of

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PROVIDERS PHIC
Accredited L1, Medical
L2, and L3 outpatient
hospital clinic
INDICATORS
FOR ACCREDITATION Accredited REMARKS
STANDARDS infirmary
Accredited
ambulatory
surgical clinic

Service Delivery
Support.
4.1 Individual health profiles in Ask for print outs of an
EMR or equivalent ______ ______ ______ individual health profile
from the EMR
4.2 Monthly and annual Ask for a sample report
Report of EPCB services ______ ______ ______ generated from the
availed by PhilHealth members EMR
4.3 Record of EPCB drugs Electronic system
inventory (see Annex B of the ______ ______ ______ generated reports are
Circular for the list of drugs) acceptable; logbook
4.4 Record of laboratory Electronic System
supplies inventory or attached generated reports are
valid DOH LTO of the service ______ ______ ______ acceptable; logbook
delivery provider (referral
facility)
4.5 Record of radiology Electronic system
supplies inventory or attached generated reports are
valid DOH LTO of the service ______ ______ ______ acceptable; logbook
delivery provider (referral
facility)
4.6 Record of submission of Copy of report
Notifiable diseases (per DOH submitted
AO No. 2008-0009 “Adopting
the 2008 Revised List of
Notifiable Diseases,
Syndromes, Health-Related ______ ______ ______
Events and Conditions”) for
hospital and infirmaries or Top
10 outpatient cases for other
HCIs

C. Accreditation Decision Rule

A NO response in any of the above minimum requirements disqualifies the provider for EPCB accreditation.

Prepared by: _______________________________________

_____________________________
(Designation)

Attested correct by: _________________________________________________________

Medical Director/ Chief of Hospital or Medical Center Chief / Head of Facility
(Signature over name and date)

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PhilHealth Surveyors:
NAME DESIGNATION SIGNATURE

Date of Survey:______________________________________

Noted by:

______________________________________________________________
Medical Director/ Chief of Hospital or Medical Center Chief / Head of Facility/
(Signature over name and date)

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