ANNEX B. Sample Monitoring Forms (bit.

ly/OxygenDemandSupplySampleForm)

Table 1. Hospital Tool with Root Cause Analysis

# Question Answer

A. Consumption and Refilling Schedules

A.1 How many tanks of oxygen (in 50lbs) are consumed

in a day?

A.2 How many liters of liquid oxygen (LOX) are

consumed in a day?

A.3 Current Buffer Stock of Oxygen Tanks. As of 8AM

today, how many oxygen tanks are reserved/used as
buffer supply?

A.4 Available Filled Up Oxygen Tanks. As of 8AM

today, how many oxygen tanks are filled up?

A.5 Number of Empty Tanks for Refill. As of 8AM

today, what is the number of empty tanks for refill?
A.6 Total number of Oxygen Tanks. As of 8AM today,
how many oxygen tanks do you have in the hospital
(filled and unfilled)?

A.7 On the average, how often do you refill your

stockpile tanks?

A.8 Average Lead Time. How long does it take between

placing orders to suppliers and receiving delivered
orders of oxygen in the facility (in days)?

B. Oxygen Supply Source

B.1 How many tanks of oxygen are produced by own

hospital in a day (Hospital's own oxygen plant)?

B.2 List down names of Oxygen Suppliers of hospital

C. Shortage

C.1 Do you experience any shortage in oxygen supply? Yes/No

D. Root Cause Analysis (if answer in C.1. is ‘yes’)

D.1 Do you have enough oxygen cylinder tanks? Yes, we have adequate
stockpile of tanks/
No, we do not have adequate
stockpile of tanks

D.2 Do you have maximized frequency of oxygen Yes, we have maximized

refilling schedules? refilling schedules with our
suppliers (e.g. 3x a day)/
No, we have not maximized
refilling schedules with our
suppliers

D.3 Does your supplier provide enough oxygen supply Yes, our suppliers can provide
based on your agreed deliveries? enough oxygen supply/
No, our suppliers cannot
provide enough oxygen
supply

D.4 Do you have assigned personnel in managing Yes, we have assigned

oxygen supplies and deliveries (i.e personnel personnel in managing
bringing out empty tanks to suppliers, creating oxygen supplies and
delivery schedules)? deliveries/
No, we do not have assigned
personnel in managing
oxygen supplies and
deliveries
D.5 Do you have sufficient supply of gears/accessories Yes, we have sufficient
used in medical oxygen (gauge, regulators, etc.)? supply of gears/accessories
used in medical oxygen/
No, we do not have sufficient
supply of gears/accessories
used in medical oxygen

D.6 Do you have problems with your current contracts No, we do not have problems
of oxygen supply? with our current contracts
with suppliers/

Yes, we do not have a

contract with suppliers that
has capability to supply us/

Yes, I have other problems

with our current contracts

D.7 Other identified problems with oxygen supply

Main Supplier Profile (3 Major companies)

# Indicator Answer

D.1 What is the name of the supplier?

D.2 Where is/are your ASU plant/s located?

D.3 What is your average oxygen production capacity

(tanks/day)?

D.4 What is the usual ratio of manufacturers’ industrial to

medical oxygen production?

D.5 How many oxygen cylinder tanks are available?

D.6 How many isotanks do you have?

D.7 What is your average liquid oxygen price per

liter/isotank?

D.8 What is the power distribution utility / Electric

Cooperative in the region?

D.8_1 What is the power requirement for your company?

D.8_2 How many back-up generators do you have?

D.8_3 What is the frequency for power

fluctuation/interruption per month?