ANNEX M

ASSESSMENT TOOL FOR LICENSING AN INFIRMARY

AO No. 2012-0012

1. The team shall make sure they have the complete set with the following: Standards/Indicators for
an Infirmary, Attachments A, B and C.

2. The team leader shall assign sections of the assessment tool to corresponding team members.
validate findings. The team members should not limit their tour to the areas suggested under
Column "AREAS".
4. If the corresponding items are present or available, place a check (√) on the column “COMPLIED”
opposite each box alongside each corresponding item; if not, put an (X).
and initiatives undertaken by the facility under "REMARKS" Column. Indicate also if the service/s is/
are “ADD ON” in this column.
6. The Team Leader shall at the end of the inspection or monitoring visit, make sure that the team
members complete their respective tool sections.
and affix their signature and indicate the date of inspection or monitoring at the last page of the
Assessment Tool.
aforementioned pages and indicate the position, to signify that inspection or monitoring results
were discussed during the exit conference.

9. The team shall provide a copy of the accomplished and signed assessment tool to the facility.

10. The assessment tool shall be used for self-assessment, inspection and monitoring activities.
 ANNEX M
AO No. 2012-0012
I. HEALTH FACILITY INFORMATION

Name of Facility:________________________________________________________________

Address: _______________________________________________________________

____________________________________________________________________________

Geographic Coordinates of the Facility: Latitude: ___________ Longitude: _____________

Email Address: _____________________________ Tel. / Fax Nos.: __________________

Name of Owner: ____________________________ Tel. / Fax Nos.: __________________

Hosp. Administrator: ________________________ Tel. / Fax Nos.: __________________

Chief of Hospital/Med. Director: _____________ Tel. / Fax Nos.: __________________

License To Operate: ________________________ Authorized Bed Capacity: __________

Classification: INFIRMARY

Government Private

National Single Proprietorship

Local Corporation

Others: (specify) _______________ Others: (specify) _______________

Type of application: Initial Renewal

DOH STANDARDS (Indicators) for INFIRMARY
CRITERIA
Goal:
(This refers To improve
to the patient
specific and outcomes
measurable by respecting
indicators patients' rights
that help determine whetherand
or ethically relating with patients an
Standard: Organizational policies and procedures respect and support patients' rights to quality care a
1. Informed consent is obtained from patients prior to initiation of care.
2. Policies and procedures which identify and address patients’ rights and
responsibilities
II. PATIENT CARE are documented and monitored.
A. ACCESS
3. Clinical services are appropriate to patients' needs and the former's availability is
consistent
4. CLINICALwith the organization's
SERVICES service capability and role in the community.
FOR INFIRMARY
Minimal
5. NURSINGto Intermediate
SERVICES care and management in the following areas:
Minimal to Intermediate care and management in the following areas:
6.Entrances and exits are clearly and prominently marked, free of any obstruction and
readily accessible.
7. Directional signs are prominently posted to help locate service areas with the
organization.
8. Alternative
B. ENTRYpassageways for patients with special needs (e.g. ramps) are available,
clearly and prominently
Goal: The entrymarked andmeet
process free of
theany obstruction.
patient needs and are supported by effective systems and a suitable
Standard:
9. All patients The organization
are correctly identified byuniquely identifies
their patient charts.all patients including newborn infants, and creates a spe
Goal: The health care team develops in partnership with the patients a coordinated plan of care with g
Standards: The care plan addresses patient's relevant clinical, social, emotional and religious need.
10. Coordinated plan of care with goals.
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.
Standards: Each patient's physical psychological and social status is assessed.
11. An appropriate comprehensive history and physical examination is performed on
every patient within 48
Standards: hours from professionals
Appropriate admission. Theperform
history includes presentand
coordinated illness,
sequenced patient assessment to redu
12. Previously obtained information
C. IMPLEMENTATION OF CAREis reviewed at every stage of the assessment to
guide future assessments.
Goal: Care is delivered to ensure the best possible outcomes for the patients.
Standard:
13. Medicines Medicines are
are administered administered
in timely, in a standardized
safe, appropriate andmanner.
and controlled systematic manner.
14. Only qualified personnel order, prescribe, dispense prepare, and administer drugs.
15. Prescriptions or orders are verified and patients are identified before medications
are administered.or orders are verified and patients are identified before medications
16. Prescriptions
are administered.
17. Medicine administration is properly documented in the patient chart.
D. EVALUATION OF CARE
Goal: The health care team routinely and systematically evaluates and improves the effectiveness and
Standard:
18. Discharge Thepatients
plans for discharge plan iscontinuity
to ensure part of the patient's care plan and is documented in the patient's chart
of care.
Goal: The organization effectively and efficiently governed and managed according to its values and go
and community needs.
19. Organizational Structure/Chart
20. The organizational and its services develop their vision, mission and corporate
goals based
21. The on agreed-upon
organization values. develop their policies and procedures.
and its services
22. Committees within the organization which includes the terms of reference for
membership.
23. Evaluation and monitoring activities to assess management and organizational
performance.
B. OUTSOURCED SERVICES
24. Outsourced services are within the facility if applicable.
ADMINISTRATIVE SERVICES
A. Dietary
B. Linen/Laundry
C. Security
D. Housekeeping/Janitorial
E. Proper Waste Disposal
F. Maintenance
IV.G. HUMAN
AmbulanceRESOURCE MANAGEMENT
A. HUMAN RESOURCES PLANNING
Standard: Workload
25. The organization documentsisand monitored and appropriate
follows policies guidelines
and procedures consulted to ensure that appropriate sta
for hiring,
credentialing,
26. Staff and
numbers privileging of its
and skill mix are staff.
based on actual needs.
B. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES
Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are con
Standard:
27. Annual There are
planTRAINING
on training relevant orientation, training and development programs to meet the educational
activities
B. STAFF AND DEVELOPMENT
Goal: A comprehensive program of staff training and development meets individual and organizationa
28. New Standard:
personnel, There are relevant
new graduates orientation,
and external training
contractors are and development programs to meet the educational
adequately
supervised
29. The staffbyare
qualified staff
provided with a documented job description outlining
A. DATA COLLECTION AND AGGREGATION
accountabilities and responsibilities
Goal: Collection and aggregation of data are done for patient care, management of services, education
30. The organization defines data sets, data generation, collection and aggregation
methods
31. The and the qualified
organization definesstaff
datawho aredata
sets, involved in eachcollection
generation, stage. and aggregation
B. RECORDS MANAGEMENT
methodsGoal:
and the qualifiedsafety,
Integrity, staff who are involved
access in eachofstage
and security records are maintained and statutory requirements are m
32. WhenStandard: Clinical
patients are records
admitted or areare
seereadily accessible
for ambulatory to facilitate
or emergency patient
care, care, are kept confidential and safe
patient
charts documenting any previous care can be quickly retrieved for review, updating
33. The organization has policies and procedures, and devotes resources, including
A. PATIENT
infrastructure, AND STAFF
to protect SAFETY
records and patients charts against loss, destruction,
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and e
34. The organizational environment complies with structural standards and safety
codes as prescribed
35. Presence by law
of a management plan, policies and procedures addressing safety
36. There are management plans for the safe and efficient use of medical equipment
according
37. Designtoofspecifications.
patient areas provides sufficient space for safety, comfort and privacy
of the patient and security
38. A coordinated for emergency care. in the organization assures protection of
arrangement
patients,Standard:
staff and visitors.
The organization plans a safe and effective environment of care consistent with its mission, s
39. An
B. incident reporting OF
MAINTENANCE system
THEidentifies potentialOF
ENVIRONMENT harms,
CAREevaluates casual and
contributing
Goal: A comprehensive and maintenance programaction
factors for the necessary corrective and preventive ensures a clean and safe environment
Standard:
40. Generator Emergency
/ emergency light,light
waterand/or
system,power supply,
adequate waterorand
ventilation air ventilation systems are provided for, in ke
conditioning
41. Training of the staff who is in charge of the maintenance of the equipment
Standard: Current information and scientific data from manufacturers concerning their products are av
42. Operating manuals of equipment
C. INFECTION CONTROL
Standard: An interdisciplinary infection control program ensures the prevention and control of infectio
43. Physician and nurse in charge of infection control.
Standard: The organization uses a coordinated system-wide approach to reduce the risk of healthcare-
44. Organization takes steps to prevent and control outbreaks of healthcare
associated infections.
45. There are programs for prevention and treatment of needle stick injuries, and
policies and procedures for thedisinfecting,
Standard: Cleaning, safe disposal drying,
of used needles are and
packaging documented and
sterilizing of equipment, and maintenance of as
(Annex B ofand
46. Policies A.O. No. 2012-0012:
procedures DOHdisinfecting,
on cleaning, Guidelinesdrying,
in thepackaging
Cleaning,and
Disinfecting,
sterilizing Drying, Packaging and Sterilizing
of equipment, instruments and supplies.
Standard: When needed, the organization reports information about infections to personnel and public health a
47. Policies and procedures in reporting notifiable diseases (Refer to AO No. 2008-
C. ENERGY AND WASTE MANAGEMENT
0009).
Standard: The handling, collection and disposal of waste conform with relevant statutory requirement
48. Licenses/permits/ clearances from pertinent regulatory agencies
49. Policies and procedures on waste disposal
Goal: The Organization continuously and systematically improves its performance by invariably doing
clients.
50. Continuous Quality Improvement Program
Standard: The organization provides better care service as a result of continuous quality improvement
51. Customer satisfaction survey
52. Better patient outcome.
VII. DOH PROGRAMS IMPLEMENTED IN HOSPITALS AND OTHER HEALTH FACILITIES
53. Newborn Screening
54. Mother– baby
Friendly Facility
55. Immunization of newborn babies with BCG and first dose Hepatitis B vaccine
56. Hospital is a “No Smoking zone”
57. Generic prescribing and recording
58. Emergency Preparedness, Response and Recovery Plan
59. Newborn Hearing Screening
60. Family planning service
61. National Tuberculosis Program
 INDICATOR EVIDENCE AREAS
ights and ethically relating
(This is the with patients
REQUIREMENT of theand other organizations.
standard. (Proof of compliance to the indicator: (Not limited to
nd support patients' rights to quality care and their responsibilities in that care. (A standard shall be expressed as a gener
All patient charts have signed consent. DOCUMENT Wards
Presence of policies and procedures to Patients charts – get charts
DOCUMENT REVIEW Policies and of patients Wards
identify and address patients' rights: procedures on patients' rights.
Presence of facilities consistent with clinical DOCUMENT REVIEW ER
service capability as stipulated in its DOH LTO 1. List of services
DOCUMENT available.
REVIEW OPD
Medical Records
Check
DOCUMENTfinal diagnosis
REVIEW and interventions Room
Wards,Wards
ER, OPD
Check final diagnosis and interventions
 Presence of entrances and exits that are OBSERVE
readily accessible and free form obstruction
Presence of directional signages to locate 1. With entrance and exit signs. Check
OBSERVE ER
service
Presenceareas
of alternative passageways (ramps, Directional
OBSERVE signs are prominently OPD
ER
elevators)systems
ported by effective that are prominently marked
and a suitable and Check:
environment OPD
cluding newborn infants,
The contents and creates
of patient's a specific
charts are the patient chart for each patient that is readily
DOCUMENT ER accessible to authorized pers
patients afollowing:
coordinated plan of care with goals. Patient chart from ER, ward, and OPD OPD
l, social, emotional and religious need.
Presence of adopted/developed protocols, DOCUMENT Wards
he planningCPGs
and delivery of patient care. Proof of implementation of ER
tatus is assessed.
All patients have comprehensive history of PE DOCUMENT Wards
within
and sequenced 48 hours
patient from admission.
assessment to reduce waste and Patient chart fromrepetition.
unnecessary wards
All patient charts have progress notes by CHART REVIEW Medical Records
doctors and other health professionals.
s for the patients. Patients chart from medical Room Wards
systematicAllmanner.
medicines are administered observing the CHART REVIEW Wards
five (5) R's ofpharmacists
All doctors, the medication which are:
and nurses have Check patients charts from the wards:
INTERVIEW Wards
updated
Proof thatlicenses.
prescriptions or orders are verified Randomly
INTERVIEWcheck the licenses of some ER
Wards
before medications
Proof that arecorrectly
patients are administered.
identified Ask staff how they verify orders from
INTERVIEW ER
Wards
prior to administration of medications.
All charts have proper documentation of Verify
CHARTfrom patients if they were
REVIEW ER
Medical records
luates and medicine
improvesadministration.
the effectiveness and efficiency Medication sheet into
of care delivered patient chart.
patients. office wards
n and is documented in the
All charts have patient's
discharge chart.
plans. CHART REVIEW Medical records
nd managed according to its values and goals to ensure that care
Patient's chartsproduces the desired
from medical records, health
Roomoutcomes, and is responsiv
Presence of organizational structure OBSERVE Other Areas
Presence of written vision, mission, and goals Observe
DOCUMENT if the organizational
REVIEW Lobby
Medical Nursing
of the hospital
Written policiesand
andallprocedures
services/departments.
manual for Written
DOCUMENT vision, mission and goals.
REVIEW and
Medical Nursing
all services/departments/units.
Proof of the creation of all committees within 1. Written Policies
DOCUMENT REVIEW and
Administrative
the organization
Presence which and
of evaluation includes the terms of
monitoring Proof of the creation
DOCUMENT REVIEW of all committees office
Administrative
activities to assess management and Accomplishment reports or other office
Presence of memorandum of DOCUMENT REVIEW Administrative
agreement/contract for all outsourced 1. Contracts/MOA for outsourced office
If not contacted out, there shall be DOCUMENT REVIEW
Administrative
maintenance andout,
If not contacted provision of safe,
there shall be quality -DOCUMENT
Check policies and procedures in the
REVIEW
- Sorting of soiled and contaminated linens in Check procedures on how soiled linens
office

DOCUMENT REVIEW
Policies and procedures on security of Security check for internal and external
patients, visitors
Policies and and hospital
procedures staff waste
on proper DOCUMENT REVIEW
disposal
Proof of implementation of policies and Proof of implementation of policies and Lobby
OBSERVE
procedures
(Use separate assessment tool for OBSERVE ER/OPD
Ambulance)
s consultedPresence
to ensure that appropriate
of policies staff for
and procedures numbersDOCUMENT
and skill mix are available to achievePersonnel/
REVIEW desired patient and organizati
hiring, credentialing and privileging of staff.
Staff to be ratio for licensed doctors, Policies and procedures for hiring,
DOCUMENT REVIEW Personnel/ Administrative
ONSIBILITIES
ly with statutory requirements and are consistent with the organization's human resourceAdministrative
registered nurses and midwives/nursing aides 201 files of employees. policies.
opment programs to meet the educational needs of management
Presence of annual plan on training activities DOCUMENT REVIEW and staff. Personnel/
pment meets individual and organizational needs. Annual plan (including Administrative
opment programs tonew
Proof that meet the educational
personnel needs of management
are adequately and staff.
DOCUMENT REVIEW Personnel/
oriented
Proof thatand supervised
staff are provided with job Documentation
DOCUMENT REVIEW of orientation Administrative
Personnel/
description outlining their accountabilities Written job descriptions with conforme Administrative
t care, management of services, education and research.
Presence of annual statistical reports and DOCUMENT REVIEW Medical records
other additional
Presence hospital
of qualified staffstatistics
involvedasin data Compilation
DOCUMENT of Annual Statistical Report
REVIEW room
Medical records
definition,
intained and statutorygeneration, collection
requirements areand
met. Policies and procedures on record room
patient care, are kept
Presence confidential
of policies and safe, on
and procedures and comply
filing with all relevant statutory requirements
OBSERVE Medical and codes of practice.
Records
and retrieval of charts Ask the medical records officer to Room/Office
 Presence of procedures to protect records DOCUMENT REVIEW Medical Records
and patient charts against loss, destruction, Policies and procedures on records Room/Office
ation are provided a safe, functional and effective environment of care.
Presence of updated DOH license to operate DOCUMENT REVIEW Administrative
Presence of a management plan, policies and Updated
DOCUMENT DOHREVIEW
license office
Administrative
procedures addressing:
Preventive Maintenance Program of Management
DOCUMENT REVIEWplan, policies and office
ER
Equipment
Presence adequate space, lighting and Proof of implementation of Preventive
OBSERVE OPD
ER
ventilation
Presence ofinancompliance
appointed with structural
personnel in Observe
DOCUMENT for the following:
REVIEW OPD
charge
nment of care of security.
consistent Contract
with its mission, services, and or Appointment
with laws of person in
and regulations.
Presence of incident reporting DOCUMENT REVIEW Administrative
a clean and system/sentinel
safe environment event monitoring system Record of sentinel events office
ventilationPresence
systemsof
are provided
generator for, in keeping
/ emergency light, withDOCUMENT
relevant statutory
REVIEW requirements andMaintenance
codes of practice.
water system,
Proof of adequate
training ventilation
of the staff orcharge
who is in air Check result of
DOCUMENT water Certificate
REVIEW analysis forofthe Other
Maintenance
of the maintenance of the equipment training of service personnel if in-house
ufacturers concerning their products are available for reference and guidance in the operation officeand maintenance of plant
Presence of operating manuals equipment DOCUMENT Operating manual of Engineering/
Medical equipment, generators, air Maintenance
ures the prevention and control of infection in all services.
A designated doctor and nurse in-charge of DOCUMENT REVIEW Nurse
infection
approach to reducecontrol
the risk of healthcare-associated1.infections.
Proof of designation of a doctor and Supervisor's
Presence of a coordinated system-wide DOCUMENT REVIEW ER
procedure for prevention of hospital Validate
Presence of policies and procedures on the INTERVIEW hospital policies on infection Wards
ER
prevention and treatment of needle stick Ask staff their policies on needle stick
izing of equipment, and maintenance of associated environment, conform to relevant statutory Wards requirements and codes
sinfecting, Drying,
PresencePackaging
of policies and Sterilizing of
and procedures on Reusable Items in REVIEW
DOCUMENT Hospitals and Other Health Facilities).
CSSU
cleaning,
out infections disinfecting,
to personnel drying,
and public packaging
health and Policies and procedures on cleaning,
agencies.
Presence of policies and procedures in DOCUMENT REVIEW
reporting notifiable diseases Copies of reports submitted to PIDSR.
nform with relevant statutory requirements and code of practice
Presence of licenses/permits/ clearances Administrative
from pertinent regulatory agencies
Healthcare Waste Manual, 3rd Revision roof DOCUMENT REVIEW office
proves its performance by invariably
of implementation of policiesdoing the right thing
and procedures the right
1. Issuances way the
- memos, first time
guidelines onand meeting the needs of its interna
Presence of Quality Improvement Program DOCUMENT REVIEW Administrative
result of continuous quality improvement activities CQI plan and proof of implementation office
Presence of customer satisfaction survey DOCUMENT REVIEW Administrative
Proof of better patient outcomes 1. Domains ofREVIEW
DOCUMENT the survey form used. office
Administrative
EALTH FACILITIES Documentation of better outcomes for office
Newborn Screening being implemented. DOCUMENT REVIEW OB WARD
Certified “Mother –Baby Friendly Hospital -DOCUMENT
Logbook of REVIEW
Newborns who were (Rooming
OB Ward In)
Facility
Newborn babies given BCG and first dose MBFHI
DOCUMENT Certificate
REVIEW Hallways
Hepatitis B vaccine
Policies and procedures on anti-smoking Records
DOCUMENT REVIEW given BCG and
of Newborns Hallways
Policies and procedures on generic Policies
DOCUMENT and procedures
REVIEW on anti- Wards
prescribing
With designated -DOCUMENT
Prescriptions filled in the Pharmacy
REVIEW Pharmacy,
ER if
HEMS
Newborn Coordinator
Hearing Screening being -DOCUMENT
Hospital/Office order designating one
REVIEW OB Wards
implemented
Presence of Family planning services Logbook
DOCUMENT of Newborns
REVIEW who were tested OPD
Implementation of National TB Program List of FP acceptors
DOCUMENT REVIEW OB
OPDWards
- Presence of Hospital TB Referral Wards
 ANNEX M
AO No. 2012-0012

Put a check if REMARKS

complied.
all be expressed as a general statement.

x --ultrasound not
yet installed
cessible to authorized personnel.

outcomes, and is responsive to patient's

ired patient and organizational outcomes.

icies.

nts and codes of practice.

es of practice.

and maintenance of plant and equipment.

ry requirements and codes of practice.

cilities).

ting the needs of its internal and external