Republic of the Philippines

PROVINCE OF AURORA
● “S- '—y*. V
■o
●y> AURORA MEMORIAL HOSPITAL co&Vernong
■B
KUMAKALiNGA
■V Brgy. Reserva, Baler, Aurora
●. -\
■J949‘ Email; auroramemhos@gmail.com
Phillleallh Accredited Health Care Provider

Januar)' 27, 2023

CORAZON I. FLORES, MD,MPH,CESO IV

Director IV
Department of Health Region III
San Fernando, Pampanga

Thru: Lilia A. Pascua MD

DM0 V
Provincial Department of Health- Aurora

Dear Dir. Flores,

We would like to express our intent on the Monitoring and Accreditation of our Animal Bite
Treatment Center in AURORA MEMORIAL HOSPITAL for the CY 2023

Attached herewith are the Assessment Tool for your Reference.

'fhank you ver\' much.

KRIS MADON^V. ROXAS-RIMANDO M.D

PHO-I/ChiefofHcspital
 tr^piT/vo
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DOH / CHD SELF ASSESSMENT TOOL

Facility:
Major Requirements: YES NO
1.Trained Physician and Nurse on Management of Animal Bites from DOH
recognized training institution
2.Cold Chain equipment(Refrigerator and Vaccine carrier)
3.Standard recording & reporting system

PART! PART II
Item Criterion Evidence by Certifiers’ Certifiers’
Facility
Progress and Rating Comments Team Rating
Achievements
The Animal Bite Treatment Center/ Animal Bite Center provides a safe and
Goal 1
effective physical environment to its patients and staff
Standard 1 The ABTC/ABC is easily located and patients have convenient and safe access to
the center
This standard will be achieved when:
1.1. ABTC signage is
There is appropriate signage bearing the properly installed
name of the ABTC/ABC to assist patients at the main road, 2
lospital gate and
accessing the center
inside hospital
premise
1.2 ABTC is located
at the OPD ground 2
Physical access is appropriate for the needs floor Room 1.
of the patients d/Ornpf
Lobb>' is free from
obstruction.
1.3 Entrance and Exit
IS clearh- marked
Entrance/exits are clearly marked and free
of obstruction and of other hazardous with No 2 ocn-p (\ a
Obstruction
conditions
1.4 Aside from the
There are resources to inform patients of the clinic hour posted 2
on the signage. 2,
daily schedule of the facility
Schedule is posted
at the treatment
center itself.
TOTAL RATING 8 ¥
Rating Scale
0- Non
Compliant 1-
Incomplete
2- Complete

REMARKS BY THE CERTIFIERS’ TEAM

(To be completed if and when there are disparities with the information provided by the
facility staff)

Goal: The Animal Bite Treatment Center/Animal Bite Center provides a safe and effective
physical environment to Its patients and staff.
Standard 1: The Animal Bite(and) Treatment Center/Animal Bite Center is easily located
and patients have convenient and safe access to the center.

DOH-RO3-LHSD-WI-19-00- Forml Rev.O

 PARTI PART II
Evidence by Facilitj- Rating Certifiers' Certifiers'
Item Criterion
Progress and Comments Team
Achievements Rating
The Animal Bite Treatment Center/Animal Bite Center provides a safe and effective physical
Goal 1
environment to its slafY and patients
The ABTC/ABC provides facilities for the comfort and privac>' of its patients and staff
Standard 2

This standard wall be achieved when:

; 2.1 Trash Bin is
i The ABTC/ABC maintains a clean and health available in the area. 2
CO a
I promoting environment within and immediately
i outside its premises.
1 2.2 There are I EC
materials available 2 , W0i4t'
: There are resources and processes to ensure the
i quality of patient waiting time. in the waiting area.
There are chairs
provided while
waiting.
2.3 Proper lighting is 2
I The facility is adequately lighted. maintained in the
room.
a
: 2.4 Only one patient is 2
' The prit acy of every' patient is assured allow ed inside the
treatment room.
8
TOTAL RATING _7.
Rating Scale

0- Non Compliant
1 - Incomplete
2 - Complete

REMARKS BY THE CERTIFIERS' TEAM

(To be completed if and when there are disparities w'ilh the information provided by the facility stafl)

Goal; The Animal Bite Treatment Center/Animal Bite Center provides a safe and elTective physical
environment to its patients and staff
Standard 2: The ABTC/ABC provides facilities for the comfort and privacy of its patients and staff.

DOH-RO3-LHSD-WI-19-00- Forml Rev.O

 PARTI PART II
E\idence by Facility Rating Certifiers' Cerlifiers'
Item Cnteiioii
Progress and Comments Team
Achievements Rating
The Animal Bite Treatment Center/Animal Bite Center Provides a safe and effective physical
Goal 1
environment to its paligits and staff
Standard 3 The ABTC/ABC provides safety to its patients and staff

This standard will be achiex ed when:

3.1 Clean Water.
The facilitv' has adequate clean water for wound soap and iilcohol
cleaning, personal hygiene, and sanitation is always 2
available. Wash -2.
purposes area is also
available.
3.2 Maintained
The faciliw maintains appropriate levels of Cleanliness and
:lcrili:'ed 2
cleanliness and antisepsis of all physical areas,
equipment.
equipment and instruments.
3.3 Properly disposal
General waste, sharps, pathological and and segregation 2 2
of waste. Color
infectious waste, pharmaceutical and chemical
wastes are appropriately segregated, safely :oded Waste bags
are used.
handled and disposed of according to accepted
safe disposal practices.
3.4 riiere is Policy
There are documented, disseminated, and and procedure for 2
implemented procedures to identify and address implementation
of risk COr^p a
the risks of contamination of patients and staff contamination of
from sources of infectious diseases.
oatienl and staff.
8
TOTAL RATING 7

Rating Scale

0- Non Compliant
i - Incomplete
2- Complete

REMARKS BY THE CERTIFIERS'TEAM

(To be completed if and when there are disparities with the information provided by the facility stafO

Goal; The Animal Bite Treatment Center/Animal Bite Center provides a safe and effective physical
environment to its patients and staff

Standard 3 The ABTC/ABC provides safety to Us paiiciiis and staff

DOH-RO3-LHSD-W1-19-00- Forml Rev.O

 PARTI PART II
Evidence by Facilih' Rating Certifiers’ Certifiers'
Item Cnteiion
Progress and Comments Team Rating
Achievements

Goal 2 Patients receive appropriate and efTective clinical management based on rabies exposure categoiy.

standard 4 All patients have continuous access to accurate and reliable animal bite exposure management-

This standard will be achieved when;

4.1 Completeness
A physician completes and documents the relevant of every patient 2
history for each patient record.
4,2 Avail t^le
The facilit>' implements policies and procedures for polity and 2 -for
assuring the qualirt' of bite exposure management, procedure on
the quality of +VOO
bite exposure
and managment
4.3 Available
If Rabies Vaccine/RIG is not available, policies policy and 2
and procedures for referring patients to another procedure on
accessible ABTC/ABC are implemented and referral-
monitored for elTectiveness.
4.4 Accurate 2
Rabies Vaccine / RIG are secured and proper cold temperature for
chain management is observed. vaccines are C<5tov|d1) X
maintained.
TOTAL RATING 8
E
Rating Scale

0- Non Compliant
1 - Incomplete
2 - Complete

REMARKS BY THE CERTIFIERS'TEAM

(To be completed if and when there are disparities with the information provided by the facility stafO

Goal: Patients receive appropriate and effective clinical management based on rabies exposure category.

Standard 4: All patients have continuous access to accurate and reliable animal bite exposure management.

DOH-RO3-LHSD-WI-19-00- Forml Rev.O

 PART I PART II
Evidence by Facility Certifiers' Certifiers'
Item Criterion
Progress and Rating Comments Team
Achievements Rating
Goal 2 Patients receiv e appropriate and effective clinical management based on rabies exposure
calegoiy’-
Standaixl 5 A comprehensive management approach is developed and followed for all patients

This standard will be achieved when:

5.1 Management of
Management of rabies exposure is consistent rabies exposure is 2
with Rabies Prevention and Control Program based on the 0.
Guidelines, Guidelines.
5.2 Available flow
2 —tC
Flow chart of patient management is visible
and accessible to expedite the provision of
chart of patient
management in
a
ser\ ices to patients. the center.
5.3 Completeness of
A comprehensive evaluation of the patient's Medical Record. 2 <NV
progress is documented.
5.4 Health Education
Health education is provided to all patients on is conducted in 2
adherence to management and on responsible everx’ patient.
pet ownership.
5.5 Available
Policies and procedures for detecting PEP Policies and
defaulters and getting them back for procedures 2
management are implemwted and monitored for detecting f
for effectiveness. PEP
defaulters.
(Sijtoak
TOTAL RATING 10 S'

Scale Rating

0- Non Compliant
1 - Incomplete
2 - Complete

REMARKS BY THE CERTIFIERS’ TEAM

(To be completed if and w hen there are disparities with the information provided by the facility stafO

Goal; Patients receive appropriate and elTeclive clinical management based on rabies exposure category.

Standard 5: A comprehensive management approach is developed and followed for all patients

DOH-RO3-LHSD-WI-19-00- Forml Rev.O

 PARTI PART II
Evidence by Facility Certifiers' Certifiers'
Item Criterion
Progress and Rating Commits Team
Achievements Rating
Goal 3 The health staff adheres to clear policies and guidelines on efficient ABTC /ABC operation
Standaixl 6 The ABTC/ABC maintains accurate and updated records and reports to all animal bite victims.

This standard will be achieved when:

6.1 Identifi'ing patient
Each patient is uniquely identified throughout the correctly is always 2
course of management. observed and y
practiced-
6.2 Completeness and
The facility maintains an updated database of updated Patient 2
patient records that is accessible to authorized Record. Logbooks
4
personnel. are available.
6.3 Properly recorded
The facility maintains quarterly reports of both and timely 2
animal and human bite cases. submitted animal a
bite and human bite
quarterly.
6.4 In\ entor\' of
The facility maintains a quarterly inventoiy' of vaccine is done 2
Rabies vaccine/RIG. quarterly. '4=vcc'('«vX-
Requisition slip is
properly filed.
TOTAL RATING 8
2.
Rating Scale

0- Non Compliant
1 - Incomplete
2- Complete

REMARKS BY THE CERTIFIERS'TEAM

(To be completed if and when there are disparities with the information provided b>' the facility staff)

Goal: The health staff adheres to clear policies and guidelines on efficient ABTC /ABC operation

Standard 6; The ABTC/ABC maintains accurate and updated records and reports of all animal bite victims.

DOH-RO3-LHSD-WM9-00- Forml Rev.O

 I
PART I PART n
Evidence by Facility Certifiers' Certifiers'
Item Criteiion
Progress and Rating Comments Team
Achievements Rating
Goal IV The ABTC/ABC Provides qualit>^ ser\nces with competent manpower to its patient
Standard 7 The ABTC/ABC has complete manpower complement performing assigned tasks.

This standard will be achieved when:

7.1 The facility has qualified personnel I Trained Doctor and 1 2
trained on Animal Bite Management Nurse in the Animal Bite
Management
7.2 There are personnel responsible for
the following
7.2.1 Diagnosis and Management 1 Trained Doctor and 1 2
Nurse in the Animal Bite a
Management Dr. Sqfcptof
7.2.2 Provision of Rabies Vaccine/RIG 1 Trained Doctor and 1 2
Nurse in the Animal Bite 'X
Management 'fc rQg)

7.2.3 Logistics Management PHO/DOH/Hospital 2

:i
Procuremait
7.2,4 Information Management HEPO of the Center. 2
1

7.2.5 Financial Management Willen Bitong- Accountant 2

of AMH
Availability offund, <3/
trvvpfj.'dj' >
procurement of Vaccine
and supply
TOTAL RATING 12 /O-

Rating Scale

0- Non Compliant
1 - Incomplete
2- Complete

REMARKS BY THE CERTIFIERS^ TEAM

(To be completed if and when there are disparities with tlie information provided by the facilib.- staff)

Goal; The ABTC/ABC Provides quality services with competent manpower to its patient

Standard 7: The ABTC/ABC has complete manpower complement performing assigned tasks.

DOH-RO3-LHSD-WT-19-00- Forml Rev.O

OVERALL RATING AND SUMMARY PER GOAL

TOTAL
GOAL MAXIMUM RATING
ABTC RATING ASSESORS
8 8 I
8
2 8 I
3 8 8
7.
4 8 8 c
5 10 10
6 8 8 1
7 12 12
TOTAL 62 62

RATER
REMARKS BY THE CERTIFIERS' TEAM
(To be completed if and when there are disparities with the information provided by the facility staff)

The decision of the CHD certifying team shall remain FfNAL and OFFICIAL

The certification of the facility shall be valid for period of two(2)years but can be revoked at any point in time
if for three(3)consecutive occasions seem to be not adhering to the standards.

DOH-RO3-LHSD-WT-19-00- Forml Rev.O

 oftt^e Ph<iipp\nes
Dspartirent of Hsaftn
CENTER FOR HEALTH DEVELOPMENT 3
Ci^ ofSar .“erncrfoo, Pampargo

ANtMAL BrTE TREATMENT CEMTER (ABTC)f ANIMAL BITE CENTER (ABC) CERTIFICATION

SUMMARY

FacMiry: t^UdCxflA
jaddr€53:
Date cf Assessnent: X(^ -ypv^

STANDARDS RATING
1. Tr-& ABTC/A5C <s easily ocstss and patients t%ave conveni :t and safe access tc the
center.

2. Tr-e ABTC/A5C orcvioes facilities fcr the comfort and p’-ivecy of .ts patient ana staff
7
3. TrrS ABTC/A5C orcvices safety to its patient and stsff.
T
4. Ail patients have ccr.tinuous excess to accurate ana reliable animal bite exoosure
management.

S. A compreherjive rrsnagement aoproach is developed and folickved for aM patients.

5. T>-.e ABTC/ASC maintains acc*.rste and updated records and reports to si- animal bite
victims. T
7. Tre ABTC/A5C ras comolece manpcwer complerr.ent performing assignee tasks.
TOTAL SCORE
rr

REMARKS.

CHARK .PAfiiaO, MD, f.:-

0«velop<Mi>t r