Name of Facility

Province
Region
WATER EFFICIENCY, SANITATION AND HYGIENE
RESPONSE REMARKS
QUESTIONS Yes/No/In Progess (Please provide additional details to your
(IP) response)
Does the Health Facility (HF) conform to the latest Philippine National Standards for
Drinking
Does theWater, with regard
HF conduct to the sufficient
water quality testing andquantities and qualityas
regular monitoring ofindicated
drinking-water?
in the
Philippine
Has the HFNational
developedStandard for Drinkingthe
and implemented Water of 2017
Water forPlan
Safety all water
(WSP)supplies
to ensure
drinking
Does thewater safety
HF have as per DOH
a guaranteed AO No.
3-day 2014-0027?
water reserve?
Does the HF include safe drinking water, with a guaranteed capacity that would last at
Does the HF have the capacity to provide/source
least 72 hours to address emergency needs, in addition out water for3-day
of the at least 7 days
water if
reserve?
interruption persists?
Does the HF include clean water for identified priority/critical areas/units (e.g. OR,
ICU, ED, Dialysis Unit, Laboratory Unit, Dietary Unit, etc.), with a guaranteed capacity
Adequate and Safe Water Does the HF have an existing MOA/MOU with local drinking water suppliers and/or *Specify local drinking water suppliers/agencies
Supply agencies?
Does the HF have an existing MOA/MOU with local water suppliers and/or agencies? *Specify local drinking water suppliers/agencies
Does the HF have enough capacity to store potable drinking water (e.g. jerry cans,
containers)?
Does the HF have existing water efficiency and conservation program/plan?
Is the HF able to utilize available alternative water sources (e.g. deepwell)?
Does the HF have an existing Rainwater Collection System?
Do they conduct water audit in the HF to determine qualitative and quantitative
analysis
Does theofHFwater
haveconsumption?
an educational program for health care workers and stakeholders
that
Doeshighlights the needthe
the HF maximize to use
conserve,
treatedthe efficient use
wastewater forof water and
cleaning their different
of service vehicles,
ENERGY EFFICIENCY
toilet flushing, and for other non-potable purposes?
Is there an on-site renewable energy generation or backup electricity generation for
Does the HF
identified have the capacity
priority/critical to provide/source
areas/units (e.g. OR, ICU,out
ED,power forUnit,
Dialysis at least 7 days if Unit,
Laboratory
interruption
Dietary Unit,persists?
etc.) that can power these areas/units’ emergency power needs for at
least 48 hours? areas/units (e.g. OR, ICU, ED, Dialysis Unit, Laboratory Unit, Dietary
priority/critical
Unit, etc.)?
Does the HF have an existing MOA/MOU with local gasoline stations and other
renewable *Specify local gasoline stations/suppliers/agencies
Does the HFenergy
have ansources suppliers
existing MOA/MOUand/or agencies?
with local energy suppliers and agencies for
prioritization and load distribution in caseconnected
of intermittent *Specify local gasoline stations/suppliers/agencies
Adequate Supply of Does the HF have an emergency system to thesupply of electricity?
alternate power or back-up
Electricity energy
transferssource?
a power supply from its primary source to a backup source when it senses a
failure or outage? *Specify the time interval in seconds of the ATS
activation
Does the HF have existing energy efficiency and conservation program/plan?
Has the HF used
ventilations, light bulbs
conduct and electrical
of regular maintenancedevices with more and
of ventilation efficient models/types?
air conditioning
systems,
Does the etc.)?
HF adopt/use renewable energy strategies as back-up or secondary line for
electricity?
Does the HF perform Preventive Maintenance Schedule (PMS) in the facility,
service/public health vehicle, and equipment?
MANAGEMENT
disorders related to El Niño, as based onOF CONSULTATIONS
existing DOH manuals of proceduresAND or DOH-ADMISSIONS
approved CPGs?
Adequate Supply of Does
Does the
the HF
HF conduct health promotion
have adequate campaigns
supply of essential in relation to
commodities, El Niño? and other
medicines
resources, medicines, logistics
Does the(e.g. IV fluids,
HF have antibiotics,
an existing ORS, laboratory
MOA/MOU supplies,
with identified testingand
partners kits, etc.)? of
suppliers
supplies and equipment essential commodities, medicines and other logistics? *Specify identified partners and suppliers
Is there a functional Health Care Provider Network (HCPN) and referral system within
the area of the HF?
Does the HF have alternative water source to be FOOD SECURITY
used in the preparation of food in the
Dietary
Does theUnit?
HF include the Dietary Unit as a priority area for emergency provision of
electricity
at least 72in case of power interruption?
hours?
Adequate and Safe Supply
of Food Does the HF have the capacity to provide/source out food for at least 7 days if
interruption persists?
Does the HF include dietary provisions to all its personnel?
WASTE
Is there an available Healthcare Waste Treatment MANAGEMENT
for HF, specifically on the infectious
waste?
types of wastes generated in HF, which involves segregation, collection, handling,
storage, treatment,
Has the hospital andand disposal
other of waste generated
HFs encouraged the use offrom health
reusable care activities?
packaging and to start
minimizing
conduct the volume
orientation of waste
to the healthupon
careentry to their
workers facility?
regarding the standards, guidelines
and protocols
Is there a wastestipulated herein? plant (WWTP)/sewage treatment plant (STP) present
water treatment
Sustainable Health Care in your facility or is their sewer line connected to Service Providers for waste water?
Waste Management the HF implement patient safety, infection prevention and control, and occupational
(HCWM) healththe
Does and HFsafety programs/intervention?
establish proper waste recycling that reduces the demand for new
resources, cuts downhospital
and also encourage on the staff,
effortpatients
of transportation
and carersand production?
to limit the use of plastics within
the biodegradable
for facility? wastes, non-biodegradable wastes, infectious wastes and recyclable
waste?
Has the HF conducted a formal waste audit?

ADDITIONAL QUESTIONS:
What is the estimated monthly drinking water requirements of the HF? (staff, patients, watchers)
What is the estimated monthly water requirements for all units/departments of the HF?
What is the maximum capacity of the existing water resorvoir of the HF?
What is the maximum capacity of the existing drinking water resorvoir of the HF?
Gaps Identified on the water supply/system Estimated Cost
1
2
3
4
5

What is the estimated monthly energy requirements for the HF? Total Number of
Estimated energy requirement of patients that can be
List of identified priority/critical areas in the facility (e.g. OR, ICU, etc.)
each priority/critical area accommodited of each
1 Operating Room priority/critical area
2 Intensive Care Unit (NICU, SICU, PICU)
3 Emergency Room
4 Delivery Room
5 Laboratory Unit
6 Blood Bank
7 Dialysis Unit
8 Out Patient Department
9 Pharmacy
10 Dietary Unit
OTHERS:

How many functional generator sets does the HF have?

List of Available Functional Generator Set with Specifications (KVA) Daily fuel needs of each generator set
1
2
3
4
5
List of Identified Sources for Fuel for Generator Sets:
1
2
3
Gaps Identified on the power supply/system Estimated Cost
1
2
3
4
5

Available/Possible Sources of Funds:

1
2
3
4
5
Other Concerns related to the Effects of El Niño:
1
2
3

Prepared by:

Name and Signature

Verified by:

Name and Signature

 e additional details to your
response)

nking water suppliers/agencies

nking water suppliers/agencies

oline stations/suppliers/agencies
oline stations/suppliers/agencies

interval in seconds of the ATS

d partners and suppliers

Cost

Total Number of
patients that can be
accommodited of each
priority/critical area
ch generator set

Cost