Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
MONITORING TOOL
INFECTION PREVENTION AND CONTROL IMPLEMENTATION
IN LEVELS II AND III HOSPITALS
I. GENERAL INFORMATION
Name of Hospital ________DR. RAFAEL S. TUMBOKON MEMORIAL HOSPITAL_________
Date: ____March 25, 2020
Complete Address: ___ KALIBO, AKLAN ____
Region:_____________VI_______
Level:_______2________ Authorized Bed Capacity: ________300____________
Data collection method: ___ Phone call interview _X__ Email correspondence ___ Monitoring Visit
Name of Hospital Informant: _____________________________________________________________
I. ISOLATION ROOM STATISTICS
ISOLATION ROOMS
In Emergency Room
In Nursing Unit
Improvised Isolation Room
SUBTOTAL
NUMBER OF ISOLATION
ROOMS WITH NEGATIVE
PRESSURE
0
0
0
NUMBER OF ISOLATION
ROOMS WITHOUT NEGATIVE
PRESSURE
1
37
5
43
SUBTOTAL
1
37
5
TOTAL NUMBER OF
ISOLATION ROOMS:
43
ISOLATION BED STATISTICS
ISOLATION ROOMS
In Emergency Room
In Nursing Unit
Improvised Isolation Room
SUBTOTAL
NUMBER OF ISOLATION BEDS
OCCUPIED
0
8
3
11
NUMBER OF ISOLATION BEDS
AVAILABLE
1
29
2
32
SUBTOTAL
1
37
5
TOTAL NUMBER OF
ISOLATION BEDS: 43
II. INFECTION CONTROL Date:
PROGRAM
Assessment
Remarks
INDICATOR
YES
NO
1. Presence of functional
Infection Control Committee
(ICC).
✓
cxcgfx
2. Presence of functional
Infection Control Team (ICT).
✓
1
III. POLICIES AND PROCEDURES
1. Written infection control
policies and procedures are
available and updated.
✓
2. Policies and procedures on the
use of Personal Protective
Equipment (PPE).
✓
3. Hospital has policies that
clearly define responsibilities
for cleaning and disinfection
of non-critical equipment,
✓
1
Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
mobile devices, and other
electronics (e.g., ICU
monitors, ventilator surfaces,
bar code scanners, point-ofcare devices, mobile work
stations, code carts, airway
boxes).
4. Policies and procedures on
✓
healthcare waste management.
✓
IV. IMPLEMENTATION OF INFECTION CONTROL POLICIES AND PROCEDURES
INDICATOR
Date:
Assessment
YES
NO
1. Hospital strictly adheres to hand hygiene
✓
2. Supplies necessary for adherence to hand hygiene (e.g., soap, water, paper towels, alcohol-based hand rub) are
readily accessible in patient care areas.
✓
3. Hospital strictly adhere to proper PPE selection and use, including donning and doffing.
✓
4. Supplies necessary for adherence to personal protective equipment as specified under Standard and Transmissionbased Precautions are available.
Remarks
(If NOT AVAILABLE,
please indicate REASON)
a. Gowns
50
b. Gloves
150
c. Face Mask
d. Goggles
85
Boxe
s
17
5. Supplies necessary for adherence to personal protective equipment as specified under Standard and Transmissionbased Precautions are adequate.
(If INADEQUATE, please
indicate REASON)
Daily inventory of the following:
a. Gowns
b. Gloves
c. Face Mask
d. Goggles
6.
7.
If PPE is NOT AVAILABLE or INADEQUATE, improvised PPEs are used
a.
Gowns
b.
Gloves
c.
Face Mask
d.
Goggles
(If specify improvised PPEs
used)
Readiness for use of equipment by the next patient.
8. Hospitals strictly adhere to cleaning and disinfection procedures, including use of products in accordance with
manufacturers’ instructions
(e.g., dilution, storage, shelf-life, contact time).
✓
Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
V3