Department of Health
Bureau Of Health Facilities And Services (BHFS)
ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS
OUTLINE OF CONTENTS
I.
8.
9.
GENERAL INFORMATION(page 2)
II. HOSPITAL ADMINISTRATION
A.
Services
1. Administrative Service (pages 3-8)
1.1.
Human Resource
1.2.
Accounting
1.3.
Budget and Finance
1.4.
Billing and Claims
1.5.
Procurement
1.6.
Property and Supply Management
1.8
Linen and Laundry
1.9
Housekeeping
1.7.
Nutrition and Dietary
1.8.
Security Services
1.9.
Ambulance Services
1.10. Central Information Management
1.11. Medical Records (Including Dental
Records)
1.12. Medical Social Services
1.13. Nutrition and Dietetics
1.14. Pharmacy
2. Patients Rights and Organizational Ethics
(pages 9-10)
3. Patient Care (pages 11-13)
4. Implementation of Care (pages 13-15)
5. Evaluation of Care (page 15)
6. Leadership and Management (pages 16-17)
7. External Services (page 17)
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10.
11.
12.
13.
14.
Human Resource Management (page 17-18)
Data Collection, Management and Use
(pages18-19)
Safe Practice and Environment including
Patient and Staff Safety (pages 20-25)
Maintenance of Environment of Care (pages
25-27)
Infection Control (pages 28-32))
Energy and Waste Management (page 33)
Improving Performance (page 34)
III.
CLINICAL SERVICES (pages 35-36)
IV. PERSONNEL
POSITION STAFFING REQUIREMENT(pages 37-43)
1. Top Management Personnel Qualification
Standard
2. Administrative
3. Clinical
4. Nursing
5. Ancillary
IV. EQUIPMENT AND INSTRUMENTS (pages44-51)
List of Equipment and Instrument Requirement
1. Administrative
2. Clinical
2.1.
Emergency Room
2.2.
Outpatient Care
2.3.
Operating Room
2.4.
Recovery Room
2.5.
High Risk Pregnancy Unit
2.6.
Delivery Room
2.7.
Neonatal Intensive care Unit
2.8.
Intensive Care Unit
3. Nursing Unit/Ward
4. Isolation Room
5. Central Supply and Sterilization Unit/ Room
6. Physical Medicine and Rehabilitation Unit
7. Dialysis Clinic
8. Ambulatory Surgical Clinic
9. Dental Clinic
10. Dietary
V. PHYSICAL PLANT REQUIREMENT(52-56)
Required rooms/areas/offices
VI.HOSPITAL PROGRAMS (pages 57-59)
1. Blood Services
2. Newborn Screening
3. Mother-Baby Friendly Hospital Initiative
4. Health Promotion and Disease Prevention
5. Generics Act
6. Health Emergency Management Services
VII. HOSPITAL COMMITTEES (page 60)
VII. HOSPITAL OPERATIONS CRITERIA (page 61)
VIII. SIGNATURE PAGE (page 62)
Page 1
I. GENERAL INSTRUCTIONS:
1. Check to make sure that you have the complete tool with a total of
sixty-three (63) pages and copies of the SOE,SOM and NOV Forms.
2. Assign sections of the tool to corresponding team members.
3. To properly fill-out this tool, the Regulatory Officer shall make use of:
INTERVIEWS,  REVIEW OF DOCUMENTS, OBSERVATION
and VALIDATION of findings.
If the corresponding items are present or available, place a ✔on each
of the appropriate boxes alongside each corresponding item. If not,
put an X instead.
5. The REMARKS column shall document relevant observations both
positive and negative, including innovations and initiatives undertaken
by those responsible in the facility.
6. Make sure to fill-in the blanks with the needed information. Do not
leave any items blank; write N.A. if not applicable.
7. (Sh shaded cell means that specific items are not applicable to the
hospital level.
8. means the service can be outsourced but must be inside hospital
premises.
9. The Team Leader shall at the end of the inspection or monitoring visit,
make sure that the team members complete their respective tool
section and proceed to accomplish the Summary of Evaluation (SOE)
or Summary of Monitoring (SOM) Form and if warranted, the Notice of
Violation (NOV) Form.
10. The Team Leader shall ensure that all team members write down their
printed names, designation and affix their signatures and indicate the
date of inspection or monitoring,all at the last page of the Assessment
Tool, on the SOE and SOMForms and if warranted, also on the NOV
Form.
11. The Team Leader shall make sure that the Head of the facility or, when
not available, the next most senior or responsible officer affix his/her
signature on the same aforementioned pages and indicate the position,
to signify that inspection or monitoring results were discussed during
the exit conference and a copy of the SOE or SOM and, only if
warranted, that of the NOV, were received.
12. This shall also serve as self-assessment tool for facility owners and
monitoring tool.
4.
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II. GENERAL INFORMATION:
Name of Hospital:
Address:
(Number & Street)
(Barangay/District)
(Municipality/City)
(Province & Region)
Telephone No../ Fax No.
E-mail Address:
License No (for renewal):
Date Issued
Hospital Category:
Expiry Date:
Level 1 Level 2
Level 3
Philhealth Accreditation:Center of:  Safety  Quality  Excellence
Classification According to Ownership:  Government
No. of: Authorized Bed Capacity
 Private
Implementing Beds
Name of Owner or Governing Body (if corporation):
Name of Hospital Administrator, Medical Director or Chief of Hospital
Page 2
INDICATOR
DOH MONITORING
CRITERIA
DOH INSPECTION
STANDARDS
SELF-ASSESSMENT
CODE
EVIDENCE
AREA
REMARKS
HOSPITAL ADMINISTRATION:
Goal- To be responsive to the requirements of quality health service delivery, health regulation, health financing and good governance.
ADMINISTRATIVE AND
FINANCE SERVICE: The
AFS shall ensure adequate
●Documented and
implementable policies and
1.1.1 and timely financial and
direct support services to all procedures
hospital units.
Approved documented policies,
guidelines and procedures on:
Administrative Group:
a) Staffing plan
Human Resource
b) Recruitment and
● Complete, updated and
Management
Selection
easily retrievable
There shall be a
c) Hiring/Appointment
individual personnel file
comprehensive human
d) Orientation & Staff
● Evidence of continuous
resource management plan
Development
improvement
1.1.1.a
which
includes
recruitment,
e)
continuing
education,
and
1.1.1.a.1
selection, promotion,
training
separation, welfare and
Approved documented policies,
benefits in accordance with
guidelines and procedures on
applicable laws.
a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training
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Page 3
:
f)
g)
h)
i)
Performance Evaluation
Rotation/Transfer
Succession Plan
Merit, Promotion, Awards
& Incentives
j) Resignation, Termination
and Retirement
k) Physical Examination
● record of schedule of duties
● appointment/employment
contract, if valid
● updated health certificate (as
required)
● orientation plan/program of
new employees implemented
●record of schedule of duties
●appointment/employment
contract, if valid
● updated health certificate (as
required)
● orientation plan/program of
new employees implemented
1.1.1.b
1.1.1.b.1
1.1.1.b.2
Financial Management
Group
Accounting
There shall be a systematic
recording of all financial
transactions, preparation of
financial statements and
relevant reports, and maintenance and safekeeping of
Books of Accounts.
Budget
There shall be a
consolidation and
preparation of the Budget
Proposal, Work and
Financial/ Operational
Plans including its
implementation and
monitoring by the hospital
staff concerned.


documented and
implementable policies and
procedures
documented and
implementable policies and
procedures
Verifier:
Documents review,
Observe
 Interview staff,
Validate
▪ List of personnel –
check if
Current
Verifier:
Documents review, 
Interview staff,
Validate
Verifier:
Documents review, 
Interview staff,
Validate
Billing And Claims
There shall be a system of
billing patients and
processing of claims
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
documented and
implementable policies and
Page 4
1.1.1.b.3
1.1.1.c
1.1.1.d
1.1.1.e
1.1.1.f
Billing and Claims
There shall be a system of
billing of patients and
processing of claims
documented and implementable
policies and procedures
Procurement:
There shall be a
comprehensive plan of
systematic management of
procurement and
acquisition of supplies,
materials,
healthcare equipment,
vehicles, services,
infrastructure work and
other required logistics for
the effective and efficient
delivery of quality services
●Policies, guidelines and
procedures on requisition,
purchase, issuance and
inventory; disposal of nonfunctional equipment,
instruments, supplies, expired
drugs and medicines and
reagents are in place.
Property and Supply
Management:
There shall be a systematic
way of receipt, storage,
issuance and conduct of
inventory .
documented and implementable
policies and procedures
Proof of transactions
Documents are readily
Available
Linen and Laundry
There shall be adequate
supply of clean linens for
patients and other hospital
units.
● Sorting of soiled and
contaminated linens in
designated areas
● Systematic washing of laundry
with safeguard against spread of
infection
● Disinfection of laundry
Policies, procedures and
guidelines in cleaning and
washing of soiled linens
 Housekeeping
There shall be provision
and maintenance of clean,
safe and sanitary facilities
and environment for
hospital personnel, patients
and clients
[Type text]
Verifier:
Documents review, 
Interview staff,
Validate
Documents are readily
available
Verifier:
Documents review,
Observe
 Interview staff
Validate
Look for approved Work
and Financial Plan and its
implementation
● Adequate
housekeeping
supplies.
●evidence of continuous
review of policies and
procedures
Verifier:
Documents review, 
Interview staff,
Validate
Verifier:
Documents review, 
Interview staff,
Validate
Verifier:
Documents review, 
Interview staff,
Validate
Page 5
1.1.1.g
1.1.1.h
1.1.1.i
. Security
There shall be order within
the hospital premises and
protection of lives,
properties and critical
infrastructure from threats,
harm and losses
 Ambulance Services
(Compliance to A.O. 20100003- National Policy on
Ambulance Use and
Services)
Central Information
Management
There shall be a
comprehensive plan of
systematic management of
data and research for the
improvement of acquisition,
utilization of finances,
assets and development of
human resources,
operating systems and
procedures.
[Type text]
●Security check for internal and
external customers including use
of visitor’s pass
●evidence of continuous
review of policies and
procedures
Verifier:
Documents review, 
Interview staff,
Validate
●Documented and approved
policies and procedures on
patient transport to and from the
facility
●24 hour availability of
ambulance for ready use
●Available contract/ MOA, if
contracted out
●Logbook on transport of
patients/clients by ambulance to
and from the facility
With appropriate
manpower, equipment and
supplies during patient
transport
Verifier:
Documents review,
Observe,
 Interview
staff&Validate
●documented and
implementable policies and
procedures
If contracted out; note
specifications in contract or
MOA
Verifier:
Documents review,
Observe,
 Interview
staff&Validate
Page 6
1.1.1.i.a
1.1.1.j
Medical Records
(Including Dental
Records)
● Documented and
implementable policies and
procedures
There shall be an organized
system of recording,
processing, analyzing,
maintaining and
safekeeping of all patients'
records through the written
data in sequence of events
covering the diagnosis,
treatment and discharge of
patients
● ICD-10 reference books with
additional ICD-10 modification
● Logbooks on:
Admission
OR
DR
ER
OPD
Verifier:
Documents review, 
Interview staff,
Validate
Medical Social Services
There shall be policies and
procedures in place
pertaining to social case
work, multisectoral
networking and linkages in
understanding the sociobehavioral and economic
plight of patients and their
families for the holistic
approach in their
management and treatment
● Approved documented
policies and procedures and
records on:
a)Patient classification according
to their capacity to pay
b) Continuity of care
c) Counselling of patients/clients
and their families
d) Records of pre-admission and
pre- discharge assessment, and
discharge plan
Verifier:
Observe,  Interview
staff, Validate
Verifier:
Documents review, 
Interview staff,
Validate
●Available contract or MOA with
DSWD or the LGU whenever
applicable
● (for private hospitals)
Allocation of not less than 10% of
its Authorized bed capacity as
charity beds.
●Compliance to RA 9439, “An
Act Prohibiting the Detention of
Patients in Hospitals and Medical
Clinics on Grounds of
Nonpayment of Hospital Bills or
Medical Expenses”, (IRR, AO
No. 2008-0001)
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Page 7
1.1,1.k
 Nutrition And Dietetics
There shall be maintenance
and provision of safe, high
quality and nutritious food
to patients and personnel.


1.1.1.l
 Pharmacy
There shall be 24 hours, 7
days a week provision of
safe, affordable and
efficacious drugs and
medicines in accordance
with the Generics Act,
PNDF and DOH policies,
rules and regulations.
[Type text]

Actual implementation and
evidence of continuous
review of policies and
procedures
If contracted out; note
specifications in contract or
MOA

documented and
implementable policies
and procedures
Actual implementation and
evidence of continuous
review of policies and
procedures

documented and
implementable policies
and procedures
Verifier:
Observe,  Interview
staff, Validate
Verifier:
Observe,  Interview
staff, Validate
Page 8
2.1
INDICATOR
DOH MONITORING
CRITERIA
DOH
INSPECTION
STANDARDS
SELFASSESSMENT
CODE
EVIDENCE
AREA
REMARKS
PATIENTS’ RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations
2.1.1
1.Organizational policies
and procedures respect and
support patients' right to
quality care and their
responsibilities in that care.
Informed consent is obtained
from patients prior to initiation
of care.
All patient charts have
signed consent.
DOCUMENT
Patient charts – sample
charts of patients currently
admitted. If hospital is
department-alized, get
samples during tour of the
different departments.
Note: *Informed consent includes a patient-doctor
discussion of the following
issues: the nature of the
decision or procedure;
reasonable alternatives to
the proposed intervention;
the relative risks, benefits,
and uncertainties related to
each alternative;
assessment to patient
understanding; and
patient's acceptance or
refusal of the intervention.
[Type text]
Wards
(sample
size-10
charts, if
departmentalized, get
two from
each department; when
a chart is
found to
have no
consent
before you
reach 10,
you do not
have to go
further.)
Page 9
2.1.2
2.The organization informs
the community about the
services it provides and the
hours of their availability.
Clinical services are
appropriate to patients' needs
and the former's availability is
consistent with the
organization's service
capability and role in the
community.
Presence of facilities
consistent with clinical
service capability based on
DOH license in accordance
with the hospital’s level (e.g.
level 1 surgical capability,
level 2 – ICU, level 3–
teaching and training
hospital).
DOCUMENT REVIEW
List of services available
OBSERVATION:
Look at the facilities,
structure, manpower,
equipment and supply.
Check if the service
capability of the hospital is
in accordance with
the hospital level.
ER
OPD
ICU
OR
RR
PACU
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Page 10
2.2
2.2.1
PATIENT CARE
ACCESS - Goal: The organization is accessible to the community that it aims to serve.
2.2.1.a
3.Physical Access to
the organization and its
services is facilitated
and is appropriate to
patients' needs.
2.2.1.b
4.Physical access to the
organization and its services
is facilitated and is
appropriate to patients'
needs.
2.2.1.c
5.Physical access to the
organization and its services
is facilitated and is
appropriate to patients'
needs.
[Type text]
Entrances and exits are
clearly and prominently
marked, free of any
obstruction and readily
accessible.
Presence of entrances and
exits that are readily
accessible and free from
obstruction.
Directional signs are
prominently posted to help
locate service areas within
the organization.
Presence of directional
signages to locate service
areas.
OBSERVATION
Entrances and exits are
accessible and free from
any obstruction.
Note: Exit signs should be
luminous or illuminated
and prominently marked.
There should be exit signs
in major areas of the
hospital and all doors
leading to the
outside.(Reference: RA
6541 Building Code of the
Philippines)
ER
OPD
Wards
Other Areas
Lobby
Directional signs are
prominently posted. Check
ER, OPD, wards and lobby.
Alternative passageways for
patients with special
needs(e.g.ramps and
elevators) are available,
clearly and prominently
marked and free of any
obstruction.
.Presence of alternative
passageways (ramps and
elevators) that are
prominently marked and
free from obstruction for
patients with special needs.
ER
OPD
Wards
ICU
OR/RR/
DR/PACU
Imaging
Laboratory
OBSERVATION
1.There are alternative
passageways for patients
with special needs. Check
ER, OPD, wards and
other areas
2. They are prominently
marked and
3. They are free from
obstruction
ER
OPD
Wards
Other
areas
Page 11
2.2.2.
2.2.2.a
2.2.3
2.2.3.a
ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment
6.The organization uniquely
identifies all patients
including newborn infants,
and creates a specific
patient chart for each
patient that is readily
accessible to authorized
personnel.
All patients are correctly
identified by their patient
charts.
All patients are correctly
identified by their charts.
DOCUMENT and
INTERVIEW
Patient chart from ER,
ward, OPD and ICU and
verify with patient if he/she
really is the person
indicated in the chart.
ER
CHART REVIEW
Wards
OPD
Wards
ICU
ASSESSMENT
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.
7.Each patient's physical,
psychological and social
status is assessed.
An appropriately
comprehensive history and
physical examination is
performed on very patient
within 24 hours from
admission. The history
includes present illness, past
medical, family, social and
personal history.
All patients have
comprehensive history and
PE within 24 hours from
admission.
ER
DOCUMENT
Patient chart from wards
or ER.
NOTE: comprehensive
history includes present
illness, review of systems,
past medical, family and
personal history.
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Page 12
2..2.3.b
2.2.3.c
2.3
2.3.1
8.Appropriate professionals
perform coordinated and
sequenced patient
assessment to reduce
waste and unnecessary
repetition.
Previously obtained
information is reviewed at
every stage of the
assessment to guide future
assessments.
All patient charts have
progress notes by doctors.
9.Assessments are
performed regularly and
are determined by patient's
evolving response to care.
Qualified personnel give
patients for surgery preoperative physical and preanesthetic assessment.
All patients for surgery have
undergone pre-operative
anesthetic assessment.
CHART REVIEW
Medical
Records
Office
Patient chart from medical
records
Note: The progress notes
should be done regularly
and documented in the
patient chart either as
separate “progress notes”
sheet or side notes in the
doctor’s order sheet.
CHART REVIEW
Note: Look for preoperative anesthetic
evaluation in the patient
chart. Pre-operative
assessment should be
done for patients requiring
more than local
anesthesia.
IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients
10.Diagnostic examinations
appropriate to the provider
organization's service
capability and usual case
mix are available and are
performed by qualified
personnel.
[Type text]
Policies and procedures for
the standard performance,
monitoring and quality control
of diagnostic examinations
are documented and
monitored.
Proof of monitoring of the
implementation of the
policies and procedures on
quality control of diagnostic
examinations
DOCUMENT REVIEW
Monitoring reports,
e.g..utilization review of
diagnostics exams done,
audit reports, manual of
procedures, or DOH
monitoring reports e.g..
Quality control diagnostic
reports (QC reports on
softwares, calibration of
diagnostic equipment, film
reject analysis, etc.)
X-ray
Laboratory
Page 13
2.3.2.a
11.Drugs are administered
in a standardized and
systematic manner in the
provider organization.
Drugs are administered in a
timely, safe, appropriate and
controlled manner.
All drugs are administered in
a timely, safe, appropriate
and controlled manner to the
right patient
2.3.2.b
12.Drugs are administered
in a standardized and
systematic manner in the
provider organization.
Only qualified personnel
order, prescribe, prepare,
dispense and administer
drugs.
All doctors, dentists, nurses
and pharmacists have
updated licenses
2.3.2.c
13.Drugs are administered
in a standardized and
systematic manner in the
provider organization
Prescriptions or orders are
verified and patients are
identified before medications
are administered.
Proof that the prescriptions
or orders are verified before
medications are
administered.
. For the timeliness of
drug administration, check
the hospital policy. If
hospital does not have
policy, frequency of drug
administration in the chart
should be checked and
validate it thru patient
interview
Note: Surveyor may also
check for administration of
any of the following:
antibiotics,
anticonvulsants, MgSO4,
KCl drip and other drips,
calcium gluconate, sodium
bicarbonate, etc. For oral
medications, do direct
observation
Randomly check the
licenses of
doctors,dentists, nurses
and pharmacists.
Chart
Review
Wards
Pharmacy
OPD
ER
DOCUMENT
Procedures on verification
of orders. INTERVIEW
Observe if staff verifies
the prescriptions or orders
for drugs with the doctor
and the drug against the
doctor's order
Note: This is on a case to
case basis; includes the
route of administration
(slow IV) and other
precautionary
measures/instruction e.g..
ANST
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Page 14
2.3.2.d
14.Drugs are administered
in a standardized and
systematic manner in the
provider organization
INTERVIEW
Verify from patients if they
were correctly identified
prior to drug
administration.
Prescriptions or orders are
verified and patients are
identified before medications
are administered.
Medical
Records
Room
OBSERVATION
Observe if the staff
verifies the identity of
patient prior to
administration of
medications.
2.3.2.e
2.
2.4.1
15.Drugs are administered
in a standardized and
systematic manner in the
provider organization
Drug administration is
properly documented in the
patient chart.
All charts have proper
documentation of drug
administration
CHART REVIEW
Medication sheet in
patient chart from the
medical records.
.
EVALUATION OF CARE
Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the
needs of the patient are continuously met.
CHART REVIEW
16. The discharge plan is
All charts have discharge
part of the patient's care
plans
Patient chart from medical
plan and is documented in
records room, the
the patient chart.
discharge orders should
contain the ff.:
1. May go home order
2.Home medications (if
applicable)
3.Follow up
visits/schedule
4. Home care/advise
Note: Discharge plan is not
synonymous with discharge
summary.
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Page 15
2.5
2.5.1.a
2.5.1.b
LEADERSHIP AND MANAGEMENT
Management team
Goal: The organization effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health
outcomes, and is responsive to patient's and community needs.
17.The organization regularly
reviews and updates its
policies, guidelines and
procedures
18.Terms of reference,
membership and procedures
are defined for the meetings
of all committees within the
organization. Minutes of
meetings are recorded and
approved.
2.5.1.c
19.The organization's
management team regularly
assesses its own
performance and the
performance of the
organization.
[Type text]
● Strategically Posted Vision
and Mission of all the
Services
●Approved Manual of
Operations and/ or Written
Policies, Guidelines and
Procedures on Clinical
Services Offered
●Strategically Posted
Functional and
Organizational Chart with
Photos Showing Names and
Relationship by Positions
Proof of the creation of all
committees within the
organization which includes
the terms of reference for
membership
Presence of evaluation and
monitoring activities to
assess management and
organizational performance
OBSERVATION
DOCUMENT REVIEW
INTERVIEW
1. Ask the management
team about priorities for
performance improvement
that relate to hospital wide
activities and patient
outcomes
2. Ask management team
how targets are set.
Page 16
EXTERNAL SERVICES
2.6.1
20. Documented
agreements and contracts
cover external service
providers and specify that the
quality of services provided
must be consistent with
appropriate set standards.
Presence of MOA/ contract
for all out-sourced services
(e.g. dialysis unit, dietary,
laboratory, radiology).
(Outsourced are services/
facilities provided by third
party but are inside the
hospital)
DOCUMENT REVIEW
1.Contracts/MOA for
outsourced services.
2. Valid licenses of all
providers of the
outsourced services.
OBSERVATION
Actual presence of the
outsourced services within
the hospital if applicable
Document
review
Imaging
Laboratory
Other areas
Note: The contracts/MOA
should be updated. MOA
is sufficient for some
hospitals where the
outsourced services are
not within the facility.
3.1
3.1.1
3.1.1.a
Human Resource Management
Human Resource Planning
Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and
external customers and to achieve its goals.
21. Planning ensures that
Policies and procedures
The organization
Presence of policies and
appropriately trained and
for credentialing and
documents and follows
procedures for
qualified (and where relevant, policies and procedures
privileging of staff
credentialing and
credentialed) staff are
for hiring, credentialing,
privileging of staff
available to undertake the
and
privileging
of
its
staff.
type and level of activity
performed by the
organization. This includes
those who are consulted
when suitable expertise is
not available within
the organization
[Type text]
Page 17
3.1.1.b
22.Workload is monitored
and appropriate guidelines
consulted to ensure that
appropriate staff numbers
and skill mix are available to
achieve desired patient and
organizational outcomes.
Staff numbers and skill
mix are based on actual
clinical needs.
Staff to bed ratio for
licensed doctors,
registered nurses and
midwives/nursing aides
follow the DOH
prescribed ratio.
DOCUMENT REVIEW
1. List of total number
of licensed doctors and
dentists, registered
nurses and midwives/
nursing aides based on
HR records and
2. The schedule of
duties for the previous
and current month
3. Number of beds
applied for and the
actual being used.
OBSERVATION
Number of beds
4.1
4.2
4.2.1
4.2.1.a
DATA COLLECTION, AGGREGATION AND USE
Goal: Collection and aggregation of data are done for patient care, management of services, education and research.
RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.
Medical Record
DOCUMENT REVIEW
When patients are admitted
●Presence of policies and
23.Clinical records are
or are seen for ambulatory or procedures on systematic
Policies and
readily accessible to
emergency
care,
patient
filing,
retrieval,
retention,
procedures on
facilitate patient care, are
charts
documenting
any
storage,
disposal
and
systematic record filing,
kept confidential and safe,
previous care can be quickly
management of medical
retrieval. retention,
and comply with all
retrieved for review, updating records. Patient’s chart
storage, safekeeping
relevant statutory
and concurrent use.
contents include the
and maintenance and
requirements and codes
following:
disposal.
of practice
-Doctor’s Progress Notes
-Informed Consent
-Problem List
-Medication and Treatment
Record
-Laboratory and X-ray Reports
-Dietary Assessment Clinical
and Graphic Record of Vital
Signs (TPR sheet)
-Personal History and
Physical Examination records
-Newborn Record and
Physical Maturity Rating, if
warranted
[Type text]
Page 18
-Doctor’s Progress Notes
-Medication and Treatment
Record
-Laboratory and X-ray Reports
-Dietary Assessment Nurses
Progress Notes
-Records of Transfer/Referral to
another Physician or Health
Facility
-Inpatient Referral/Consultation
Notes of Other Physicians
-Final Diagnosis
-Advance Directive, if any
24.There shall be an
organized
system of processing,
analyzing, maintaining and
safekeeping of all patients'
records through the written
data in sequence of events
covering the diagnosis,
treatment and discharge of
patients.
25.Clinical records are readily
accessible to facilitate patient
care, are kept confidential
and safe, and comply with all
relevant statutory requirements and codes of practice
[Type text]
The organization has policies
and procedures and devotes
resources including
infrastructure to protect
records and patients charts
against loss, destruction,
tampering and unauthorized
access or use. Only
authorized individuals make
entries in the patient chart.
Presence of procedures to
protect records and patients
charts against loss,
destruction, tampering and
unauthorized access or use
DOCUMENT REVIEW
Note also the following:
1. ICD-10Coding is being
used.
2. Medical Records
Officer is trained on ICD10 Coding and Medical
Records Management
DOCUMENT REVIEW
Polices and procedures
on records management
for the entire hospital to
maintain privacy,
accuracy and prevent
loss and destruction.
OBSERVATION
Observe 20 nurses in the
wards and records
personnel on how they
protect patient chart
against loss, tampering
and unauthorized use.
Page 19
6.1
6x1.1
6.1.1.a
6.1.1.b
SAFE PRACTICE AND ENVIRONMENT
PATIENT AND STAFF SAFETY
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective
environment of care.
If facility has nuclear
26.The organization plans a
The organizational
medicine, ask for the
safe and effective environment
environment complies with
certificate issued by the
of care consistent with its
structural standards and
Philippine Nuclear
mission, services, and
safety codes as prescribed by
Research Institute
with laws and regulations.
law.
(PNRI).
27.The organization plans a
safe and effective environment
of care consistent with its
mission, services, and with
laws and regulations.
There are management plans
which address safety,
security, disposal and control
of hazardous materials and
biological wastes
Emergency and disaster
preparedness, fire safety,
radiation safety and utility
systems.
6.1.1.c
28.The organization plans a
safe and effective environment
of care consistent with its
[Type text]
There are management plans
for the safe and efficient use
of medical equipment
Presence of a management
plan addressing safety,
security, disposal and
control of hazardous
materials and biologic
wastes, emergency and
disaster preparedness, fire
safety, radiation safety and
utility systems.
DOCUMENT REVIEW
Management plan which
includes polices,
procedures and
programs, risk
assessment, hazards
surveillance among
others that address the
following:
1. Safety
2. Security
3. Disposal and control of
hazardous
materials/biologic wastes
4. Emergency and
disaster preparedness
5. Fire safety
6. Radiation safety
7. Utility systems
Note: The hospital must
have plans for all the
elements enumerated in
the criteria. Plans should
have guiding policies and
specific procedures.
Presence of operating
manuals of the medical
equipment.
DOCUMENT REVIEW
ER
OPD
Wards ICU OR/
DR/RR
Facilities and
maintenance
Imaging
Laboratory
Others
Page 20
6.1.1.d
mission, services, and with
laws and regulations.
according to specifications.
29.The organization provides a
safe and effective environment
of care consistent with its
mission and services, and with
laws and regulations.
Policies and procedures that
address safety, security,
control of hazardous
materials and biological
wastes, emergency and
disaster preparedness, fire
safety, radiation safety and
utility systems are
documented and
implemented.
DOCUMENT
Operating manuals for
the medical equipment
Proof of implementation of
the policies, procedures and
safety programs on
Document review
1. Water safety - water
analysis results for the past
6 months.
1. electrical safety
2. Fire and emergency
preparedness - check for
exit plans, plans for
earthquake and other
disasters.
2. medical device safety
3. chemical safety
4. radiation safety
5. mechanical safety
6. water safety
7. combustible material
safety
8. waste management
9. hospital safety program
(fire, emergency and
disaster preparedness)
3. Control of hazardous
materials - MOA/Contract
of outsourced services for
waste management
INTERVIEW
1. Ask staff from ER, Wards,
OPD, Laboratory,
Pharmacy, and facilities
and maintenance on the
manner of waste
segregation and disposal
(general waste, liquid &
solid waste, infectious
waste; non-infectious,
hazardous and nonhazardous
2. Hospital safety program
3. Mechanical safety
program of the hospital
ER
OPD
Wards
Imaging
Laboratory
Pharmacy
Facilities and
maintenance
Other areas
OBSERVATION
[Type text]
Page 21
1. Electrical safety - check
for exposed wires and
sockets, “octopus
connections"
2. Emergency
preparedness - check for
evacuation plans, presence
of fire extinguishers
3. Control of hazardous
waste - waste disposal
system, segregation of
waste, proper labeling of
waste receptacles
4. Chemical safety - check
safe storage and disposal of
reagents
DOCUMENT
1. Quality control
programs and corrective
and preventive
maintenance programs
2. Record of disposal of
radiologic wastes
3. Preventive and
corrective maintenance
logbook
4. Film reject analysis
test results
INTERVIEW
Ask staff about their role
in the hospital waste
management program
particularly manner of
radiologic waste
disposal.
OBSERVATION
DOCUMENT REVIEW
Presence of policies and
procedures for the safe and
efficient use of medical
equipment (including the
implementation of DOH
AO#2008-0021on the
gradual phase-out of
mercury)
[Type text]
ER
Page 22
6.1.1.e
6.1.1.f
30.The organization provides a
safe and effective environment
of care consistent with its
mission and services, and with
laws and regulations.
31.The organization provides a
safe and effective environment
of care consistent with its
mission and services, and with
laws and regulations.
[Type text]
Policies and procedures for
the safe and efficient use of
medical equipment according
to specifications are
documented and
implemented
The design of patient areas
provides sufficient space for
safety, comfort and privacy of
the patient and for emergency
care.
Proof of the implementation
of the policies and
procedures for the safe and
efficient use of medical
equipment.
Presence of adequate
space, lighting and
ventilation in compliance
with structural requirements
(for patient safety and
privacy).
DOCUMENT
1. Operating manual
2. Preventive and
corrective maintenance
logbook
3. Qualifications of staff
handling medical
equipment
INTERVIEW
1. Ask staff in the ER,
ICU, wards, OR/RR/DR,
facilities and
maintenance, imaging
and laboratory about the
policies and procedures
for use of medical
equipment and their role
in the implementation of
such policies and
procedures.
2. Ask staff in the ER,
wards, ICU and
OR/RR/DR for the
hospital's program on the
gradual phase-out of
mercury.
OBSERVATION
1. Adequate space
2. Adequate lighting
(lights are working,
lighting is adequate
enough for conduct of
general activities)
3. Adequate ventilation
Wards
OR/RR/DR
Facilities and
maintenance
Imaging
Laboratory
Other areas
ER
OPD
Wards
ICU
OR/RR/DR
Imaging
Laboratory
Pharmacy
Other areas
Page 23
6x1.1.g
32.The organization provides a
safe and effective environment
of care consistent with its
mission and services, and with
laws and regulations.
Risks are identified, assessed
and appropriately controlled.
Where elimination or
substitution is not possible,
adequate warning and
protection devices are used.
Presence of policies and
procedures on risk
identification, assessment
and control.
DOCUMENT REVIEW
policies and procedures
on risk identification,
assessment and control,
security risks and use of
personal protective
equipment, etc.
33. The organization provides
a safe and effective
environment of Care consistent
with its mission and services,
and with laws and regulations.
A coordinated security
arrangements in the
organization assures
protection of patients, staff
and visitors.
Presence of an appointed
personnel in charge of
security.
Hospital order or Memo.
6x1.1.h
[Type text]
Document
review
DOCUMENT REVIEW
Policies and procedures on
risk identification,
assessment and control,
security risks, use of
personal protective
equipment, etc.
or Appointment of person
in charge of security
INTERVIEW
Ask the personnel in
charge of security what
the policies on security of
the hospital are .
OBSERVATION
Presence of security
guard/s or personnel in
charge of security.
Page 24
7.1
7.1.1
MAINTENANCE OF THE ENVIRONMENT OF CARE
Goal: A comprehensive maintenance program ensures a clean and safe environment.
34.The organization routinely
An incident reporting system
Presence of incident
collects and evaluates
identifies potential harms,
reporting system/sentinel
information to improve the
evaluates causal and
event monitoring system
safety and adequacy of the
contributing factors for the
(which may include
environment of care
necessary corrective and
nosocomial infections,
preventive action.
unexpected deaths, adverse
drug reactions, flood
transfusion reactions, falls,
etc).
"Sentinel event" refers to
injuries caused by medical
management (not necessarily
the disease process) that either
caused death, prolonged hospitalization or produced a disability during the time of confinement or by the time of
discharge.
[Type text]
DOCUMENT REVIEW
●Minutes of Leadership
meeting
●Incident/sentinel event
reports or communications/memoranda/o
rders or proceedings on
sentinel events
INTERVIEW
Ask readers and staff from
wards and ER how the
incident reporting system
works.
Wards
ER
ICU
OR
Page 25
7.1.2
35. Emergency light and / or
power supply, water and
ventilation systems are
provided for, in keeping with
relevant statutory requirements
and codes of practice.
Presence of
generator/emergency light,
water system, adequate
ventilation or air
conditioning.
DOCUMENT
Preventive and corrective
maintenance logbooks
for generator/ emergency
light/ water tanks/
airconditioners .
Facilities and
maintenance
Other areas
OBSERVATION
1. Presence of
generator/emergency
light, water tanks,
adequate ventilation or
air conditioning
2. Test if faucets and
water closets are
working
7.1.3
36.Equipment is serviced only
by people trained in the
maintenance of that
equipment. Registers and
records of equipment and
related maintenance are kept.
[Type text]
Proof of training of the staff
who is in charge of the
maintenance of the
equipment.
Facilities and
maintenance
Facilities and
DOCUMENT REVIEW
Proof of training of service
personnel if in-house or
Certificate of Training,
attendance sheet,
Certificate of Attendance,
diploma, citation or
MOA/Contract for
outsourced services
(verify qualification of
technicians).
maintenance
Imaging
Laboratory
Other
areas
Page 26
7.1.4
37.Current information and
scientific data from
manufacturers concerning their
products are available for
reference and guidance in the
operation and maintenance of
plant and equipment.
INTERVIEW
Ask about how
equipment (generator,
airconditioner, medical
devices and other
equipment etc.) are
maintained.
Presence of operating
manuals equipment
DOCUMENT
Operating manual of
generators, air
conditioners and other
non-medical equipment.
[Type text]
Page 27
8.1
INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel,
visitors and trainees are identified and
8.1.1.a
38.An interdisciplinary infection
control program ensures the
prevention and control of
infection in all services.
8.1.1.b
39.An interdisciplinary infection
control program ensures the
prevention and control of
infection in all services.
Presence of an Infection
Control
Committee (ICC) with
defined goals, objectives,
strategies and priorities or
for a primary hospital - a
designated doctor and nurse
in-charge of infection
control.
Presence of an infection
control program ensuring
prevention and control of
infections on all services.
DOCUMENT
REVIEW
DOCUMENT REVIEW
1. ICC composition (for a
primary hospital - proof of
designation of a doctor and
nurse in-charge of = in2.
ICC functions and activities
fection control)
3. Minutes of meeting, at
least quarterly activities
4. Statistics on nosocomial
infections
INTERVIEW
Ask a member of the ICC
regarding infection control
program of the hospital.
DOCUMENT REVIEW
1. Policies and procedures
on prevention and control
of nosocomial infection or
Infection control manual
2. Policies on rational antimicrobial use based on the
hospital antibiogram in
coordination with
Microbiology laboratory
and Pharmacy Therapeutics
Committee
3. Reports of infection
control activities e.g.
training,outbreak
investigation,
preventive programs
[Type text]
Page 28
8.1.2.a
40.The organization uses a
coordinated system-wide
approach to reduce the risks of
nosocomial infections.
The organization takes steps
to prevent and control
outbreaks of nosocomial
infections.
Presence of coordinated
system-wide procedure for
isolation of nosocomial
infections.
Document
review
DOCUMENT REVIEW
Procedures on isolation of
nosocomial infections
INTERVIEW
8.1.2.b
41.The organization uses a
coordinated system-wide
approach to reduce the risks of
nosocomial infections.
The organization takes steps
to prevent and control
outbreaks of nosocomial
infections.
Presence of coordinated
system-wide procedure for
case containment of
nosocomial infections.
.
8.1.2.c
42.The organization uses a
coordinated system-wide
approach to reduce the risks of
nosocomial infections.
[Type text]
The organization takes steps
to prevent and control
outbreaks of nosocomial
infections.
Presence of coordinated
system-wide procedure for
asepsis.
ER
Wards
Ask= staff in ER, wards and
ICU the procedures on
isolation
isolation - physical isolation
of a patient with infection
ICU
DOCUMENT
REVIEW Procedures on
case containment of
nosocomial infections
Note: case containment
- means prevention of
spread of infection
examples: reverse isolation,
prophylaxis for exposed
personnel, vaccination,
immunization
Document
review
ER
Wards
ICU
INTERVIEW
Validate from staff in ER,
wards and ICU the
procedures on case
containment
DOCUMENT REVIEW
Procedures on asepsis
INTERVIEW
Ask staff from ER, wards,
laboratory and ICU about
the approaches for asepsis
during diagnostic and
treatment procedures.
ER
Wards
ICU
Laboratory
Page 29
8.1.3.a
43.The organization uses a
coordinated system-wide
approach to reduce the risks of
infection the staff are exposed
to in the performance of their
duties.
There are programs for
prevention and treatment of
needle stick injuries, and
policies and procedures for
the safe disposal of used
needles are documented and
monitored.
Presence of policies and
procedures on the
prevention and treatment of
needle stick injuries and
safe disposal of needles.
.
8.1.3.b
44.The organization uses a
coordinated system-wide
approach to reduce the risks of
infection the staff are exposed
to in the performance of their
duties.
[Type text]
There are programs for the
prevention of transmission of
airborne infections, and risks
from patients with signs and
symptoms suggestive of
tuberculosis or other
communicable diseases are
managed according to
established protocols.
Presence of program on
prevention of transmission of
airborne infections and risks
from patients with signs and
symptoms suggestive of
tuberculosis or other
communicable diseases .
DOCUMENT REVIEW
1. Policies and procedures
for prevention and
treatment of needle stick
injuries
2. Policies and procedures
on proper handling and
safe disposal of
sharps/needle sticks
INTERVIEW
Interview hospital staff on
how they handle and
dispose needles
OBSERVATION
Presence of receptacles for
proper disposal of sharps.
DOCUMENT REVIEW
1. Infection control
procedures on isolation
and universal precaution
2. Program for the
protection of healthcare
workers e.g. personal
protective equipment
(PPEs)
3. Policies on all patient
admission/referral,
isolation and timely case
reporting of highly
transmissible and notifiable
infectious disease e.g.
meningococcemia, SARS,
avian flu, etc.
4. Hand hygiene
procedures
5. Environmental care and
healthcare waste
management
6. Procedures on recycling
& reuse of equipment i.e.
personal protective
equipment
ER
Wards
ICU
Laboratory
ER
Wards
ICU
Laboratory
Page 30
INTERVIEW
Validate hospital policies
on infection control such as
use of PPEs, isolation
precautions and hand
washing.
OBSERVATION
1. Observe for use of
gloves, surgical masks.
OR/DR
3. Look for separate
holding area/room for
highly infectious cases.
4. Ask a hospital staff to
demonstrate hand washing
technique.
8.1.4
45.Cleaning, disinfecting,
drying, packaging and
sterilizing of equipment, and
maintenance of associated
environment, conform to
relevant statutory requirements
and codes of practice.
[Type text]
Presence of policies and
procedures on cleaning,
disinfecting, drying,
packaging and sterilizing of
equipment, instruments and
supplies. (Refer to Annex__
Sterilization Guidelines in
Hospital Setting)
Ward
ER
OR/DR
DOCUMENT REVIEW
1. Policies and procedures
on cleaning, disinfecting,
drying, packaging and
sterilizing of equipment,
instruments and supplies.
2. Policies on
decontamination,
disinfection, sterilization,
disinfectants for specific
medical equipment/items
and area.
3. Housekeeping
procedures in specific
patient areas.
Page 31
8.1.5
46.When needed, the
organization reports
information about infections to
personnel and public health
agencies.
[Type text]
Presence of policies and
procedures on reporting of
infections to personnel and
public health agencies.
DOCUMENT REVIEW
Presence of policies,
procedures and guidelines
for safe reuse of items which
comply with relevant
statutory requirements.
DOCUMENT REVIEW
INTERVIEW
Ask heads and staff about
the following:
1. Policy on reuse of items
2. SOPs on reuse
3. Reporting
4. Personnel in charge
Page 32
9.1
ENERGY AND WASTE MANAGEMENT
Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to
achieve environmental sustainability
9.1.1
47.The handling,
collection, and disposal
of waste conform to
relevant statutory
requirements and codes
of practice.
9.1.2
48.The organization
implements a waste
disposal program which
involves reuse, reduction
and recycling.
[Type text]
Presence of
licenses/permits/
clearances from
pertinent regulatory
agencies implementing
among others the
following: RA 9003, RA
6969, RA 275, PD 1586
DOH Hospital Waste
Management Manual,
RA 8749 (Clean Air Act
DOCUMENT
REVIEW
Pertinent
licenses/permits
from regulatory
agencies (LGU,
DENR, etc.)
Proof of implementation of
policies and procedures
on waste disposal.
DOCUMENT
REVIEW
1. Issuances - memos,
guidelines on waste
disposal
2. Contracts with waste
handlers or disposal
contractors, (if
applicable)
3. Hospital policy that
conforms to the joint
DOH-DENR circular on
waste management for
LGUs
1. Waste Segregation
2. Proper labeling of
waste receptacles
3. Recyclable waste
staging areas
4. Proper management
of temporary storage
areas prior to hauling for
disposal.
ER
Wards
ICU
Imaging
Laboratory
Facilities and
maintenance
Page 33
10.1
IMPROVING PERFORMANCE
Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and
meeting the needs of internal and external clients.
10.1.1
49.The organization has
a planned systematic
organization- wide
approach to process
design and performance
measurement,
assessment and
improvement
10.1.2
50.The organization
provides better care
service as a result of
continuous quality
improvement activities.
[Type text]
Presence of Quality
Improvement Program
Presence of patient
satisfaction survey
DOCUMENT REVIEW
1. Policy creating the QI
program
2. Proof of meetings or
similar documents of QA
Committee activities
3. Policies and
procedures on a
performance
measurement and
improvement
INTERVIEW
Validation of alI activities
thru interview of
pertinent staff including
frontliners and
Committee members.
DOCUMENT REVIEW
1. Patient satisfaction
survey results
2.Patient satisfaction
survey
questionnaire(may check
on the domains and
items)
Note: Look for analysis of
the results of survey;
correction, corrective
and preventive actions
done ii warranted.
Page 34
DOH
MONITORING
DOH
INSPECTION
REQUIRED CLINICAL SERVICES:
SELFASSESSMENT
CODE
REMARKS
2.1 Level 1 (With Consulting Specialists in the four major specialties plus Anesthesia)
General Medicine
General Pediatrics
Obstetrics and Gynecology
Surgery
Anesthesia
Emergency
Outpatient Service
2.2 Level 2 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus Anesthesia)
Departmentalized Clinical Care
Medicine
Pediatrics
Obstetrics and Gynecology
Surgery
Anesthesia
Emergency Service
Outpatient Service
2.3. Level 3 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus and Anesthesia and other specialties and subspecialties present).
Specialty Clinical Care
- Dept. of Medicine
- Dept. of Pediatrics
- Dept. of Obstetrics and Gynecology
- Dept. of Surgery
- Dept. of Anesthesia
- General Dentistry
Sub-specialty Critical Care
- Intensive Care
- High Risk Pregnancy care
[Type text]
Page 35
- Neonatal Intensive care
Emergency Service
Outpatient Service
Accredited Residency Training Program for Physicians in the four major
departments namely:
1. Medicine
2.
3. Surgery
4. Obstetrics and gynecology
5.
6. Pediatrics
Nursing Services:
3.1.
General Nursing ( for all levels)
3.2.
Highly Specialized Critical Care and Management in the
3.3.
following areas: (for levels 2 and 3)

Medicine

Pediatrics

Obstetrics and Gynecology

Surgery and Anesthesia
●
In areas with other Specialties (aside from the five) and
Subspecialties, there should be corresponding
Nursing care.
Ancillary Services
4.1.
 Clinical Laboratory
Category of laboratory must be Secondary for level 1, Tertiary for Level 2 And for level 3,
Tertiary with histopathology.
4.2.  Radiology
Category of Radiology must be 1st level for Level 1, 2nd level with mobile Unit for Level 2,
and 3rd level for level 3.
4.3  Pharmacy
Other Services
 Dental Services ( for all levels)
 Ambulatory Surgical Clinic (for level 3)
 Dialysis ( for level 3)
Physical Medicine and Rehabilitation Services (for level 3)
Respiratory Unit for level 2 and 3.
Verifier:
 Documents review,  Observe, Interview staff & Validate
[Type text]
Page 36
10.1.1
Medical Director/ Chief of
Hospital or Medical
Center Chief
10.1.2
[Type text]

For level 1, must have
completed at least 20
units towards a
Masters Degree in
Hospital Administration
or Related Course
AND at least 3 years
experience in a
supervisory/
managerial position

For levels 2 and
3,must have
completed a Master’s
Degree in Hospital
Administration or
Related Course AND
at least 5 years
experience in a
supervisory
managerial position
INDICATOR
DOH
MONITORING
CRITERIA
DOH
INSPECTION
POSITION STAFFING
REQUIREMENT I:
(Top Management
Positions)
SELFASSESSMENT
CODE
10.1
EVIDENCE
AREA
REMARKS
Verifier:
Documents review, 
Interview staff,
Validate:
 Diploma/ Certificate
of units earned
● Proof of
employment/appointment
Page 37
10.1.3
Chief of Clinics/Chief
Medical Professional
Services
10.1.4
Department Head
Training Officer
Chief Nurse/Director
of Nursing/Deputy
Director for Nursing
[Type text]
●For levels 2 and 3,must
be a Diplomate/ Fellow in a
Specialty area AND at least
5 years experience in a
supervisory/managerial
position
●For levels 2 and 3, must
be a Diplomate/ Fellow in a
Specialty Society of the
Specialty Department
he/she heads
●For level 3, must be a
Diplomate/ Fellow in a
Specialty Society.
●For level 1, must
have completed at
least 9 units towards a
Masters Degree in
Nursing AND at least 2
years experience in
nursing
supervisory/managerial
position
●For levels 2 and 3, must
have a Masters Degree in
Nursing AND at least 5
years experience in a
nursing supervisory
position
Verifier:
Documents review, 
Interview staff,
Validate:
 Diploma
● Proof of
employment/appointment
Verifier:
Documents review, 
Interview staff,
Validate:
●Diploma
●Proof of
employment/appointment
Verifier:
Documents review, 
Interview staff,
Validate:
 Diploma
● Proof of
employment/appointment
Verifier:
Documents review, 
Interview staff,
Validate:
●Diploma/ Certificate of
units earned
●Proof of
employment/appointment
Page 38
3.5 Administrative
Officer
10.1.5
[Type text]
For level I, must have
completed at least 20 units
towards a Masters Degree
in Hospital Administration
or Related Course
AND at least 3 years
experience in a supervisory
/managerial position.
For levels 2 and 3, must
have completed a Master’s
Degree in Hospital
Administration or Related
Course AND at least 5
years experience in a
supervisory managerial
position.
Verifier:
Documents review, 
Interview staff,
Validate:
●Diploma/ Certificate of
units earned
●Proof of
employment/appointment
Page 39
11.1
11.1.1
11.1.2
11.1.3.a
11.1.3.b
ADMINISTRATIVE
* Chief of Hospital /Medical
Director/Medical Center Chief
Administrative Officer
Clerk:
- Pool
- Accounting
1
1
1
1
1:50 beds
1
1:50 beds
1
1:50 beds
1
1
1
1:50 beds
1:50 beds
1:50 beds
11.1.5
11.1.6
11.1.7
11.1.8
11.1.9
11.1.10
11.1.11
11.1.12
11.1.14
11.1.15
11.1.16
11.1.17
Medical Records Officer trained in
ICD-10 and Medical Records
Management
Cash Clerk
Accountant
Budget /Finance Officer
Bookkeeper
Billing Officer
Cashier
Human Resource Mgt. Officer
Training Officer
Supply Officer
Storekeeper/ Linen Custodian
Laundry Worker
Utility Worker
0
1
1
1
1
1
1
1
1
1
1:50 beds
1:50 beds/shift
1
1
1
1
1
1
1
1
1
1
1:50 beds
1:50 beds/shift
11.1.18
Security Guard
1/shift
11.1.19
Engineer
1/entrance/exit
per shift
1
1/entrance/exit per
shift
1
11.1.20
Medical Equipment/Biomedical
Technician
Maintenance Personnel
1
1
1
1/shift
1/shift
Mechanic
Driver
0
3
0
3
1
4
11.1.4
11.1.1.21
11.1.1.22
[Type text]
1
0
1
1
1(designate)
1(designate)
1
1
1
1/Shift
DOH
MONITORING
NUMBER REQUIRED
DOH
INSPECTION
STANDARD REQUIREMENT FOR
PERSONNEL
SELF –
ASSESSMENT
CODE
REMARKS
Page 40
11.1.1.23
Nutritionist-Dietitian (for level 2 and in
case of sharing, must be residing within
the locality)
11.1.1.24
11.1.1.25
11.1.1.26
11.1
Cook
Food Service Worker
Food Service Supervisor
Medical Social Worker (For level 1, may
be part time but the schedule should be
specified in the MOA or Contract.)
11.2
11.2.1
11.2.2
11.2.3
11.2.4
CLINICAL:
* Chief of Clinics/Chief Medical
Professional Services
* Department Head
* Consultant Staff and Medical
Specialists in Ob-Gyn, Pediatrics,
Medicine, Surgery and Anesthesia.
(should be Diplomate/ Fellow of a
Specialty/ Sub-Specialty Society after a
formal residency training program)
* Training Officer
* Physician (must not go on duty more
than forty-eight (48) hours continuous
duty)
* Shall be Philhealth Accredited.
[Type text]
1 (sharing is
allowed e.g.
hospital and
municipal/city
government)
1
0
0
1
1:100 beds
1:100 beds
1:100 beds
1:50 beds
1
1
1:100 beds
1:50 beds
1
1
0
1
1
0
1/
department
1/
department
(number not prescribed)
0
1:20 beds at
any time plus 1
reliever
0
 50 beds = 6
Every additional
50 beds =
additional 2
1:10
beds/department
(as suggested
by specialty
boards)
1
 100 beds = 8
Every additional
50 beds =
additional 3
( For Departments
with accredited
residency training
program, number
will depend on the
requirement of
specialty board
concerned).
1:10
beds/department
(as suggested by
specialty boards)
Page 41
11.3
11.3.1
NURSING:
Chief Nurse/Director of Nursing
1
1
1
100 beds and
above=1
11.3.2
Asst. Chief Nurse (maybe
designated as
Training Officer)
0
100 beds and
above=1
11.3.3
Supervising Nurse
1:50 beds
50 beds and
below = 1,
51-100 beds =
2,
101-150 beds =
3,
151 beds and
above = 4
11.3.4
11.3.5
11.3.6
11.3.7
11.3.8
11.3.9
11.3.10
Supervising Nurse (Critical Care
Units)
-CCUs include all types of ICUs,
including Post-Anesthesia Care
Unit
(PACU) and RR
Head Nurse
Staff Nurse
-For every three (3) RNs, there
must be one (1) reliever)
Staff Nurse (CCUs)
-Base the ratio on the actual number
of occupied CCU beds at the time of
inspection
1:15 RNs
1:12 beds at any
time
Nursing Attendant/ Midwife
-Optional if the Authorized Bed
Capacity (ABC) is less than twentyfour (24) beds. If the ABC is 24
beds and above, the ratio will apply.
Nursing Attendant/ Midwife (CCUs)
-For every three (3) Nursing
Attendants/Midwives, there must be
one (1) reliever
Operating Room Nurse
1:24 beds at any
time
[Type text]
1/shift
1 per department
/special area
1 per critical
care unit
1 per critical care
unit
1:15 RNs
1:12 beds at
any time
1:15 RNs
1:12 beds at any
time
1:3 beds at any
time
1:3 beds at any
time
1:24 beds at
any time plus 1
reliever
1:24 beds at any
time plus 1
reliever
1:15 beds at
any time
1:15 beds at any
time
1/shift( may
increase
1/OR/shift( may
increase
Page 42
11.3.11
Delivery Room Nurse
1 per/shift
11.3.12
11.3.13
Emergency Room Nurse
Out-Patient Department Nurse
1/ shift
1
depending on
the average
number of OR
cases per day)
1/shift( may
increase
depending on
the average
number of
deliveries per
day)
1 shift
1
depending on the
average number
of OR cases per
day)
1/DR/shift( may
increase
depending on the
average number
of deliveries per
day)
Adequate
1/Dept/shift
1/Dept.
11.4
ALLIED MEDICAL PERSONNEL
11.4.1
Pharmacist (full-time,registered);
Adequate
Adequate
11.4.2
Pathologist
1
1
11.4.3
Med. Technologist (full-time,
registered)
Adequate
Adequate
Adequate
11.4.4
Other Lab. Personnel (specify)
Adequate
Adequate
Adequate
11.4.5
Dentist
1
1
2
11.4.6
Dental Aide
1
1
2
11.4.7
Radiologist
1
1
2
11.4.8
Radiology Technologist
Adequate
11.4.9
Radiation Safety officer
1(designate)
11.4.10
11.4.11
Physical Therapist
Respiratory Therapist( may be “on call”
for level 2)
[Type text]
1
Adequate
Adequate
1(designate)
1
0
1
1
1
Page 43
12.1
12.1.1
12.1.1.1
12.1.1.2
12.1.1.3
12.1.1.4
12.1.1.5
12.1.1.6
Level 1
Level 2
Level 3
DOH
MONITORING
STANDARD REQUIREMENT
DOH
INSPECTION
CODE
SELF –
ASSESSMENT
REQUIRED NUMBER
FINDINGS
(Indicate actual
no.
equipment
& instruments)
REMARKS
EQUIPMENT/INSTRUMENT REQUIREMENT
1.ADMINISTRATIVE
Computer with Internet Access
 Ambulance (Available 24 hours, 7 days a week
and
physically present) (Refer to A.O. 2010-0003National Policy on Ambulance Use and Services)
Standby Generator with Automatic Transfer
Switch (ATS) (KVA may depend on the load)
Emergency Light
Fire Extinguisher
Overhead Projector/ LCD
 DIETARY
Oven
Refrigerator/Freezer
Osterizer/Blender
Food Conveyor
Food Scale
Exhaust Fan
Utility Cart
Garbage Receptacle with Cover
[Type text]
1
1
1 or more
depending on the
need
1
1 or more
depending on
the need
1
1
1
1
1/station/
lobby/
stairways
1/room/unit
1
1/station/lobby/st
airways
1/room/unit
1
1/station
/lobby/
stairways
1/room/unit
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page 44
13.1
13.1.1
13.1.1.1
13.1.1.1.a
13.1.1.1.b
13.1.1.2
CLINICAL
EMERGENCY ROOM
Bag-valve-mask unit
 Adult
 Pediatric
1
1
1
1
1
1
Clinical Weighing Scale

13.1.1.3
Defibrillator
1
1
1
13.1.1.4
ECG Machine
1
1
1
13.1.1.5
EENT Diagnostic Set
1
1
1
13.1.1.6
Emergency Cart (complete with ER
Medicines.) See annex for the list and
quantity.
1
1
1
13.1.1.7
Examining Table
1
1
1
Examining Table with stirrup
Gooseneck Lamp/Examining Light
Instrument Table
Laryngoscope with Different sizes of Blades
Medicine Cabinet
Minor Surgery Instrument Set
Nebulizer
Neurological Hammer
Oxygen Unit (anchored)
Pulse oximeter
Sphygmomanometer (non-mercurial)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
13.1.1.8
13.1.1.9
13.1.1.10
13.1.1.11
13.1.1.12
13.1.1.13
13.1.1.14
13.1.1.15
13.1.1.16
13.1.1.17
13.1.1.18
13.1.1.18a
13.1.1.18b
13.1.1.19
13.1.1.20
13.1.1.21
13.1.1.22
13.1.1.23
13.1.1.24
13.1.1.25
13.1.1.26


Adult Cuff
Pediatric Cuff
Stethoscope
Suction Apparatus
Suturing Set
Thermometer (non-mercurial)
Tracheostomy Set
Vaginal Speculum Set
wheelchair
Wheeled Stretchers with guard and wheel lock
or anchored.
[Type text]
Page 45
13.2.1
13.2.1.1
13.2.1.2
13.2.1.3
13.2.1.4
13.2.1 5
13.2.1.6
13.2.1.7
13.2.1.8
13.2.1.9
13.2.1.10
13.2.1.11
13.2.1.12
13.2.1.13
13.2.1.14
13.2.1.15
13.3.1
13.3.1.1
13.3.1.2
13.3.1.3
13.3.1.4
13.3.1.5
13.3.1.6
13.3.1.7
13.3.1.8
13.3.1.9
13.3.1.10
13.3.1.11
13.3.1.12
13.3.1.13
13.3.1.13a
13.3.1.1b
13.3.1.14
13.3.1.15
13.3.1.16
13.3.1.17
13.3.1.18
OUTPATIENT CARE
1. Clinical Weighing Scale
2. ECG Machine
3. EENT Diagnostic Set
4. Gooseneck Lamp/Examining Light
5. Examining Table with wheel lock or anchor
6. Instrument Table
7. Minor Surgery Instrument Set
8. Neurological Hammer
9. Oxygen Unit
10.Sphygmomanometer (non-mercurial)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
4. C/S Set
5. Instrument Table
6. Laparotomy Set
7. Laryngoscope with Blades
8. Major Surgical Instrument Set
9. OR Light
10.OR Table
11. Ortho Instrument Set
12. Oxygen Unit (anchored)
13. Sphygmomanometer (non-mercurial)

Adult Cuff

Pediatric Cuff
14. Spinal Set
15. Stethoscope
16. Suction Apparatus
17. Thermometer, non-mercurial
1
1
Pulse
Oximeter
1
1
1
1 set
1
1
1
1
1
1
1
1
1
1
1
1
1
1/OR
1/OR
1 set/OR
1/OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
1
1/OR
1/OR
1 set/OR
1OR
1/OR
1/OR
1
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1/OR
1
17. Wheeled Stretcher
1
1
1

Adult Cuff

Pediatric Cuff
11. Stethoscope
12. Suture Removal Set
13. Thermometer, non-mercurial
13. Vaginal Speculum Set
14. Wheelchair
OPERATING ROOM
1. Air-conditioning Unit
2. Anesthesia Machine
3. Cardiac Monitor with pulse oximeter
[Type text]
Page 46
13.4.1
13.4.1.1
13.4.1.2
13.4.1.3
13.4.1.4
13.4.1.4a
13.4.1.4b
13.4.1.5
13.4.1.6
13.4.1.7
13.5.1
RECOVERY ROOM/ POST ANESTHESIA CARE UNIT (PACU)
1.
2.
3.
4.
Air-conditioning Unit
Bed with Guard Rail and wheel lock or anchor
Oxygen Unit (anchored)
Sphygmomanometer (non-mercurial)

Adult Cuff

Pediatric Cuff
5. Pulse Oximeter
6. Stethoscope
7. Suction Apparatus
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1/DR
1/DR
1/DR
1/DR
1/DR
1
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1/DR
1
1
1
1
1
1
1
1
1
1
1
1
LABOR ROOM
13.5.1.1
13.5.1.2
13.5.1.3
13.5.1.4
1. CTG Machine
2. Amniotome (Optional)
3. Sphygmomanometer (non-mercurial)
4. Stethoscope
13.6.1
DELIVERY ROOM ( IF APPLICABLE)
13.6.1.1
13.6.1.2
13.6.1.3
13.6.1.4
13.6.1.5
13.6.1.6
13.6.1.7
13.6.1.8
13.6.1.9
13.6.1.10
13.6.1.11
13.6.1.12
1. Air-conditioning Unit
3. D/C Set
4. Delivery Set
5. DR Light
6. DR Table with Stirrup
7. Foetoscope (Doppler)
8. Instrument Table
9. Kelly Pad
10.Oxygen Unit, Anchored
11.Sphygmomanometer (non-mercurial)
12.Stethoscope
13.Suction Apparatus
13.6.1.13
13.6.1.14
13.6.1.15
13.7.1
13.7.1.1
13.7.1.2
13.7.1.3
14.Wheeled Stretcher
1
15.Bassinet
1
16.Infant Weighing Scale
1
HIGH RISK PREGNANCY UNIT ( Not required in Level 1)
1. Cardiac Monitor
No need for separate
equipment if patient is
2. Suction Apparatus
placed in ICU.
3. Oxygen Unit, Anchored
4. Fetal Monitor (CTG Machine)
[Type text]
Page 47
NEONATAL INTENSIVE CARE UNIT
1. Bassinet
2. Bili Light
3. Cardiac Monitor
4. Emergency Cart
5. Umbilical Cannulation Set
6. Laryngoscope with Neonatal Blades
7. Examining Light
8. Incubator
9. Infant Bag valve mask unit
10. Infant Weighing Scale
Oxygen Unit, anchored
Respirator/Mechanical Ventilator
Radiant Warmer
Infusion Pump/Syringe Pump
Glucometer
Nebulizer
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
13..8.1.17
Pulse Oximeter
1
1
13..8.1.18
13..8.1.19
Neonatal Stethoscope
Suction Apparatus
Air-conditioning unit
INTENSIVE CARE UNIT(NOT REQUIRED IN LEVEL 1
Air-conditioning Unit
1
1
1
1
1
1
1
1
Bag-valve-mask unit
Adult (in adult units)
Pediatric (in pediatric units)
Bed with Guard Rail
Cardiac Monitor
Defibrillator
ECG Machine
Emergency Cart with emergency
Medicines(Refer to annex for medicines and
supplies)
Laryngoscope with Blades of different sizes
Endotracheal Tubes of different sizes
Oxygen Unit, anchored
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
13..8.1.1
13..8.1.2
13..8.1.3
13..8.1.4
13..8.1.5
13..8.1.6
13..8.1.7
13..8.1.8
1 13..8.1.9
13..8.1.10
13..8.1.11
13..8.1.12
13..8.1.13
13..8.1.14
13..8.1.15
13..8.1.16
[Type text]
1
1
1
Page 48
Sphygmomanometer (non-mercurial
Adult Cuff (in adult units)
Pediatric Cuff Set (in pediatric units)
Stethoscope
Suction Apparatus
Tracheostomy Set
Pulse Oximeter
Mechanical Ventilator
Infusion Pump
NURSING UNIT OR WARD
Bag-valve-mask unit
Adult (if Adult ward)
Pediatric ( if Pediatric ward)
Clinical Weighing Scale (per nursing unit)
ECG Machine
Emergency Cart or its equivalent (per
nursing unit)
Mechanical Bed/Patient Bed with Side Rails (include
beds in Critical care Areas).
(Patient beds in ER, Labor Room, and Recovery room
and bassinets are not included in the count)
Bedside Table should correspond to total beds
Laryngoscope with different Sizes of Blades
Nebulizer
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Actual bed
count should
correspond to
ABC applied
for.
Actual bed count
should
correspond to
ABC applied for.
Actual bed
count should
correspond to
ABC applied
for.
1`
1
1
1
1/Medical/
Pedia ward
1
1
Neurological Hammer
Oxygen Unit, Anchored
(may increase depending on the need)
Sphygmomanometer (non-mercurial)
Adult Cuff
Pediatric Cuff
Stethoscope
Suction Apparatus
Thermometer (non- mercurial)
CENTRAL STERILIZING & SUPPLY ROOM
1
1
1/Medical/
Pedia ward
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Autoclave ( may increase depending on
the need)
1
1
1
[Type text]
Page 49
Steam Sterilizer ( may increase depending
on the need)
0
1
1
Dental Chair Unit
Operating Stool per Dental Chair
1
1
1
1
1
1
Autoclave
Air Compressor
Dental X-ray
Mouth Mirror Explorer
Explorer, double end
Scaler jacquettes set No. 1,2,3
Low speed hand piece (angled head)
Cotton pliers
High speed hand piece with bur remover
No.150 forceps (maxillary universal forceps)
No.151 forceps (lower universal)
No.150 S forceps (primary teeth)
No. 8L and No18R forceps(upper molar)
No.151A forceps (mandibular premolar)
No.17 forceps
No.15 S forceps (lower primary teeth)
Rongeur forceps
Surgical chisel and mallet
Bone file
Surgical Scissor
Root elevator
Periostal elevator No. 9 double end
Gum Separator double end
Cowhorn forceps
Bonefile Stainless end
DIALYSIS CLINIC- Not required for Levels 1 and 2.
(Refer to AO 2012-0001 “ New Rules and Regulations
Governing the Licensure and Regulation of Dialysis
Facilities in the Philippines”
Use checklist for Dialysis facility
( Can be Hemodialysis or Peritoneal Dialysis)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 DENTAL CLINIC
[Type text]
Page 50
AMBULATORY SURGICAL CLINIC
Use checklist for Ambulatory Surgical Clinic
Level 3 should have access to CT Scan and
Endoscopy.
(With MOA, and not necessarily within the hospital
premises).
PHYSICAL MEDICINE AND REHABILITATION UNIT
Ultrasound
TENS
Electric Stimulator
Exercise plinth/bed
Overhead pulley
Exercise stair with rails
Paraffin wax
Parallel bars with postural mirrors
1
1
1
1
1
1
1
1
RESPIRATORY/PULMONARY UNIT
ABG machine
Spirometer
[Type text]
Page 51
PHYSICAL PLANTREQUIRED ROOMS AND AREAS:
LEVEL 1
LEVEL 2
LEVEL 3
•
•
•
•
•
•
•
•
•
•
•
•
Lobby
Waiting Area
Information and Reception
Communication Booth (Area for level 1)
Toilet
Admitting Office ( Area for level 1)
Medical Records Office/Room
Business Office with the following sections
Billing
Cashier
Budget and Finance
Personnel Office (may be combined with
Administrative Office for level 1)
• Office of the Admin. Officer
• Office of Chief of Hospital
• Office of the Chief of Clinics/Chief Medical
Professional Services
•
Conference and Training Room
•
Library
•
Staff Toilet
•
Property/ Supply Office /Room for level 1
 Laundry and Linen Room or Area
•
Receiving and Releasing Area
not required
•
Sorting and Washing Area
if contracted•
Pressing and Ironing Area
out.
•
Storage Area
 Engineering /Maintenance Office for Level 2
•
Maintenance Area
not required
•
Motor Pool Area
if contracted•
Housekeeping Area
out.
WASTE HOLDING /STORAGE AREA (color
coded)
[Type text]
Page 52
NUTRITIONIST-DIETITIAN OFFICE ( AREA FOR
LEVEL 1)
 DIETARY
• Supply Receiving Area
not required
• Cold and Dry Storage Area
if contracted• Food Preparation Area
out.
• Cooking and Baking Area
• Washing Area
• Serving and Food Assembly
• Dining Area
• Garbage and Disposal Area
• Toilet
SOCIAL WELFARE/SERVICE
• Social Worker’s Office
• Counselling Area
MORGUE for Level 3, Cadaver Holding Area
for Level 1 and 2
• Pathologist Office
• Autopsy Area
• Shower Area
• Toilet
CLINICAL SERVICE
EMERGENCY ROOM
• Waiting Area
• Toilet (adjacent or w/in ER)
• Nurse Station
• Examination & Treatment Area with Lavatory
• Observation Area
• Minor Operating Room
• Resuscitation Area for Level 2 and 3
• Equipment & Supply Storage Area
• Wheeled Stretcher Area
• Decontamination Area for level 3
• Holding Area for Infectious Cases
awaiting transfer to other hospital for level 1
and 2
• Doctor’s Quarter (with toilet)
[Type text]
Page 53
OUTPATIENT DEPARTMENT
•
Waiting Area
•
Toilet (accessible)
•
Admitting and Records Area
•
Consultation Area (required)
•
Examination & Treatment Area With Lavatory
OFFICE OF THE DEPT. HEADS
•
Medicine
•
Pediatrics
•
OB-GYNE
•
Surgery
•
Anesthesia
•
Emergency Medicine
OPERATING ROOM (MAY BE
COMBINED IN ONE COMPLEX WITH DELIVERY
ROOM FOR LEVEL 1)
•
Major OR
•
Minor OR
•
Sub-Sterilizing/Work Areas
•
Storage Area for Sterile Instruments
And Sterile packs
•
Storage Area for supplies
•
Scrub-up Area
•
Clean-up Area
•
Male Dressing Room and Toilet
•
Female Dressing Room and Toilet
•
Nurse Station/Work Area
•
Wheeled Stretcher Area
•
Janitor’s Closet
RECOVERY ROOM/POST ANESTHESIA CARE UNIT
May be
combined
•
Nurse’s Station with :
- Medication area
- Cabinets
- Toilet
OBSTETRICS OPERATING ROOM
(MAY BE COMBINED WITH SURGICAL
OPERATING ROOM FOR LEVEL 1)
DELIVERY ROOM
•
Transvaginal Ultrasound Room for Level 3
[Type text]
Page 54
•
Equipment and Supply Storage Area
•
Scrub-up Area
•
Clean-up Area
•
Male Dressing Room with Toilet
•
Female Dressing Room with Toilet
•
Wheeled stretcher area
•
Janitor’s Closet
HIGH RISK PREGNANCY UNIT (May be put up as
part of the Labor room or patient may be placed in
ICU)
LABOR ROOM
•
Patient bed areas
•
Toilet
NEONATAL INTENSIVE CARE UNIT
•
Work Area with Sink
•
Incubator Area
•
bassinet Areas
•
Treatment Area
•
Viewing Area
•
Breastfeeding Area with lavatory
INTENSIVE CARE UNIT
•
Nurses’ station with sink
•
Medication Area with sink
•
Patient Area
•
Toilet
NURSING UNIT/WARD
•
Medication Area w/ lavatory
•
Dressing Area
•
Equipment & Supply Storage Area
•
Patients Room/Area (Separate Male from
Female)
•
Toilet ( Separate Male & Female)
•
Utility Area
•
Linen Area
•
Toilet
•
Treatment Area
•
Internal examination area for OB-GYNE ward
•
With Color-Coded Waste Bins
•
Janitor’s Closet
•
Nursing Office; Office of Chief Nurse with toilet
[Type text]
Page 55
ISOLATION ROOM
•
•
•
•
•
Ante room with lavatory and PPE rack
Windows and doors including are
closed and air tight or leak proof
With negative pressure for infectious case and
positive pressure for immuno-compromised
cases.
Handwashing Facility/Hand Disinfection
Toilet
 DIALYSIS
CLINIC (not required in levels 1
and 2)
•
Refer to A.O. 2012-0001, “ Regulation of
Dialysis Facilities in the Philippines
AMBULATORY SURGICAL CLINIC(not required in
level 1 AND 2) –May use the hospital’s OR as long as
Policies in Sterilization and Infection Control are in
place and implemented.
•
Required rooms /areas depend on the surgical
procedures the clinic is authorized to perform.
PHYSICAL MEDICINE /REHABILITATION UNIT (not
required in level 1)
 DENTAL CLINIC
•
Dental Chair Unit A
•
Consultation room
•
Toilet
CENTRAL STERILIZING AND SUPPLY UNIT/ROOM
•
Receiving and Cleaning Area
•
Inspection Area
•
Packaging Area
•
Sterilizing Area
•
Sterile Supply Storage Area
•
Releasing Area
PRAYER ROOM/AREA
[Type text]
Page 56
41
41x1
41x1.a
CRITERIA
B.DOH Programs
Implemented in the
Hospital>
1.Blood Services
Compliance to RA 7719
and its IRR, AO 20080008 Levels 1 and 2,
should be at least a
Blood Station Facility .
• Documented policies:
 To ensure adequate
supply of safe blood
and blood products.
 blood and blood
products obtained from
blood service facilities
licensed by DOH
 for BC, blood and
blood products
collected, obtained
from healthy voluntary
blood donors only•
1.2 Level 3 hospital
should be a Blood Bank
(BB) facility
Documented policies:
 To ensure adequate
supply of safe blood
and blood products



[Type text]
INDICATORS
Actual implementation and
evidence of continuous
review of policies and
procedures
MONITORING
STANDARDS
SELF –
ASSESSMENT
DOH
INSPECTION
CODE
EVIDENCE
AREA
REMARKS
Verifier:
Documents review,
Observe
 Interview staff
Validate
Verifier:
Documents review,
Observe
 Interview staff
Validate
Blood
and
blood
products obtained from
blood service facilities
licensed by DOH
For BC, blood and
blood products are
collected/ obtained
from healthy voluntary
blood donors only
Page 57
41x2
41x2,a
2.Health Promotion
and Disease
Prevention
2.1 Newborn Screening
- Compliance to
RA9288 and it’s
IRR
Verifier:
Documents review,
Observe
 Interview staff
Validate
• Documented policies
regarding NewbornScreening
• Logbook of Newborns who
were tested and copies of
waiver for those who were not
screened
• Documented policies
regarding Rooming-In and
practice of Breastfeeding
• There should be no nursery
for normal newborns
• Breastfeeding area should
be provided at the NICU
• Certification as “Mother –
Baby Friendly Hospital”
• Certification as “Mother –
Baby Friendly
Workplace”
2.5 Immunization
(Republic Act
No. 309)
• Documented policies and
SOPs
Records of Immunizations
given to newborn:
BCG, Hepa-B Vaccine
41x5
2.4 Family Planning
• Documented policies and
SOPs specific to the program
Records of Counselling and
motivations done;
Records of Acceptors i.e.
BTL, Vasectomy, IUDs, Pills,
etc.
41x4
2.3 Healthy Lifestyle
Advocacy
41x3
41x3.a
2.2 Mother-Baby
Friendly
Hospital Initiative
- Compliance to RA
7600 and its IRR
and R.A. 10028
and its IRR
- Milk Code (EO
No. 5
[Type text]
• Documented policies and
SOPs specific to the program
Verifier:
Documents review,
Observe
 Interview staff
Validate
Verifier:
Documents review,
Observe
Verifier:
Documents review,
Observe
Verifier:
Documents review,
Observe
 Interview staff
Validate
Page 58
41x8
2.6. Anti-Smoking
Program
(per RA 9211)
• Documented policies
• No smoking signages posted
at conspicuous areas
3.Generics Act of
1988
(R.A.6675)
• Documented policies
implementing the EDPMS
in compliance with DOH
A.O. No.2008-0014”Guidelines
on the
Pilot Implementation of the
e-EDPMS and A.O. No.
2011-0012 “Implementing
Guidelines on Electronic
Drug Price Monitoring
System Version 2.0”
41x8.a
1. e-EDPMSR.A.7581”Price Act
of 1992; R.A.
9502”Universally
Accessible Cheaper and
Quality
Medicines Act of 2008”
41x9
4. Health Emergency
Management
Service(HEMS)
A.O. No. 2004-0168, “
National
Policy on Health
Emergencies
and Disasters”
41X9.a
[Type text]
Verifier:
Documents review,
Observe
 Interview staff
Validate
Actual implementation and
evidence of continuous
review of policies and
procedures; reports on
uploading of essential drug
prices, etc.
• With designated HEMS
Coordinator
• Documented Health
Emergency Preparedness,
Response and Recovery Plan
●Hospital/Office order
designating one
• Conduct of drills/exercises
i.e, Fire,Earthquake, etc. (For
fire, it should be supervised by
the Bureau of Fire Protection).
● Documentation of
drills/exercises conducted.
●Proof of implementation of
the plan.
Verifier:
Documents review,
Observe
 Interview staff
Validate
Verifier:
Documents review,
Observe
 Interview staff
Validate
● Evacuation Plan/Route
posted in every room/area
Page 59
CODE
42
C.HOSPITAL COMMITTEES:
Written
Designation of
Members and
their
roles/functions
Written Policies
and Procedure
Updated and
Relevant Minutes
of Meeting
Reports/ Records
of Implementation
REMARKS
1.Credentials
42x1
2.Blood transfusion
42x2
3.HIV/AIDS Core Team
42x3
4.Waste Management
42x4
42x5
40x6
40x7
5.Patient Safety
6.Infection Control
7.Pharmacologic/Therapeutics
428
8.Health Emergency/
Crisis Management
42x9
42x10
9.CQI
10.Tissue
(for levels 2 and 3 only)
42x11
11.Ethics
(for levels 2,and 3 only)
12.Grievance
42x12
42x13
Other committees, please
specify
Verifier: Documents review and  Interview staff
[Type text]
Page 60
SERVICES (levels 1 & 2) / DEPARTMENT (level 3)
Rehab
Anesthesia
Surgery
OR
Pediatrics
OB/ Gyne
(Delivery
Room)
OPD
43
Medicine
D.HOSPITAL OPERATIONS:
Emergency
CODE
REMARKS
1.Clinical Practice Guidelines
(CPG)
43x1
2.Recording, Reporting,
Records Keeping
43x2
43x3
43x4
3.Inter/Intra Departmental
Referrals
4.Disaster
Management/Crisis
Management
5.Infection Control
43x5
43x6
6.Drug Management and
Control
7.Blood Service
43x7
43x8
43x9
8.Pre-Operative and Post-Op
Care
9.Triaging (when applicable)
10.Referrals/ Transfer
43x10
11.Others, please specify
43x11
[Type text]
Page 61
ASSESSED BY:
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
_______________________________
Position
_______________________________
Position
_______________________________
Position
_______________________________
Date
_______________________________
Date
_______________________________
Date
_______________________________
Signature over Printed Name
_______________________________
Signature over Printed Name
________________________________
Signature over Printed Name
_______________________________
Position
_______________________________
Position
________________________________
Position
_______________________________
Date
_______________________________
Date
________________________________
Date
CONCURRED BY:
_______________________________
Signature over Printed Name
_______________________________
Position/Designation
_______________________________
Date
[Type text]
Page 62
[Type text]
Page 63