Beruflich Dokumente
Kultur Dokumente
This tool serves as a guide for self-assessment of the health facility in preparation for
inspection/ monitoring visits.
1. GENERAL INFORMATION
Owner
Chief of Hospital/Medical Director
:
:
Classification
General
Special
[
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Government
[
]
National
Local
Others, please
specify
[
]
Single
Proprietorship
Partnership
Corporation
Civic Organization
Religious
Foundation
Others, please
specify
Private
:
:
]
]
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Page 1 of 13
Form HOS-LTO-AT/L1-2007
2. SERVICE CAPABILITY
Service Capability of a Level 1 Hospital:
2.1.1.
( if Available)
Manual of
Operations/
Written Policies
and Procedures
AVAILABILITY
Written Vision
and Mission
SERVICE
Duties and
Responsibilities
The hospital shall render quality health services appropriate to the level
of care being provided:
Master Staffing
Plan
2.2.
Organizational
Chart
2.1.
REMARKS
Administrative Service
General Administrative
Service
Records
Bookkeeping
Clerical Work
Maintenance
Patient Transport Service
(May be contracted out;
available for 24 hours)
Clinical Service
General Medicine
General Pediatrics
General Obstetrics and NonSurgical Gynecology
Minor Surgery
Emergency and Outpatient
Service
Non-surgical Gynecology involves the diagnosis and treatment of gynecologic problems through
non-surgical or medical means.
Nursing Service
Minimal Care and
Management
Health Education and
Counseling
As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the minimal or
self-care category, the patient is capable of carrying out daily activities as long as the nurse provides
the necessary materials and supplies.
Page 2 of 13
Form HOS-LTO-AT/L1-2007
AVAILABILITY
SERVICE
( if Available)
LICENSE
NUMBER
DATE
ISSUED
VALIDITY
REMARKS
Ancillary Service
Clinical Laboratory
Radiology
Pharmacy
The health facility must be affiliated with a licensed clinical laboratory and radiology facility.
A licensed pharmacy is optional.
2.3.
Hospital Operations
2.3.1.
Administrative Service
The performance of each personnel is monitored and
evaluated.
[
] Yes [
] No
New personnel receive an orientation program that covers the
essential components of the service being provided.
[
] Yes [
] No
An exit interview is conducted for personnel who resign or
retire from the service.
[
] Yes [
] No
2.3.2.
Emergency Room
Personnel to deliver emergency care are available for 24
hours.
[
] Yes [
] No
All equipment, medicines and supplies necessary to provide
emergency care are available.
[
] Yes [
] No
2.3.3.
Obstetrical Service
Proper identification of newborns is ensured before they leave
the delivery room and until discharge.
[
] Yes [
] No
2.3.4.
Nursing Service
Nursing care is provided at all times.
] Yes
] No
Page 3 of 13
Form HOS-LTO-AT/L1-2007
Medical Records
Medical records contain patient information that is uniquely
identifiable, accurately recorded, current, confidential and
accessible when required.
[
] Yes [
] No
Medical diagnoses, procedures and/or operations performed
on patients are recorded using ICD 10.
[
] Yes [
] No
ICD 10 reference books are available. [
] Yes
] No
] No
Available)
Identification Data
Chief Complaint
History of Present Illness
Physical Examination
Diagnosis/Admitting Diagnosis
Admitting/Attending Physician
Clinical Laboratory Report
X-ray Report
Consultation/Referral Notes
Medication/Treatment
Progress Notes
Final Diagnosis
Nursing Record
Discharge Summary
Obstetrical Record (if
applicable)
Consent
Doctors Order Sheet
Records of newborns are properly and completely filled up.
[
] Yes [
] No
Records of medico legal cases are properly and completely
filled up.
[
] Yes [
] No
Page 4 of 13
Form HOS-LTO-AT/L1-2007
Blood Services
The hospital ensures that its supply of blood and blood
products is safe.
[
] Yes [
] No
The hospital obtains blood and blood products only from
blood service facilities licensed/authorized by the Department
of Health (as required by R.A. 7719 National Blood Services
Act of 1994 and Its Implementing Rules and Regulations).
[
] Yes [
] No
The hospital obtains blood and blood products collected from
healthy voluntary blood donors only (as required by R.A. 7719
National Blood Services Act of 1994 and Its Implementing
Rules and Regulations).
[
] Yes [
] No
2.4.
Programs
2.4.1.
2.4.2.
Disaster Management
The hospital has a documented emergency and disaster
management plan.
[
] Yes [
] No
2.4.3.
Page 5 of 13
Form HOS-LTO-AT/L1-2007
Quality Management
The hospital has an established, documented and maintained
quality management program that reflects continuous quality
improvement principles.
[
] Yes [
] No
The program identifies the organizations quality goals,
objectives and scope; quality responsibility, authority and
resources; and quality activities and review processes.
[
] Yes [
] No
There is an exception reporting system that includes the
recording, reporting, investigation, analysis, corrective action
and review process for adverse, unplanned, or untoward
events such as:
Accidents, incidents, near misses, and adverse clinical events
[
] Yes [
] No
Complaints and suggestions
[
] Yes [
] No
Infectious / Notifiable diseases
[
] Yes [
] No
Service shortfalls
[
] Yes [
] No
3. PERSONNEL
3.1.
The health facility appoints and allocates personnel who are suitably
qualified, skilled and/or experienced to provide the service and meet
patient needs.
3.1.1.
3.1.2.
3.1.3.
POSITION
Administrative
Service
Administrator
Clerk (Accounting and
records)
REQUIREMENT
COMPLIANCE
( if Compliant)
STATUS
(FT if Full Time)
(PT if Part Time)
REMARKS
1
1
Page 6 of 13
Form HOS-LTO-AT/L1-2007
POSITION
REQUIREMENT
Utility Worker
Driver (May be
contracted out)
Clinical Service
1
1
Physician
COMPLIANCE
( if Compliant)
STATUS
(FT if Full Time)
(PT if Part Time)
REMARKS
The physician must not go on continuous duty for more than forty-eight (48) hours.
Nursing Service
Nurse
Nursing Attendant/
Midwife
For every three (3) Nurses, there must be one (1) reliever.
Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four
(24) beds. If the ABC is 24 beds and above, the ratio will apply.
For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever.
4. EQUIPMENT/INSTRUMENT
4.1.
All equipment and instruments necessary for the safe and effective
provision of services are available and are properly maintained.
4.1.1.
4.1.2.
4.1.3.
4.1.4.
4.1.5.
Page 7 of 13
Form HOS-LTO-AT/L1-2007
ITEM
REQUIREMENT
COMPLIANCE
CONDITION
( if Compliant)
( if Serviceable)
REMARKS
Administrative Service
Emergency Light
Fire Extinguisher
Standby Generator
Transport Vehicle
(Available for 24 hours)
Typewriter/Computer
Clinical Service
Ambu Bag
Adult
Pediatric
Clinical Weighing Scale
Delivery Set
Emergency Cart (or its
equivalent)
Examining Table with
Stirrup
Gooseneck Lamp /
Examining Light
EENT Diagnostic Set (or
its equivalent)
Instrument Table
Kelly Pad
Minor Surgery Instrument
Set
Neurological Hammer
Oxygen Unit
Sphygmomanometer
Adult Cuff
Pediatric Cuff Set
Sterilizer
Stethoscope
Suction Apparatus
Suturing Set
Vaginal Speculum Set
Wheelchair
Wheeled Stretcher
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
5. PHYSICAL PLANT
5.1.
All physical facilities and utility systems necessary for the safe and effective
provision of services are available and are properly maintained.
Page 8 of 13
Form HOS-LTO-AT/L1-2007
AREA
COMPLIANCE
LIGHTING
VENTILATION
( if Compliant)
( if Adequate)
( if Adequate)
REMARKS
Administrative Service
Waiting Area
Admitting and Records
Area
Administrative and
Business Office
Staff Toilet
Parking Area for
Transport Vehicle
Clinical Service
Emergency and
Outpatient
Waiting Area
Toilet (adjacent or
within ER)
Nurse Station
Consultation Area
Examination and
Treatment Area with
Lavatory/Sink
Equipment and
Supply Storage Area
Wheeled Stretcher
Area
Delivery Room
Birthing Area
Scrub-up Area
Newborn Area with
lavatory/sink
Equipment and
Supply Storage Area
Nursing Unit
Patient Room
Toilet
Nurse Station
5.2.
Environment
The hospital is:
Readily accessible to the community.
] Yes
] No
] No
Page 9 of 13
Form HOS-LTO-AT/L1-2007
Occupancy
The location of the hospital complies with all local zoning ordinances.
[
] Yes [
] No
5.4.
Safety
The hospital provides and maintains a safe environment for patients,
personnel and public.
[
] Yes [
] No
Buildings pose no hazards to the life and safety of patients, personnel
and public.
[
] Yes [
] No
Exits are restricted to the following types: door leading directly outside
the building, interior stair, ramp, and exterior stair.
[
] Yes [
] No
A minimum of two (2) exits, remote from each other, are provided for
each floor of the building.
[
] Yes [
] No
Exits terminate directly at an open space to the outside of the building.
[
] Yes [
] No
5.5.
Security
The hospital ensures the security of person and property within the
facility.
[
] Yes [
] No
5.6.
5.7.
5.8.
Patient Movement
Adequate space is provided to allow patients and personnel to move
safely around patient bed areas.
[
] Yes [
] No
Patients who use mobility aids are able to safely maneuver with the
assistance of their aid within their bed area.
[
] Yes [
] No
Page 10 of 13
Form HOS-LTO-AT/L1-2007
] Yes
] No
] Yes
] No
The hospital has available water supply that is potable and safe for
drinking.
[
] Yes [
] No
Records of water analysis (bacteriological examination) are available
and updated regularly (at least annually).
[
] Yes [
] No
Frequency
.....................................................
5.12. Waste Management
5.12.1.
Liquid Waste
Liquid waste is discharged into a multi-chamber septic tank.
[
] Yes [
] No
5.12.2.
Solid Waste
Solid waste is collected, treated and disposed of in
accordance with the Health Care Waste Management Manual
of the Department of Health, 2004.
[
] Yes [
] No
Page 11 of 13
Form HOS-LTO-AT/L1-2007
] No
5.14. Maintenance
A building maintenance program is in place to ensure that all
buildings/facilities are kept in a state of good repair.
[
] Yes [
] No
A building/facility inventory is maintained and updated regularly.
[
] Yes [
] No
Frequency
.....................................................
5.15. Material Specification
Floors, walls and ceiling are made of sturdy materials that allow
durability, ease of cleaning and fire resistance.
[
] Yes [
] No
Page 12 of 13
Form HOS-LTO-AT/L1-2007
5.16. Signage
There are visual aids and devices for:
Information and Orientation
Direction
Identification
[
[
[
] Yes
] Yes
] Yes
[
[
[
] No
] No
] No
5.17. Permits
A Permit to Construct is available for:
Construction of New Hospital (if applicable)
[
] Yes [
] No
Alteration/Expansion/Renovation of Existing Hospital (if applicable)
[
] Yes [
] No
Change in Classification (if applicable)
[
] Yes [
] No
Increase in Bed Capacity (if applicable)
[
] Yes [
] No
Page 13 of 13