EXECUTIVE SUMMARY

This report summarizes the key findings of the audit

team on the extent of compliance of Manuel J. Santos
Hospitals Housekeeping Department with the standards for
its cleaning, laundry and linen, and transport functions
including the said departments compliance with the 5S of
good housekeeping. This report also summarizes the
recommendations of the audit team with regards to their
findings on the aformentioned functions of the said
department.
A checklist based on Manuel J. Santos Hospitals
Revised Housekeeping Department (MJSH-HK) Policy No. 332-
500 of 2014, licensed and approved by the Department of
Health (DOH) and Environmental Management Bureau (EMB),
was used by the auditors in observing the procedures for
hospital cleaning and disinfection.

Overall, the internal audit them observed that the

main problems in the hospital cleaning and disinfection
are:
1. The lack of manpower in the housekeeping department.
2. The multitasking of the institutional workers including
the housekeeping supervisor.

The audit team recommends the following for the

cleaning function of Manuel J. Santos Hospital's
Housekeeping Department:

1. Develop a Manual for Housekeeping Services.

2. Improve the cleaning checklist for occupied rooms.
3. Strictly implement personal hygiene routine practice
for housekeeping orderlies.

1
4. Standardize the policies and procedures for the use of
Personal Protective Equipment (PPE).

5. Improve the policies and procedures for waste management

from the generation, segregation, transportation and
disposal of wastes.

6. The housekeeping department should provide a cleaning

standard for building, fixture, equipment, and
environmental elements in the hospital.

A checklist based on Philippine Hospital Infection

Control Society LINEN AND LAUNDRY MANAGEMENT GUIDELINES
FOR HOSPITALS AND OTHER HEALTHCARE FACILITIES was used by
the auditors in observing the said process.
In totality, the main problem with the laundry and
linen function of the housekeeping department is that the
outsourced laundry contractor does not follow any standard
for hospital laundry and linen sanitation. All of the
laundry contractor's methods in doing the hospital's
laundry are based on personal ways since the laundry
contractors claims to have sufficient experience and
knowledge in hospital laundry. This claim, however, has no
supporting evidences like certifications of the laundry
cotractor's laundry system.

Overall, the audit team recommends the housekeeping

department to have a monthly check/visit to the outsourced
laundry contractor to assure that they are following the
set requirements for laundering linens and in order to
secure the patients health and not put them into risk due
to decontaminated linens.

2
 The audit team conducted an observation on Manuel J.
Santos Hospitals actual process of transfer of patients
within the hospital. A checklist based on Aneurin Bevan
Health Boards Guidance for the Transfer of Patients
between Wards and Departments within Hospitals was used
by the auditors in observing the said process.

The findings of the audit team shows that Manuel J.

Santos Hospital's Housekeeping Department, with regards to
its transport function, complies with almost all of the
guidelines in the given standard with an exception to the
fact that the said department does not have written
guidelines for transferring deceased patients and
transferring heavier patients and that the said department
does not have a written risk assessment plan for violence
or aggression the workplace.

The audit team recommends that the Housekeeping

Department of Manuel J. Santos Hospital, for its transport
function, should:

1. Standardize or have written guidelines for transferring

deceased patients, preferably the guidelines in the
checklist used by the auditors;

2. Standardize or have written guidelines for transferring

heavier patients, preferably the guidelines in the
checklist used by the auditors;

3. Make a risk assessment plan for violence or aggression

the workplace.

The audit team conducted an observation and

assessment regarding 5S for basic good housekeeping on
Manuel J. Santos Hospitals Housekeeping Department. A

3
checklist based on International Trade Centres 5S
Diagnostic Checklist was used by the auditors in observing
and assessing the 5S of the said department.

Substantially, the housekeeping of Manuel J. Santos

Hospital's Housekeeping Department generally complies with
the 5S of good housekeeping with some minute noncompliance
on few aspects, all attriburable to a simple "momentary
clutter".

The audit team recommends the following for the full

compliance of the said department to the 5S of good
housekeeping:
Fix the defective door of linen cabinet as soon as
possible.
Since in the department they frequently follow 5S,
maintaining cleanliness in the linen cabinets, windows and
floors under the linen cabinet must be observed.