inspection - level 1 hospital

8/7/2019 Inspection - Level 1 Hospital

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Form HOS-LTO-IT/L1-2007

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Republic of the PhilippinesDepartment of Health

BUREAU OF HEALTH FACILITIES AND SERVICESBuilding 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila

Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179URL: http://www.doh.gov.ph/

INSPECTION TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL

Name of Hospital :

Address of the Hospital :

1. GENERAL INFORMATION

Owner :Chief of Hospital/Medical Director :

Classification : General [ ]Special [ ]

Government [ ]National [ ]Local [ ]Others, pleasespecify

Private [ ]SingleProprietorship

[ ]

Partnership [ ]Corporation [ ]Civic Organization [ ]Religious [ ]Foundation [ ]Others, pleasespecify

Chairman of the Board (If Corporation)

:

Authorized Bed Capacity :Implementing Bed Capacity :


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LEVEL 1 HOSPITAL

Name of Hospital :


2. SERVICE CAPABILITY

2.1. Service Capability of a Level 1 Hospital:

2.1.1. Provides emergency treatment and care to the sick andinjured, as well as clinical care and management to mothersand newborn

2.2. The hospital shall render quality health services appropriate to the levelof care being provided:

SERVICE AVAILABILITY( if Available)Organizational

Chart

Master Staffing

Plan

Duties and

Responsibilities

Written Vision

and Mission

Manual of

Operations/

Written Policies

and Procedures

REMARKS

Administrative ServiceGeneral AdministrativeService Records Bookkeeping Clerical Work MaintenancePatient Transport Service(May be contracted out; available for 24 hours)Clinical Service

General MedicineGeneral PediatricsGeneral Obstetrics and Non-Surgical Gynecology Minor SurgeryEmergency and OutpatientService

Non-surgical Gynecology involves the diagnosis and treatment of gynecologic problems throughnon-surgical or medical means.


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SERVICE AVAILABILITY( if Available)Organizational

Chart

Master Staffing

Plan

Duties and

Responsibilities

Written Vision

and Mission

Manual of

Operations/

Written Policies

and Procedures

REMARKS

Nursing ServiceMinimal Care and

Management Health Education andCounseling

As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the minimal orself-care category, the patient is capable of carrying out daily activities as long as the nurse providesthe necessary materials and supplies.

SERVICE AVAILABILITY( if Available)LICENSENUMBER

DATEISSUED VALIDITY REMARKS

Ancillary ServiceClinical 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 andevaluated. [ ] Yes [ ] No

New personnel receive an orientation program that covers theessential components of the service being provided.

[ ] Yes [ ] No

An exit interview is conducted for personnel who resign orretire from the service. [ ] Yes [ ] No

2.3.2. Emergency Room

Personnel to deliver emergency care are available for 24hours. [ ] Yes [ ] No

All equipment, medicines and supplies necessary to provideemergency care are available. [ ] Yes [ ] No

2.3.3. Obstetrical Service

Proper identification of newborns is ensured before they leavethe delivery room and until discharge. [ ] Yes [ ] No


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2.3.4. Nursing Service

Nursing care is provided at all times. [ ] Yes [ ] No

Written policies for all nursing service areas within thehospital are available and reviewed annually.

[ ] Yes [ ] No

A Nursing Procedure Manual and a properly utilized Kardexare available in all patient care units.Nursing Procedure Manual [ ] Yes [ ] NoProperly Utilized Kardex [ ] Yes [ ] No

The delivery of nursing care utilizes the nursing process.[ ] Yes [ ] No

2.3.5. Medical Records

Medical records contain patient information that is uniquelyidentifiable, accurately recorded, current, confidential andaccessible when required. [ ] Yes [ ] No

Medical diagnoses, procedures and/or operations performedon patients are recorded using ICD 10.

[ ] Yes [ ] No

ICD 10 reference books are available. [ ] Yes [ ] No

The Medical Records Officer is trained in ICD 10.[ ] Yes [ ] No

A Patient Logbook is properly filled up in the following areas:Admitting Office [ ] Yes [ ] NoEmergency and Outpatient [ ] Yes [ ] NoDelivery Room [ ] Yes [ ] No

Patient Charts are properly and completely filled up andcontain up-to-date information on the following:

In-Patient Out-PatientContents of Medical Chart ( if

available)( if

Available)Identification Data

Chief ComplaintHistory of Present IllnessPhysical ExaminationDiagnosis/Admitting DiagnosisAdmitting/Attending PhysicianClinical Laboratory ReportX-ray ReportConsultation/Referral NotesMedication/TreatmentProgress Notes


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In-Patient Out-PatientContents of Medical Chart ( if

available)( if

Available)Final DiagnosisNursing RecordDischarge SummaryObstetrical Record (ifapplicable)ConsentDoctors Order Sheet

Records of newborns are properly and completely filled up.[ ] Yes [ ] No

Records of medico legal cases are properly and completelyfilled up. [ ] Yes [ ] No

Birth certificate forms are properly and completely filled up.[ ] Yes [ ] No

Death certificate forms are properly and completely filled up.[ ] Yes [ ] No

Confidentiality of patient information is maintained at all times.[ ] Yes [ ] No

2.3.6. Blood Services

The hospital ensures that its supply of blood and bloodproducts is safe. [ ] Yes [ ] No

The hospital obtains blood and blood products only fromblood service facilities licensed/authorized by the Departmentof 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 fromhealthy 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. Health Promotion and Disease Prevention

The hospital has a health promotion and disease preventionprogram that shall include the following:Breastfeeding (as required by R.A. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] NoFamily Planning [ ] Yes [ ] NoImmunization [ ] Yes [ ] No


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Newborn Screening (as required by R.A. 9288 Newborn Screening Act of 2004 and Its Implementing Rules and Regulations) [ ] Yes [ ] NoRooming-In (as required by R.A. 7600 The Rooming-In and Breastfeeding Act of 1992) [ ] Yes [ ] No

2.4.2. Disaster Management

The hospital has a documented emergency and disastermanagement plan. [ ] Yes [ ] No

2.4.3. Human Resource Development

The hospital implements a human resource developmentprogram that identifies, plan, facilitate and record training andeducation for all personnel. [ ] Yes [ ] No

An appraisal system identifies and reviews the effectivenessand appropriateness of the training provided.

[ ] Yes [ ] No2.4.4. Quality Management

The hospital has an established, documented and maintainedquality management program that reflects continuous qualityimprovement principles. [ ] Yes [ ] No

The program identifies the organizations quality goals,objectives and scope; quality responsibility, authority andresources; and quality activities and review processes.

[ ] Yes [ ] No

There is an exception reporting system that includes therecording, reporting, investigation, analysis, corrective actionand review process for adverse, unplanned, or untowardevents such as:Accidents, incidents, near misses, and adverse clinical events

[ ] Yes [ ] NoComplaints and suggestions [ ] Yes [ ] NoInfectious / Notifiable diseases [ ] Yes [ ] NoService shortfalls [ ] Yes [ ] No


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LEVEL 1 HOSPITAL

Name of Hospital :


3. PERSONNEL

3.1. The health facility appoints and allocates personnel who are suitablyqualified, skilled and/or experienced to provide the service and meetpatient needs.

3.1.1. Each personnel is qualified, skilled and/or experienced toassume the responsibilities, authority, accountability andfunctions of the position. [ ] Yes [ ] No

3.1.2. Professional qualifications are validated, including evidenceof professional registration/license, where applicable, prior toemployment. [ ] Yes [ ] No

3.1.3. An organized medical and nursing staff shall be responsiblefor the quality of patient care and for the ethical conduct and

professional practices of its members. [ ] Yes [ ] No

POSITION REQUIREMENT COMPLIANCE( if Compliant)

STATUS(FT if Full Time)(PT if Part Time)

REMARKS

AdministrativeServiceAdministrator 1Clerk (Accounting and records)

1

Utility Worker 1Driver (May be contracted out)

1

Clinical ServicePhysician 1 at any time plus

one (1) reliever

The physician must not go on continuous duty for more than forty-eight (48) hours.


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POSITION REQUIREMENT COMPLIANCE( if Compliant)

STATUS(FT if Full Time)(PT if Part Time)

REMARKS

Nursing ServiceNurse 1:12 beds at any

timeNursing Attendant/ Midwife

1:24 beds at anytime

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.


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LEVEL 1 HOSPITAL

Name of Hospital :


4. EQUIPMENT/INSTRUMENT

4.1. All equipment and instruments necessary for the safe and effectiveprovision of services are available and are properly maintained.

4.1.1. Records of equipment are maintained and updated regularly.[ ] Yes [ ] No

4.1.2. A preventive maintenance program ensures that allequipment are maintained and/or calibrated to an appropriatestandard or specification. [ ] Yes [ ] No

4.1.3. There is a plan in place for essential equipment replacement.[ ] Yes [ ] No

4.1.4. Personnel are competent when using equipment in line with

manufacturers instruction/operational manual. [ ] Yes [ ] No

4.1.5. Operational manuals of all equipment and instruments areavailable for reference and guidance. [ ] Yes [ ] No

ITEM REQUIREMENT COMPLIANCE( if Compliant) CONDITION

( if Serviceable) REMARKS

Administrative Service

Emergency Light 1Fire Extinguisher 1Standby Generator 1Transport Vehicle (Available for 24 hours)

1

Typewriter/Computer 1Clinical ServiceAmbu Bag Adult 1 Pediatric 1


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ITEM REQUIREMENT COMPLIANCE( if Compliant) CONDITION

( if Serviceable) REMARKS

Clinical Weighing Scale 1Delivery Set 1Emergency Cart (or its equivalent)

1

Examining Table withStirrup 1

Gooseneck Lamp / Examining Light

1

EENT Diagnostic Set (or its equivalent)

1

Instrument Table 1Kelly Pad 1Minor Surgery InstrumentSet

1

Neurological Hammer 1Oxygen Unit 1Sphygmomanometer 1 Adult Cuff 1 Pediatric Cuff Set 1Sterilizer 1Stethoscope 1Suction Apparatus 1Suturing Set 1Vaginal Speculum Set 1Wheelchair 1Wheeled Stretcher 1

Others (Please specify)


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LEVEL 1 HOSPITAL

Name of Hospital :


5. PHYSICAL PLANT

5.1. All physical facilities and utility systems necessary for the safe and effectiveprovision of services are available and are properly maintained.

AREA COMPLIANCE( if Compliant) LIGHTING

( if Adequate) VENTILATION( if Adequate) REMARKS

Administrative ServiceWaiting AreaAdmitting and RecordsAreaAdministrative andBusiness OfficeStaff ToiletParking Area for

Transport VehicleClinical ServiceEmergency and Outpatient Waiting Area Toilet (adjacent or

within ER) Nurse Station Consultation Area Examination and

Treatment Area withLavatory/Sink

Equipment andSupply Storage Area

Wheeled StretcherArea

Delivery Room Birthing Area Scrub-up Area


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AREA COMPLIANCE( if Compliant) LIGHTING

( if Adequate) VENTILATION( if Adequate) REMARKS

Newborn Area withlavatory/sink

Equipment andSupply Storage Area

Nursing Unit Patient Room Toilet Nurse Station

5.2. Environment

The hospital is:Readily accessible to the community. [ ] Yes [ ] No

Free from undue noise, smoke, dust, foul odor, flood.

[ ] Yes [ ] No

Not located adjacent to railroads, freight yards, childrens playgrounds,airports, industrial plants, and waste disposal plants.

[ ] Yes [ ] No

5.3. 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, personneland public. [ ] Yes [ ] No

Exits are restricted to the following types: door leading directly outsidethe building, interior stair, ramp, and exterior stair.

[ ] Yes [ ] No

A minimum of two (2) exits, remote from each other, are provided foreach 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 thefacility. [ ] Yes [ ] No


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5.6. Lighting and Ventilation

Areas used by patients and personnel are adequately lighted andventilated. [ ] Yes [ ] No

5.7. Exposure to Environmental Tobacco Smoke

Patients and personnel are not put at risk by exposure toenvironmental tobacco smoke. [ ] Yes [ ] No

Smoking is absolutely prohibited throughout the hospital in accordancewith R.A. 9211 Tobacco Regulation Act of 2003. [ ] Yes [ ] No

5.8. Patient Movement

Adequate space is provided to allow patients and personnel to movesafely 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 [ ] NoDoorways, corridors, elevators and turning areas readily accommodatethe bed, attached equipment and any escorts of patients who require tobe transported or transferred between rooms or services in their beds.

[ ] Yes [ ] No

Corridors in areas not commonly used for bed, stretcher andequipment transport are at least 1.83 Meters in width.

[ ] Yes [ ] No

A ramp or elevator is provided for ancillary, clinical and nursing

services located on the upper floor. [ ] Yes [ ] No

DOH licensed facilities shall be given until end of 2010 to comply.

5.9. Auditory and Visual Privacy

Adequate privacy for patients is provided such that sensitive or privatediscussion, examination, and/or procedure are conducted in a manneror environment where these cannot be observed or the risk of beingoverheard by others is minimized. [ ] Yes [ ] No

5.10. Power Supply

The hospital has an approved power supply system.[ ] Yes [ ] No

5.11. Water Supply

The hospital has an approved water supply system.[ ] Yes [ ] No


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The hospital has available water supply that is potable and safe fordrinking. [ ] Yes [ ] No

Records of water analysis (bacteriological examination) are availableand updated regularly (at least annually). [ ] Yes [ ] NoFrequency .....................................................

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 inaccordance with the Health Care Waste Management Manualof the Department of Health, 2004. [ ] Yes [ ] No

The hospital observes segregation, coding and labeling ofwaste.Black Trash Bag(General Non-Infectious Dry) [ ] Yes [ ] NoGreen Trash Bag(General Non-Infectious Wet) [ ] Yes [ ] NoYellow Trash Bag(Infectious Pathological) [ ] Yes [ ] NoSharp Container(Sharps) [ ] Yes [ ] No

Logbook Available and Updated [ ] Yes [ ] NoFrequency .....................................................

Protective equipment and clothing appropriate to the risksassociated with the handling, storage, and disposal of wastesare provided to and used by personnel. [ ] Yes [ ] No

5.13. Sanitation

The hospital observes pest and vermin control:In-House [ ] Yes [ ] NoContractor [ ] Yes [ ] NoCompany Name .....................................................

Memorandum of Agreement is available and updated.[ ] Yes [ ] No

Frequency .....................................................

Records are available and updated. [ ] Yes [ ] NoFrequency .....................................................


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There are screen wires on doors, windows, and other openings.[ ] Yes [ ] No

5.14. Maintenance

A building maintenance program is in place to ensure that allbuildings/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 allowdurability, ease of cleaning and fire resistance. [ ] Yes [ ] No

5.16. Signage

There are visual aids and devices for:Information and Orientation [ ] Yes [ ] NoDirection [ ] Yes [ ] NoIdentification [ ] Yes [ ] No

5.17. Permits

The hospital maintains current licenses and permits to ensure safe andeffective operations. [ ] Yes [ ] No

A Permit to Construct is available for:

Construction of New Hospital (if applicable) [ ] Yes [ ] NoAlteration/Expansion/Renovation of Existing Hospital (if applicable)[ ] Yes [ ] No

Change in Classification (if applicable) [ ] Yes [ ] NoIncrease in Bed Capacity (if applicable) [ ] Yes [ ] No

For New Hospital (Secured for Initial License)

TYPE AVAILABILITY( if Available) DATE

ISSUED REMARKS

Building Permit (includingPlumbing, Electrical andMechanical Permits)Fire Safety PermitFire Safety InspectionCertificateSanitary PermitHealth CertificateCertificate of OccupancyWater Source AnalysisReport


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ORFor Existing Hospital (Secured for License Renewal on a Yearly Basis)

TYPE AVAILABILITY( if Available) DATE

ISSUED REMARKS

Annual BuildingInspection CertificateFire Safety Inspection

CertificateSanitary PermitHealth CertificateWater Source AnalysisReport


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LEVEL 3 HOSPITAL

Name of Hospital :


PERSONS INTERVIEWED:

Printed Name and Signature Position

SURVEYED BY:

Printed Name and Signature Position

DATE ___________________________ TIME ___________________________

inspection - level 1 hospital

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