operations in hospital

7/25/2019 Operations in Hospital

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A MANUAL

OP R TIONS

FOR

SM LL

HOSPIT LS

Prepared

by

the

Committee to Develop a Manual of Operations for Small Hospitals


2/99

Registration and Issuance of License to Operate

T LE OF CONTENTS

Minimum Standards for Primary Category

LICENSING REQUIREMENTS

PART HOSPITAL CONSTRUCTION

6

7

2

5

6

4

4

7

5

7

44

24

Page o

I

~ l l l I l I l l l l i l ~

ep rtmenl orHealth

D 4

H ~ 8 4 7 M 3 h

992 A manualof optmltlons for m hospitals

Nursing Service

Clinical and Ancillary Services

Administrative Service

Patient Care Facilities

Basic Service Facilities

Physical Plant Facilities

Permit to Construct

Basic Hospital Services

Classification

Category

Definition of Terms


PART II HOSPITAL OPERATIONS

INTRODUCTION

FOREWORD

ACKNOWLEDGEMENTS

7


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APPENDICES

Office Order Creating the Committee to Develop a Manual of

Operations for Small Hospitals

Procedures 1 to 7

BLR Form 1: Application for Permit to Construct a Hospital

Letter to Hospital Owner Informing Approval of Permit to

Construct Expand or Renovate

BLR Form 4: Application for Registration and Issuance of

Renewal of License to Operate a Hospital

BLR Form 4 A: Statistical Report

BLR Form 4 B: List of Technical Equipment and Instruments

License

Medical Records Disposition Schedule


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It

is my hope that hospital managers and health workers make good

use of this carefully-crafted document designed to upgrade the quality of

hospital care for the millions of Filipinos who encounter the need for

treatment at these vital health facilities.

A critical facet in the nation s healthcare scheme is the system of

small hospitals scattered throughout the Philippines. These tacilities fill

a vital niche for specialized health services needed by small communities

in both urban and rural settings. Even as the government s thrusts on

Primary Health Care will greatly contribute to the prevention of disease

it is necessary to have in place well-equipped scphisticated health

facilities constantly prepared to respond to any contingency that may

arise.

SAN LAZAROOOMPOUND

RIZALAVENUE STA CRUZ

M NIL

PHIUPPINES

TEL

O

711 6 8

FOREWORD

Republic

of

the Philippines

eportment of Health

OFFI E OF

THE

SE RET RY

In this regard the Department of Health is mandated to support

these initiatives through establishing the appropriate conditions for small

hospitals to effectively function and serve their respective communities.

This

anual of

Operation for Small ospitals will assist owners.

administrators or operators of these

est blishments

in their

d ily

management and in maintaining the high standards set by government and

demanded by the populace. At the same time this manual will assist

operators in meeting the requirements on registration and licensure set by

tile government for these hospitals.


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JUA

~ S I

M.D.

Under ecretary of Health for

Hospital and Facilities Services

The pollcles. procedures and guidelines outlined in this manual will assist the

practicing hospital administrator in the day to day decision making process

necessary to operate an effective and efficient hospital. We urge the small-

hospital administrator to consult this manual as often as needed in order to

answer the many administrative questions which arise in the daily operation of

delivering quality patient care to a diverse opulation in need of hospital ser-

vices.

The Bureau of Licensing and Regulation of the Department of Health has

developed this

Manual of Operations for Small Hospitals

to serve as a guide to

hospital administrators of small hospitals especially those in rural areas. This

manual was developed during the period

1990 91

under the leadership and

direction of the former Undersecretary of Health for Standards and Regulation

Dr. Tomas

P

Maramba

Jr.

The information which follows is the work of a multi-

sectoral committee which received input and advice from a variety of sources

including the Philippine Hospital Association the Philippine College of Hospital

Administrators and the Private Hospital Association of the Philippines.

SANL Z RO OMPOUND

RIZAL AVENUE STA. CRUZ

MANILA PHILIPPINES

T l NO. 711 6080

FOREWORD

Republic

of

the Philippines

ep rtment of Health

OFFICE OF

THE SECRETARY

This manual is a revision and update of the

Manual of Information on Philip-

pine Hospital Licensure Standard uide for Philippine Hospital Services

originally issued by the Bureau of Medical Services in December 1965. The

contents of this manual refer to existing standards of the Department of Health

at the time of formulation and do not include any new standards after that date.

Consequently some of the items are for information only and the user will want

to check with the Department for any recent changes or additions. The

process of devolution will also bring about even more changes in the future

which will dictate new regulations and the development of new standards.

However we believe that the operating hospital administrator will find the infor-

mation contained in this manual of value and we have pushed for the publica-

tion of this manual at this time.


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KNOWLEDGMENTS

This anual Operations for Small ospitals was developed with the help

coordination and administrative support of various health agencies associa-

tions and individuals to cope with the changing community needs.

The Committee wishes to express sincerest thanks to Dr. Alfredo R. A.

Bengzon former Secretary of Health and to

Dr

Tomas

P

Maramba Jr.

former Undersecretary of Health for Standards and Regulation for their en-

couragement and wholehearted support in the preparation and finalization of

this manual during their term in office.

Several people were generous with their time and expertise; they deserve

much credit for their wisdom and sound advice but are not to be held account-

able for the end product:

Dr

Thelma N. Clemente President Philippine Hospi-

tal Association; Dr. Yolanda M. Mison Executive Director Philippine Hospital

Association; Marco Antonio C. Sto Tomas and Grace M. Valderama of the

Philippine Nurses Association; Ador A. Abueg and Ma. Theresa H. Gutierrez of

the Bureau of Food and Drugs; Agnette

P

Peralta of the Radiation Health Ser-

vice; Dr. Teresita R. Sanchez of the Philippine Academy of Family Physicians;

Dr. Ruben N. Caragay of the

U P

College of Public Health; Luis M. Ferrer of

the Hospital Infrastructure Services; Teresita G. Yambao of the DOH National

League of Nurses; Dr Amelia Fernandez of the Philippine Pediatric Society; Sr.

Paz T. Marfori D.C. of San Juan de Dios Hospital; Dr. Marietta Baccay of the

Bureau of Research and Laboratories; Velonia A. Corpus of the Nutrionist As-

sociatlon of the Philippines;

Dr

Narciso Navarro of the Private Hospital Associa-

tion of the Philippines; Dr Siopin Co of the Philippine Society of Hospital Phar-

macists; and Dr. Delfin Tan of the Philippine College of Hospital Administrators.

The Committee is likewise indebted to Dr. Primo V. Brillantes Jr. Chief of

Hospital III Jose

R

Reyes Memorial Medical Center for the use of their

facilities and resources.

Special thanks also go to the technical staff of the Hospital Operations and

Management Services for their valuable contributions in the making of the

Manual.


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astly to the Bureau of Licensing and Regulation staff who acted patiently as

secretariat typing the manuscript in its various phases of revision our

deepest thanks

R ZEN I R E

L

FUENTE

hairman

ommittee to evelop a Manual of

Operations for Small Hospitals


8/99

INTRO U TION

The Bureau of Licensing and Regulation

BLR

was created by Ex

ecutive Order No. 119, which reorganized the Department of

Health to improve the licensing and regulation of health care

facilities and make the delivery of public service more efficient and

effective. The Bureau is mandated to:

Formulate policies and establish standards for the licens

ing and regulation of hospitals, clinics, and other health

facilities

Establish standards for health field offices

Provide consultative, training and advisory regulatory

functions over hospitals, clinics, and other health facilities.

Small

hospitals evolved in considerable number especially in far

flung areas when in the mid 70 s the Philippine Medical Care Corn

mission started the implementation of the Medicare Program.

Most of the small hospitals are run by physicians, nurses, phar

macists, or businessmen, many or most of whom have not taken

hospital administration. This often leads to problems in regula

tions.

This anual of Operations for Small ospitals intends therefore

to provide guidelines not only to help minimize problems on

registration, licensure, and operations of primary hospitals but,

more importantly, to educate the non-professional small hospital

manager.

EFINITION OF TERMS

ospital is defined by the Expert Committee on Organiza

tion of Medical Care of the World Health Organization

thus: the hospital, the function of which is to provide

for the population complete health care, both curative

and preventive and whose outpatient services reach out

to the family in its home environment; the hospital is also

a center for the training of health workers and for bioso

cial research.

1


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L SSIFI TION

linical

eneral Hospital - provides services for all kinds of ill

nesses, diseases, injuries, and deformities.

Special Hospital -

provides services for one particular

kind of illness/disease or health and medical care.

Examples:

Hospitals are classified in many ways, but the most commonly ac

cepted classifications are:

Clinical, that is, depending on the type of patients treated

According to ownership and control

Whether training and nontraining

Internal Medicine

Tuberculosis

Children Pediatric

Communicable Disease

Medicine

For the purpose of this manual, however, the term hospi-

tal as defined by Republic Act No. 4226, otherwise

known as the Hospital Licensure Law of the Philippines,

shall refer to a place devoted primarily to the main

tenance and operation of facilities for the diagnosis, treat

ment, and care of individuals suffering from illness, dis

ease

or deformity, or in need of obstetrical or other

medical and nursing care. The term hospital shall also

be construed as any institution, building, or place where

there are beds or cribs or bassinets for 24-hour use or

longer by patients in the treatment of diseases, diseased

condition, injuries, deformities, or abnormal physical and

mental states, maternity cases, and all institutions such

as those for convalescence, sanatorial or sanitariaI

cases, infirmities, nurseries, dispensaries, and such other

names by which they may be designated.

Small Hospital covers all primary category, general hospi

tals, usually with less than twenty beds and providing

basic services such as: Administrative Service, Clinical

Service, and Nursing

Service

rug Room - a room for storing emergency drugs only,

which could be dispensed by a doctor.


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overnment -

operated and maintained either partially or

wholly by the National, Provincial, Municipal, or City

Government or other political subdivision, board, or other

agency thereof.

Examples:

City

Municipal

Private or ongovernmental -

privately owned, estab

lished, and operated with funds raised, capital, or other

means by private individuals, associations, corporations,

religious organizations, firms, companies, or joint stock

associations.

Examples:

Missionary

Civic Organizations

Community

Private - nonprofit

Private - for profit

Surgery

Maternity

Chronic

Convalescent

wnership and ontrol

National

Regional

Provincial

Eye, Ear, Nose and Throat

Orthopedic, etc.

Office of the President

Department of Health

Department of National Defense

Armed Forces

Government Corporation


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Training Nontraining

Training a departmentalized hospital with accredited

residency training program in one or more specified

specialty or discipline.

ontraining

a nondepartmentalized hospital without ac-

credited residency training program.

C TEGORY

Hospitals have been categorized into primary secondary and ter-

tiary

v s

of health care according to service capabilities that

they offer.

rimary equipped with the service capabilities needed

to support licensed physicians rendering services in

Medicine Pediatrics Obstetrics and Minor Surgery.

Secondary equipped with the service capabilities

needed to support licensed physicians rendering ser-

vices in the fields of Medicine Pediatrics Obstetrics and

Gynecology General Surgery and Ancillary Services.

Tertiary a fully departmentalized hospital equipped with

the service capabilities needed to support certified medi-

cal specialists and other licensed physicians rendering

services in the fields of Medicine Pediatrics Obstetrics

and Gynecology Surgery their subspecialties and Ancil-

lary Services.

N U ST ND RDS FOR PRIM RY C TEGORY

Administrative Service

Clinical Services

General Medicine

General Pediatrics

Obstetrics

Minor Surgery

Nursing Service


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SIC HOSPIT L SERVICES

dministrative Service This shall attend to the admis-

sion disposition and discharge of patients including

financial transactions and other administrative aspects of

hospital operations such as the provision of food and

preservation of medical and administrative records.

Clinical and ncillary Services The physicians shall

render services in General Medicine Pediatrics

Obstetrics and Minor Surgery. Routine laboratory ser-

vices shall be available either within the hospital

premises or by affiliation.

Nursing Service This service shall be headed by a

registered nurse and shall provide professional nursing

care at all times.

I


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Part I HOSPIT L CONSTRUCTION

As provided under the Hospital Licensure Act R A 4226 and its

implementing Rules and Regulations Administrative Order No. 68-

A series of

1989 ,

no hospital, whether government or private,

shall be constructed or renovated unless plans have been ap-

proved and a construction permit has been issued by the Bureau

of Licensing and Regulation, Department of Health. A permit to

construct is a requirement for an initial license to operate.

The following are the requirements to be fulfilled before a permit

to construct may be issued:

A letter of application from the owner addressed to the

Director, Bureau of Licensing and Regulation through the

Regional Health Director

Feasibility study

Floor plans of the physical plant of the proposed hospi-

tal, three copies in blueprint

An endorsement letter from the Regional Health Director

to the Director, Bureauof Licensing and Regulation.

The application shall be filed at the proper Regional Health Office

which shall endorse it to the Bureau of Licensing and Regulation.

It is important that all the above requirements are complied with.

Otherwise, the application shall be returned without action to the

owner through the Regional HealthOffice.

PERMIT TO CONSTRUCT

Any person, association, partnership, corporation, or government

entity desiring to construct, remodel, or repair a hospital building

shall file with the Bureau of Licensing and Regulation an applica-

tion for a construction permit using the prescribed form BLR

Form I which shall be accompanied by three copies of the floor

plans of the hospital plant proposed to be constructed,

remodeled, or repaired.


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The construction permit shall be issued by the Bureau of Licens-

ing and Regulation upon approval of the floor plans and payment

of the permit

f

Other building permits as required from other

government agencies shall be obtained.

Construction shall start within the time specified in the construc-

tion permit and shall follow the approved floor plan and specifica-

tions. A new construction permit is required if the original permit

was revoked due to violation of its terms and conditions or the

same expired before the construction could be started.

PHYSI L PL NT F ILITIES

hysical lant Any structure put to use to house or

provide direct services to patients shall conform with the

requirements prescribed by the Bureau of Licensing and

Regulation and those of local building codes applicable

thereto.

echanical and Structural Requirements New or

remodeled hospital facilities shall not be licensed by the

Bureau of Licensing and Regulation unless the following

requirements have been complied with :

Plans and Specifications

Construction of the new

building or floor remodeling shall not be undertaken

unless plans have been previously approved by the

Bureau of Licensing and Regulation. The floor plans

for any new hospital construction or any proposed

annex of an existing hospital and for remodeling pur-

poses which involve physical changes shall be sub-

mitted for approval. Said approval shall be obtained

from the licensing agency before construction work is

begun. Such floor plans shall be prepared by an ar-

chitect or a civil engineer who is licensed to practice

in the Philippines. Floor plans and specifications for

any new hospital or for changes in an existing hospi-

tal shall show that all necessary considerations have

been given to ensure proper functional relationship of

physical facilities.

General Requirements

In order that a permit to

construct a hospital may be issued the hospital plan

shall provide sufficient space as provided for in the re-

quirements.


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Walls floor, and ceilings of the hospital shall be of

sturdy materials, which shall permit frequent wash

ing, cleaning, and painting.

The hospital shall be adequately ventilated at all

times. Kitchens, bathrooms, and service rooms

shall be ventilated by properly constructed vents,

windows, or other mechanical means to prevent of

fensive odors from entering rooms of patients and

public corridors. Window screens shall be

provided for all other exterior openings whenever

necessary.

- Ventilation -

Provision shall be made for adequate

ventilation to ensure comfort and safety of patients

and personnel in every hospital.

Kitchen and toilets, service and utility and storage

rooms, and janitors closets and the like shall be

properly ventilated in compliance with requirements.

- lumbing -

All

parts of the plumbing system shall

comply with the existing rules and regulations

prescribed by the Office of the City or Provincial or

Municipal Building Official and other local plumbing

codes or ordinances.

- Water Supply System -

Each hospital shall use an

approved public water supply system whenever

avail-

able

The water service shall be adequate and water

supply shall be brought into the building free of cross

connections in accordance with the requirements

prescribed by the Office of the City or Provincial or

Municipal Building Official. If a private deep or shal

low well) water supply is provided, the requirement

prescribed by the Office of the City or Provincial Build

ing Official likewise shall be complied with.

- Sewage isposal System -

Hospital sewage shall be

discharged into an approved public sewerage system

where such system is available, otherwise, the

sewage shall be collected, treated, and disposed of in

an independent system septic tank type) which com

plies with requirements prescribed by the Office of the

City or Provincial or Municipal Building Official and

local ordinances and the Sanitation Code of the


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Philippines. Separate toilet facilities shall be main

tained for patients and personnel, male and female,

with a ratio of 8 to 10 patients/personnel for every

water closet. This shall be conveniently located in the

area served.

-

lectrical nstallations

- The installation of the electri

cal system and equipment shall comply with all local

ordinances relative thereto and with the National

Electrical Code, as well as those herein provided:

All equipment and installations shall be acceptable

as established by the Fire Department.

Emergency lighting shall be provided for exits,

stairs, patient corridors, emergency rooms and

similar areas as necessary for safe and efficient

patient care Emergency lighting shall be supplied

by an emergency generator or its equivalent.

All rooms and areas in the hospital shall be

provided with sufficient illumination to enable per

sonnel to properly carry out procedures per

formed therein.

- Solid Waste Management - All hospitals shall have a

program of solid waste management covering sorting,

storage, pre-treatment, collection, and disposal sys

tems.

All hospital infectious solid waste shall be

pretreated in any approved method before

storage, collection, and disposal.

Proper sorting of solid waste sharps, syringes,

linens, mattresses from isolation/infectious wards

must be done, segregating it from the general

waste.

Separate puncture-proof refuse containers proper

ly labelled and with covers must be assigned to

prevent any accident or contamination before dis

posal.

9


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Disposal shall be done either through burying, in

cineration or through city or other collecting agen

cy.

SIC SERVICE F CILITIES

Hospital basic service facilities shall include the following:

dministrative Service

Lobby with information counter

Admitting Office

Director s/Chief of Hospital s administrative office

Toilet facilities

Clinical and ncillary Services

Emergency Room

Examination/treatment Room

X-ray room optional)

Laboratory optional)

Emergency drug cabinets

Toilet facilities

Nursing Service

Nurses station with toilet facilities

Male ward

Female ward

Isolation ward

P TIENT C RE F CILITIES

All patient care areas and units shall be segregated from those

used by the public.

ursing nits - All nursing units shall have the following

facilities:

- Nurses Station Counter


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- Medicine Area

Fixed and locked narcotic storage facilities

Refrigerator for drugs

- Utility Facilities

Clean linen storage area

Soiled linen storage area

Lavatory

Sterilizing equipment

Treatment rea -

Area for patient treatment is re

quired in all hospitals.

Patient Rooms

- The design and equipment of patient

rooms shall be similar for all types of patients.

The maximum number of patient rooms planned for a

nursing unit shall depend on the type of patients to

be served and the plan of operation as well as other

matters.

The minimum amount of usable floor space required

shall be as follows:

For private rooms:

9 sq. m. per adult bed

7.5 sq. m. per crib or pediatric bassinet

For rooms with two or more beds:

7.5 sq. m. per adult bed or pediatric crib

4 sq. m. per pediatric bassinet

Note: It is recommended that the area and design

of the room be such as to provide 91 m. of usable

floor space.)


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Lavatories

Lavatories

shall

be in each patient s room or its adjoin

ing toilet room.

Any room used for isolation shall have a lavatory

within the room.

A lavatory

shall

be provided in toilet rooms used

by patients who give self care or which are used

for isolation.

One lavatory shall be provided for every eight beds.

Toilets -

These shall be required for rooms which do

not have adjoining ones. These shall be made avail-

able within 30.3 m.

1

feet distance from the far-

thest patient room served by such toilets. ,

Patient Bathing Facilities -

These shall be provided in

each patient unit according to the type of patients

served and procedures planned.

Janitor s Closet -

This shall be provided within the

nursing unit.

Storage Areas -

The space required depends on the

plan of operation. All nursing units shall have space

to store a reserve supply of linen and other things.

Corridors and service work areas shall not be used

for storage.

Personnel Toilets -

These shall be in or near each

nursing unit with adequate hand washing facilities.

Public Toilets -

These are required for nursing units

adjacent to public areas and shall have adequate

space and handwashing facilities.

Floor Waiting Area -

The desirability of this area is de

pendent on the plan of operation and size of the

hospital. In small hospitals this area may be com

bined with the lobby.

Gowning Area -

This is required in contagious nursing

units only.


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- It shall have an emergency drug cabinet.

Storage area Refrigerator, upright, reach-in

Bins for rice)

Receiving area Weighing scale, table model 10

kg.)

Food preparation area Utility table/work table

Hand sink

Chopping board

Garbage receptacle with cover

Kawa

30 -diameter), cast-iron

finish

10-gallon stock pot 2)

Top burners

2

Work tables

ink

2 compartments

13

Cooking area

tsolstion Facilities -

There shall be available isolation

facilities for patients who are known to have infectious,

communicable diseases, and for burn cases. The isola

tion facilities shall be provided with all utility and other

services required to carry out isolation techniques. Such

facilities shall be designated for isolation and shall be

available for use whenever necessary.

Emergency are Facilities -

Provisions shall be made for

an emergency room which may be combined with out

patient service.

- The emergency room shall be so equipped as to

provide whatever lifesaving measures may be needed

for the patients.

- It shall have a toilet with lavatory within or in close

proximity to it.

ietetic Service Facility -

For primary hospitals this ser

vice is not a requirement. A kitchen will suffice wherein

food for inpatients are prepared/dished out. However if

. the hospital opts to have one, the following shall be

provided:

Areas Equipment/Supplies


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- Screened windows and doors

Provisions shall be made for:

- Adequate ventilation

Chopping boards

Hood with filter and suction fan

Exhaust fan

Sink, 24 deep at least two

compartments)

Shelves/racks for pots and

pans drying and storage)

fus

receptacle with cover

Tray assembly area

Food carts screened, if not

metal made or finish)

Utility carts

Hand sink

Soiled dish table

Clean dish table

Utility rack for tray storage)

Garbage can with cover

Dishwashing area

Serving area

Pots and pans

_ eneral Service reas - There may be provided a

waiting area or room for patients awaiting service.

_ Laboratory Service -

This shall be provided through

affiliation with a nearby licensed laboratory. However,

if the hospital opts to provide such service within the

hospital premises, it has to obtain a license from the

Bureau of Research and Laboratories. A minimum of

18.5 - 20.9 sq. m. for exclusive washing and steriliz

ing area should be provided.

- Adequate drainage system

Facilities for ncillary iagnostic and Treatment Ser-

vices -

These are not included in the standards for

primary category hospitals. However, if the hospital opts

to have such services, they should be located con

venient to both inpatient and outpatient areas.

The following are required :


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- Radiological Service -

This shall be provided

through affiliation with a licensed x-ray facility.

However, if the hospital opts to provide such service

within its premises, it has to obtain a license from the

Bureau of Licensing and Regulation upon recommen

dation by the Radiation Health Service.

- Pharmacy Service -

In the absence of a pharmacy

service, an emergency drug cabinet kit shall be

provided. However if the hospital opts to provide

such service it has to obtain a license from the

Bureau of Food and Drugs and comply. with its re

quirements.

- Examination and Treatment Rooms -

All hospitals

shall at least have one all-purpose room for examina

tions, treatment, etc.

eneral Service acilities - Facilities for service units

may be provided and shall include the following:

Employee

F ~ i i t i e s - These may include a rest

room/lounge area with locker facilities and separate

toilets for female and male employees.

-

Laundry

-

Laundry facilities required in the hospital

will depend on whether hospital laundry is operated

within the hospital premises or commercial services

are utilized.

Housekeeping

This should include a

housekeeper s Office may be part of another ser

Vice

lavatory, storage room for supplies and equip

ment), and other facilities that may be required for the

type of service rendered. The amount of space

provided for this service shall depend on the person

nel assigned and the volume of work.

-

Maintenance

-

There should be a maintenance

shop/area in each hospital.

REGISTR TION ND ISSU N E OF LI ENSE TO

OPER TE

Section 4 of

A.A.

4226 provides that no hospital shall operate or

be opened to the pubtic unless it shall have been registered and


23/99

a license for its operation shall be obtained from the Bureau of

Licensing and Regulation, Department of Health.

nitial icense to Operate

In the issuance of the initial license to operate, there are proces-

ses involved. First after completion of the hospital bUilding the

hospital owner shall accomplish and file R form NO.4 applica-

tion for Registration and Issuance of License to operate a hospi-

tal. Next, a written request for an ocular inspection of the finished

hospital shall be submitted to the Bureau of Licensing and

Regula-

tion authorities with the prescribed requirements please see

annex procedure and checklist no. 2 . The Regional Licensing Of-

ficer has to certify that the hospital is ready for inspection. Finally

the license shall be issued if the application has been found to be

meritorious and the licensure fee duly paid.

The license specifies its bed capacity as well as its classification

and kind of service/capabilities provided, and is not transferable.

Should there be a change in ownership, management, or name of

the hospital, the licensing agency shall be notified.

The license to operate a hospital shall be placed in a con-

spicuous place readily seen by the public.

Renewal of icense to Operate

The license to operate and maintain a hospital shall be renewed

annually and shall expire on the last day of December. A transfer

of location shall require an application for a new license.

Separate licenses are required for hospitals operating in separate

premises not in the same compound even if they are under the

same ownership or management.

To renew a license, the hospital owner accomplishes and files

R

form

No

between January 2 and March 3 of each year.

For the requirements please see annex checklist 3. There is a

penalty for renewal of licenses filed after March 31.

A provisional license shall be granted to hospitals for three to six

months pending full compliance with all the necessary require-

ments and standards governing their operations.


24/99


Part II HOSPITAL OPERATIONS

ADMINISTRATIVE SERVICE

The administration of the hospital is the responsibility of the

governing body, the Administrator, and Representatives of the

medical

st ff

The Governance

The governing body, owner, or board of trustees, is the top

authority responsible for the management and control of the en-

tire institution, including employment of a hospital administrator

and appointment of members of the medical staff. In the case of

the Department of Health, it shall be the responsibility of the

Secretary of Health or his duly authorized representative.

If the governing body is composed of more than one person, it

shall be organized as a corporate body to conduct hospital affairs.

The governing body assumes responsibility for the management

and control of the hospital. Evidence that the governing body is

assuming this responsibility shall be:

That a written set of goals and policies duly promulgated

and updated by the governing body is in the hands of

the Administrator updating means review and revision

as the need arises .

That the responsibility and authority of the hospital ad-

ministrator have been written and are known to persons

working in the hospital.

That the reports of hospital operations including services

provided and results thereof in the care of the patients,

are reviewed at least once a year by the governing body.

That provisions have been made to safeguard the assets

of the hospital to insure its continuing operation.


25/99

That provisions have been made for the close relation-

ship between the hospital and the community and the

various health or welfare agencies.

The Medical Staff should review the medical records of patients.

It

should audit the medical care plans of the attending physicians

permitting only those that are acceptable.

The ospital dministrator

The Administrator/Director is responsible for planning organizing

directing coordinating and controlling hospital operations except

medical care. In the case of the Department of Health it is the

Director or Chief who is designated to carry out its policies. He

shall be expected under licensing rules and regulation to carry

out the responsibilities of the executive office which are listed as

follows:

Formulation and writing in clear statements of:

The goals or ends to be attained by the hospital

The goals or ends to be attained by each service in

terms of what the service is to produce its contribu-

tion to other services and its place in the total hospi-

tal program; and

Basic guides for attaining the established goals and

dissemination of goals.

Development with the assistance of hospital personnel

and the medical staff of a program of patient care and

hospital operation in line with the needs of patients

served.

Establishment and maintenance of an organizational

structure for the hospital which clearly defines the

authority and responsibilities of various positions and

their relationship and which should be communicated

reviewed and revised as the need arises.

Provision of an effective method of communication be-

tween the various elements in the hospital organization.

Maintenance of a written record of all business transac-

tions and patient services rendered and submission of

reports to the governing body. Effectiveness of hospital

operations

s ll

be measured in terms of the expected

results of patient care rendered.

8


26/99

Development of long-range plans for the continuing im

provement of the hospital.

Provision of the administrative control of the entire hospi

tal during the absence of the hospital administrator.

Preservation and protection of patients and personnel

against hazards and contagious diseases including:

- The checking of all patients admitted as deemed

necessary by the medical staff to insure that con

tagious diseases are made known for appropriate

measures to prevent its spread and to eradicate it;

- Pre-employment and periodic physical and laboratory

examination are deemed necessary as well as daily

observation of all personnel having direct or indirect

contact with patients; and

- Development of policies on the administration treat

ment and diagnostic procedures in cooperation with

the medical

staff

Provision of orientation and follow-up training for all

hospital personnel.

Establishment and maintenance of a plan for emergency

operation of the hospital to provide for the safety and

well being of inpatient in case of fire explosion or other

disaster occurring within the hospital as well as for the

care of casualties.

dministrative olicies

Hospital personnel are expected to maintain proper

decorum at all times in their relationship with patients

relatives and with each other.

Management shall see to it that all employees are given

proper orientation and training in the performance of

their assigned work.

All employees are required to obey the lawful instructions

of their supervisors connected with the performance of

their duties.

Administration shall establish a system of

recr uitment

selection and placement of employees on the basis of


27/99

fitness to perform the duties and responsibilities of the

position.

Management shall provide its personnel with reasonable

protection against unreasonable demands harassments

and physical harm.

The hospital management reserves the right to change

revise or amend hospital rules and regulations as the

need arises and any such changes or amendment there-

to shall become effective after proper dissemination to all

concerned.

Hospital administration is not responsible for any loss of

patients valuables.

Administration/management is tasked to direct and coor-

dinate the activities of the medical staff as well as all the

activities of the hospital to ensure efficient and judicious

delivery of hospital services based on its objectives.

Coordination and teamwork among hospital personnel

shall serve as a common approach to attain overall

goals and objectives.

The tasks of every employee shall be clearly spelled out

and mutually understood reasonably quantified and ac-

tual performance shall be regularly evaluated.

All patients shall immediately be attended to upon arrival

giving preference to emergency cases and/or seriously ill

patients.

Clinical and nursing care shall be made effective via the

following provisions:

_ Clear written hospital policies including reasonable

rates.

_ Emergency room logbooks and protocols treatment

and physical examination consent emergency room

and outpatient consultation forms.

_ Well understood and well written discharge advice

and instructions.

_ Forms for reporting/recording medico legal and report-

able diseases.

Complete and uniform in patient records.


28/99

- Equipment and instruments to comply with the

Bureau of Licensing and Regulation requirement.

Management shall ensure maintenance of ade

quate facilities, equipment, and supplies necessary

for good patient care for the nursing unit.

Management shall provide an environment that is

conducive to the physical, spiritual, and emotional

well being of patients and personnel.

ietetic Unit

This unit is not a requirement. However, if the hospital opts to

have one, for hospitals less than 20 beds, the cook acts as

marketer/menu planner and is the informal leader in the dietetic

unit, under the direct supervision of the Administrator or Medical

Director, assisted by two food service workers

FSW

or utility

workers. While it may not be required that a nutritionist-dietitian

be employed in a 10- to 15-bed hospital, it is, however, recom

mended that such hospital must try to consult, coordinate, and

avail itself of the services of a nutritionist-dietitian in a nearby

secondary category hospital, through its networking system.

Policies

The food budget shall be sufficient to provide nutritionally

adequate and palatable diets, and food served shall be

regularly evaluated to meet these ends.

Personal hygiene and proper food handling practice of

dietetic personnel shall be such as to ensure that the

patients receive

safe,

clean, and wholesome food.

Pertinent safety practices, including the control of electri

cal, flammable, mechanical, and appropriate radiation

hazards must be observed.

The dietetic unit shall be designed and equipped to

facilitate the

safe,

sanitary, and timely provision of food

service to meet the nutritional needs of patients includ

ing garbage disposal, dishwashing and general cleaning,

transport of food .

The quality and appropriateness of nutritional care

provided by the dietetic unit shall be regularly reviewed

and evaluated.

ep rtment of ealth

1I11111 1I 1Ii II 11

21

D 4

H l 8 4 ~ 3 1 h


29/99

Meals shall be provided to patients in accordance with a

written order by the responsible medical practitioner. Ap

propriate dietetic information shall be recorded in the

patient s medical records by the nurse in charge.

The hospital should have a standard diet manual or

guide to be used by the medical staff in diet ordering

and the staff in fulfilling the diet orders.

ospital Maintenance Unit

The main function of this unit is to create a pleasant and comfort

able safe and clean physical environment for patients

employees medical staff and general public by maintaining and

servicing utilities such as light water power garbage system

and security. The hospital as a whole and its various parts in

cluding fixtures

w lls

floors ceilings and furnishings shall be

well-maintained.

oli ies

It shall have a space for repair and maintenance.

It shall have the required number of personnel depend

ing on the size and needs of the hospital. There shall be

a definite assignment of maintenance functions to

qualified personnel.

t shall plan and supervise security refuse collection and

disposal and insect and rodent control.

Provision shall be made for periodic inspection and

repair of hospital plant and equipment by qualified per

sonnel. Insofar as possible repair shall be made prior

to breakdown so that plant operation and patient care

shall not be jeopardized.

Instructions for operating and maintaining equipment

shall be made available to maintenance personnel.

Operating and maintenance record shall be kept and

analyzed periodically.

Hospital maintenance may be on contractual basis.

ousekeeping Unit

The housekeeping unit shall be responsible for the maintenance

of a clean and healthful environment within the hospital premises.


30/99

t

shall ensure an environment conducive to the recovery of

patients The hospital including fixtures w lls floors ceiling and

furnishings shall be kept clean and free of vermin and rodents

The housekeeper together with the nursing staff may participate

in the formulation of hospital policies and guidelines to prevent

the occurrence of nosocomial infection

Policies

The hospital shall formulate standard procedures in the

sanitation and cleanliness of the different patient care

units

The assignment and scheduling of institutional

workers/janitors sh ll take into consideration the needs

of the patient care units for 24 hours

Janitorial cleaning supplies and equipment shall be

provided in sufficient amount and type required to ade-

quately care for the hospital

There shall be a definite assignment of housekeeping

functions preferably to one who has had institutional ex-

perience Such person shall provide immediate super-

vision over his/her staff

inen and aundry Unit

Every hospital has the responsibility of providing sufficient linen to

ensure the comfort of patients and safeguard them from infec-

tions and communicable diseases transmitted through linen The

minimum amount of linen required will vary with the number and

type of patients cared for the time required to process linen and

return to use and other factors

For small hospitals of less than 20 beds the standard manpower

complement includes one laundry worker The Nursing Service

has the added responsibility of providing these specific functions:

Determine the utilization processing life span of linen:

Develop a system to provide adequate and continuous

supply of linen required for patient care and other hospi-

tal units

Ensure efficient collection of soiled linen from and dis-

tribution of clean linen to the different units of the hospi-

tal


31/99

Conduct periodic inventory of linen materials in wards

and in stock.

Project linen requirements yearly or as the need arises,

including budgetary requirements.

Change bed linen as often as necessary.

The minimum requirement of at least four sets of linen

per bed or bassinet shall always be made available.

CLINICAL AND ANCILLARY SERVICES

Clinical Service Patient Care

The primary role of the hospital is to care for the sick and injured.

Other important functions are subordinate although recognized as

part of the responsibility of the institution insofar as they con-

tribute directly or indirectly to patient care. The existence and

viability of the small hospital is dependent on the immediate com-

munity it serves.

The secondary role is to be a relevant link in a network of clinical

care and public health services either as a referring unit or an end

unit. As a referring unit, it refers to the next higher level facility

which is accessible within an hour away by usual means of

transportation). However, when a small hospital is so situated

geographically that the nearest higher level facility is more than an

hour for emergency and/or critical cases) to four hours for non

emergency and/or elective cases)

w y

it then assumes the role

and function of an end unit which would render the needed ser-

vices.

Comprehensive patient care shall essentially be com-

posed of the activities of the patient s physician and

hospital personnel to meet specific needs of the patient

for diagnosis, treatment, rehabilitation, disease preven-

tion, and personal care. Its purpose is to cure or al-

leviate the effects of disease, injury, or disorder and to

promote a positive state of health, restoring the patient

to constructive living in consideration of his disability as

well as abilities and capacities.

Patterns of hospital organization shall provide the neces-

sary mechanism for the promotion of unity of purpose

and efforts by physicians and hospital personnel. If

necessary, control measures shall be instituted to bring

about teamwork among them.


32/99

The contents of a plan for patient care shall include the

following:

- Goals and objectives of care or what is to be ex

pected as a result of given care;

- Basic principles of care including several procedures

that the staff need to perform in carrying them out;

- Specific roles of each discipline and the means of

maintaining the necessary relationships between them

in giving care; and

- Means of determining and planning the care needs of

individual patients.

The small hospital has the following specific roles and functions:

To cater to the clinical care needs of the community it

serves.

- To render diagnostic and therapeutic services.

- To deliver emergency services to patients in terms of

evaluation/diagnosis/emergency room care and treat

ment and be able to either transfer admit or send

home patients after four to eight hours emergency

room stay at most.

To give 24-hour inpatient medical and nursing care

not ordinarily available for the following categories of

cases:

Cases which need one to seven days of confine

ment and general medical care.

Cases which need to be isolated and cared for by

a general practitioner or practitioner of family

medicine.

Cases which are very critical and cannot be trans

ferred.

Cases admitted during disasters.


33/99

Cases which need to be transferred to the next

higher accessible facility within eight to twenty four

hours.

Cases which cannot be referred right away and

need to be clinically stabilized first.

To be a relevant part of a health care delivery system as

an end unit or as a referring unit.

To acquire competencies and provision for delivering

relevant primary care services.

To have written policies procedures records of its

delivered clinical services. This shall include patient

data in the emergency room/outpatient department

OPD , wards and laboratory. There shall be ad-

ministrative records for the purpose of determining

the nature and cost of patient services and for

monitoring feedback to management government

regulatory and professional bodies.

To have procedures and forms for communicating

with and relating to other parts of the network and the

community at large.

The medical staff is responsible for the quality of medical care

provided and for submitting reports on the quality of care

provided to the governing board of the hospital at frequent inter-

vals.

While the governing body of the hospital is the final

authority as regards the administrative aspects of hospi-

tal operation it must be recognized that all elements in

the hospital including the medical staff have important

contributions to make in the area of Administration and

should be accorded a voice.

The complexity of the modern hospital requires a team

approach concept in hospital administration and opera-

tion if the best patient care is to be provided. The wide

array of services and personnel required to meet the

needs of patients today necessitates that a program of

patient care be developed for the various categories of

patients cared for. .

26


34/99

ncillary ervices

dmitting Service Unit

Provision shall be made for the admission of patients to

the hospital in accordance with their needs. and due

regard for their safety and well-being. Admitting person

nel shall not only get personal information on patients

but also on the nature and needs of other patients and

the services available in each nursing unit.

- Specific policies for the admitting service shall be as

follows:

Information about patients including an admitting

diagnosis clinical condition and their personal

characteristics shall be submitted to the admitting

service before or at the time of admission of

patients to the hospital. Physicians and nursing

service personnel shall recommend placement of

patients in the hospital in accordance with

patients needs and facilities available.

Admitting procedures shall be adapted to patients

needs. Patients shall be admitted in such a way

as to insure others against transmission of dis

e ses

Patients having or suspected of having com

municable diseases shall be assigned to beds in

such a place where transmission of diseases or in

fection of other patients or personnel could be

prevented. Any such transmission or infection

shall be promptly reported to the authorities con

cerned.

Mothers who deliver outside of the hospital s

obstetrical unit may however be admitted

provided that they are housed in a way as to

separate them from other patients.

Working arrangements with other services in the

same hospital shall be made to insure that all

patient s needs are properly met.


35/99

Hospital rules and regulations and admitting proce-

dures shall be made available at all times for the

use or reference of personnel.

Admitting personnel shall be given orientation train-

ing and kept informed of policy or procedure chan-

ges affecting their work from time to time.

The discharge of hospital patients shall be as follows:

Patients shall be discharged only upon written

order of the attending physician.

The attending physician shall be required to enter

in the summary sheets his final diagnosis of the

given case with a brief summary and final

progress note and affixes his signature thereon.

When the discharge order. is duly signed by the

physician the nursing and admitting units shall be

promptly notified.

In case of death of a patient a statement to that

effect

s ll

be entered in the progress notes of the

chart including the final diagnosis and the cause

of death duly signed by attending physician. The

nurse in charge of the ward shall notify the admit-

ting unit prepare the body and inform the rela-

tives of the deceased patient.

Policies for clinical care are as follows:

There shall be competent medical and nursing

staff supported by adequate logistics to handle

routine outpatient and inpatient needs.

There shall be a 24 hour physician staff that can

provide diagnosis and appropriate treatment of

emergency cases.

edical ecords

is said that good medical records generally imply good

medical care. Inadequate medical records often reflect

poor medical care. For this reason the medical record

is selected as one of the yardsticks to be used in


36/99

measuring the quality of medical care rendered by a

hospital and its medical staff.

They shall serve as basis for planning patient care

provide means of communication between physicians

and other professional groups contributing to patient

care furnish documentary evidence on the course of the

patient s illness and treatment and serve as basis for

review

study and evaluation of medical care rendered.

The function of the Medical Records Unit is to keep and

preserve all charts and records pertinent to the stay of

the patient in the hospital and to make the charts and

records easily available to authorized persons at all times.

For primary hospitals of less than 20 beds the standard

manpower complement includes at least one medical

records clerk. In some hospitals the medical records

clerk may be assigned other administrative functions.

- Functions of the Medical Records Unit

eceive classify analyze codify and file charts

and records of patients.

Keep and maintain all charts and records of treat

ment of patients and make them easily available

only to authorized persons.

Maintain and update patient s index death

registry and registry of admissions and dischar

ges. Accurate and complete medical records shall

be maintained on all patients from the time of ad

mission to the time of discharge. There should

be space for retrieval of records.

Prepare and issue medical birth and death certifi

cates.

Prepare periodically statistical reports of the hospi

tal as required.

- Policies

An accepted method shall be established within

each hospital for recording data. All records shall


37/99

be part of the hospital records system. No medi

cal record

s ll

be permanently filed until it is com

. pleted.

The completion of the medical records shall be

the responsibility of the attending physician. Or

ders for treatment and all reports shall be legibly

entered into the medical record either in ink or

typewritten and signed by the physician. The com

pleted medical record including signature of attend

ing physician shall be forwarded to the records

area/room within 24 hours following the patient s

discharge from the hospital.

A trained medical records clerk or any other

responsible hospital employee shall be given the

responsibility for the proper custody supervision

filing and indexing of completed medical records

of all patients discharged from the hospital. He

will also prepare medical statistics and reports.

Medical records shall be made available for inspec

tion by any authorized representative of the

Bureau of Licensing and Regulation.

Confidential information obtained from medical

records shall be furnished only on the written

authority of the patient or executor of his estate or

his attending physician. Such authorization shall

be kept on file together with the patient s record.

All previous records shall be made available for

the use of the physician attending a readmission

case.

- Content of Medical Records - All medical records

shall contain the following information:

Identification data

Chief complaint

Present illness

History and physical examination - Only physicians

are competent to write or dictate medical histories


38/99

and physical examinations. Nurses medical

records clerk or secretaries shall not be permitted

to take medical histories.

Provisional diagnosis - There shall be a provisional

or admitting diagnosis made on every patient at

the time of admission.

Clinical laboratory reports - The original signed

laboratory report shall be entered in the patient s

record. Duplicates are filed in the laboratory and

reports from laboratories outside the hospital shall

be acceptable in lieu of tests performed in the

hospital if the examination was performed in a

licensed laboratory. As the hospital shall be held li

able for the quality of laboratory work reported in

the medical record the hospital shall limit outside

laboratory work.

X-ray reports - The original report signed by the

radiologist shall be entered in the patient s record.

Consultations - Consultations shall imply an ex

amination of the patient and patient s record. The

consultation note shall be recorded and signed by

the consultant.

Medical and surgical treatment - All treatment pro

cedures shall be documented in the medical

record.

Progress notes - Progress notes give a chronologi

cal picture and basis of analysis of the clinical

course of a patient and shall be made at a fre

quency as determined by the condition of the

patient.

Final diagnosis - A definite final diagnosis shall be

written as part of the patient s records.

Nursing record - Nursing records on patient charts

shall include a graphic chart of vital signs such as

temperature pulse and respiration blood pressure

readings intake and output reports as indicated

medications and treatments given and nursing ob

servations or nursing notes.

31


39/99

Discharge summary - A summary of the patient s

condition on discharge shall be required a

recapitulation of the patient s hospitalization.

Obstetrical records - All obstetrical records shall

in addition to other required records include

reports on the following:

Past obstetrical history of the patient s previous

pregnancy.

Admission of obstetrical examination describing

condition of mother and fetus.

Complete description of the progress of labor

includinq reasons for induction or operative pro

cedures if any signed by the attending

physician.

Anesthesia analgesia and medication given.

Signed report of a qualified obstetrical consult

ant when such service was obtained.

Names of assistants present during parturition.

Condition of infant one hour after delivery.

Progress notes including involution of the

uterus type of lochia and condition of breasts

and nipples.

Records of the newborn - Records of newborn in

fants are required to form part of patient s whole

medical record and shall include the following:

Date and time of birth birth weight and length

and period of gestation.

Parents name and address.

Description of complications of pregnancy or

delivery if any inclUding premature rupture of

membranes condition at birth such as color

quality of cry and method as well as duration

of resuscitation.

32


40/99

{ Record of instillation into each eye at delivery

as prophylaxis.

{

Report of initial physical examination including

any abnormalities signed by the attending

physician.

{ Progress notes including weight and feeding

charts temperature number consistency

color of stools condition of eyes and umbilical

cord condition and color of skin and motor be-

havior.

{ Physical examination on discharge.

{ Recommendations and signature of attending

physician.

Forms

The Bureau of Licensing and Regulation shall

evaluate medical records on the basis of contents

and form that each hospital shall find useful and ac-

ceptable for their purpose.

A short form medical record which contains informa-

tion that will specifically identify the patient is accept-

able in certain treatment and diagnostic cases of a

minor nature which require less than 48 hours

hospitalization.

Ownership

The medical record is the property of the hospital and

shall be maintained for the benefit of the patient the

physician and the hospital itself. It shall be the

responsibility of the hospital to safeguard the informa-

tion on the record of each patient against loss

tampering or use by unauthorized persons.

Preservation of Medical Records

The medical records of hospital in patients shall be

kept for a reasonable length of time usually 25 years

for clinical and scientific purposes after discharge or


41/99

death. Disposition thereof after the specified period

may be made pursuant to provision of law.

In hospitals where the use of medical records for

scientific purposes is limited and the rate of read-

missions is low as well as where the needs of

medical staff and patients are adequately met and

protected by retention of medical records for less

than 25 years a 10 year period of retention is con-

sidered minimum. After said period the same

may be disposed of pursuant to legal provisions

provided the hospital retains an index registry or

summary card of such basic information as iden-

tification data of patient date of admission and dis-

charge name or responsible physician and

record of diagnosis and operation.

Hospital Records

Each hospital shall maintain the following hospital

records:

Daily census

Register of admissions and discharges

Register of outpatients

Register of births

Register of deaths

Register of operations

Narcotic register and

Emergency room admissions.

Reports

llhospitals shall comply with laws ordinances rules

and regulations which provide for the registration of

births and deaths and the reporting of communicable

diseases.


42/99

rivate

hospitals shall submit quarterly and annual

reports on patient statistics and hospital operations to

the Bureau of Licensing and Regulation on the

prescribed forms. On the other hand government

hospitals shall submit monthly and annual reports in

accordance with the existing Department of Health

rules

regulations or orders relative thereto.

Storage of Medical Records

Storage on open shelves is far preferable to the old

method of filing cabinets making records more easily

available and occupying less floor space.

mergency OPO Unit

Whether a hospital maintains an emergency unit or not

a plan for the reception and care of mass casualties

shall be required for all hospitals. If an emergency unit

is maintained the following shall be the guiding prin-

ciples:

There shall be a well organized emergency unit

headed by a competent licensed physician.

_ Facilities shall be provided to assure prompt diag-

nosis and emergency treatment.

A small observation room/area where patients can be

observed after emergency treatment may be provided.

There shall be adequate medical and nursing person-

nel available at all times for emergency service.

Adequate medical records on every patient shall be

taken and kept.

_ There shall be a written plan for the care of mass

casualties and which shall be coordinated with the in-

patient and outpatient services of the hospital.

_ The emergency operating area need not be so large

but it shall be provided with the equipment and instru-

ments required by the Bureau of Licensing and

Regulation.


43/99

aboratory nit

As a general rule, in the evaluation of a patient s condi

tion, more so when examinations have to be done else

where, the patient or a responsible family member shall

be made aware and informed of the reasons, ad

vantages, and the cost of these examinations.

When a small hospital affiliates with another in the use of

its facilities, expertise, and ancillary services, a regular

monthly or quarterly) meeting between affiliating units

shall be held to tackle problems and work out improve

ments in the network.

Feedback relating to specific critical or problematic

cases shall be instantaneous and automatic whether by

telephone, messenger, personal, or other means of com

munication.

Basic pre-analytic specimen collection, transport, han

dling, and post-analytic recording, reporting, charging)

requirements shall be written and posted in the emergen

cy room/outpatient unit/ward and the physician s office.

The following shall be met whether examinations are

done in-house or referred out:

- Specimen container specification and labeling

- Request forms, duly signed

- Accompanying data

- Method and time of specimen collection and accep

tance by laboratory

- Amount of specimen required for each requested ex

amination

- Time and method of transport

- Temperature requirements

- Precautions against infections or hazards, and

- tes and charges


44/99

Policies for emergency laboratory services

Policies for outpatient laboratory services

n Requests/results

outpatient, nonemergency

are sent out to affiliating

Surgical and nonsurgical abdominal condition HB

Hct, WBC differential indices)

Requirements shall be put in writing, or printed

and posted in the ward, emergency room/out

patient unit and in the doctor s room.

When adequacy of specimen cannot be assured

because of natural distance, weather) or human

factors, either the hospital staff or the patient him

self

if able, shall be instructed and made to go to

the affiliating hospital laboratory.

Waiting time for results shall be known to the

physician and the patient.

Specimen shall be collected and transported ac

cording to the requirements of the affiliate

laboratory pertaining to:

- When requests for

laboratory examinations

laboratories

n Specimen collection/ handling and transport

- Where there is no accessible higher level laboratory

facility within eight hours of total travel time, basic

laboratory services of a

level

determined by the

needs of the community and the expertise of the

physician shall then be set up. This laboratory

facility shall be maintained by the hospital or the corn

munity according to the rules and regulations relating

to the establishment and operations of clinical

laboratories.

- In-house or affiliate services shall be able to provide

the physician, within one hour, the laboratory support

or data needed for the initial or complete evaluation of:


45/99

Response to emergency room care

Policies for inpatient laboratorv service

Degree and type of anemia/blood loss dehydration.

amoeba/non-amoeba

auses of diarrhea

fecalysis

This is not a requirement, however. A drug room will

suffice in which prepared drugs are stored. If the hospi

tal opts to have a pharmacy which serves only

- Laboratory services and their results, whether in

house or referred, shall be available at a four-hour in

terval during a 24-hour day.

- When the nearest affiliate laboratory is more than an

hour total waiting time away, the hospital or com

munity shall set up and maintain basic laboratory ser

vices for emergency care according to the rules and

regulations relating to the establishment and opera

tions of clinical laboratories.

Pediatric diarrhea - Hct, blood smear morphology,

stool examination, urine specific gravity, and

l:l HB, Hct, indices, blood smear, morphology,

urine specific gravity

Presence or absence of urinary tract infection

urinalysis, WBC count, differential count

l:l

Blood typing, cross matching

- When this is not possible, such a capability shall be

provided by the hospital or community and main

tained according to the rules and regulations relating

to the establishment and operations of clinical

laboratories.

harmacy nit

The pharmacy is the repository of drugs, chemicals,

pharmaceuticals, and narcotics in the hospital. The law

requires that only a licensed pharmacist shall com

pound prescriptions.


46/99

inpatients the pharmacy shall be placed within the hospi-

tal premises convenient to the hospital personnel. it

serves both outpatients and inpatients it shall be easily

accessible to both and shall:

Ensure continuous supply of drugs and medicines of

quality standard to patients by maintaining adequate

quantities of stocks.

_

ill

out prescriptions and dispense drugs in accord-

ance with the laws pertinent thereto.

_ Distribute to the different units of the hospital routi-

nary drug supplies.

_ Request distribute and control the use of all drugs.

_ Maintain proper storage and preservation of drugs.

Maintain records files and reports on dangerous

drugs and other pharmaceuticals as required by law.

Serve as drug information center to all hospital per-

sonnel and patients.

Policies

Drugs and medicines used in hospitals for emergency

cases shall always be made available.

_ An official hospital formulary in generics based on

Department of Health Hospital Formulary shall be es-

tablished.

Prohibited drugs in vials shall be issued to inpatients

through the nurse on duty.

Records files and reports on dangerous drugs and

other pharmaceuticals shall be maintained in com-

pliance with government regulations.

_ There shall be a policy on paid drugs returned by

patients upon their discharge.


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- Expired and deteriorated drugs, fluids, etc. shall be

properly discarded in accordance with the policy on

deteriorated and expired drugs.

- In the sale of medicines, official receipts must be is

sued by the cash clerk or anyone designated to do

so if possible.

-

drug products delivered to the pharmacy shall be

subjected to random testing by the Bureau of Food

and Drugs.

- Drug products received shall not have less than 12

months interval between their delivery and their expiry

date.

A pharmacy unit shall provide for the following:

For the Outpatient Unit

- It shall maintain an inventory of basic generic, non

prohibited drugs and first-line antibiotics in oral

tablets/liquid , parenteral and suppository forms.

- It shall have on stock at level as dictated by its

budget and the usual demand drugs, supplies, or

agents that are not ordinarily available from regular

community outlets such as skin, eye, ear prepara

tions, and vaccines.

- It shall have adequate provisions for its usual load of

minor surgical procedures: instruments and con

sumabies such as sutures, anesthetics, antitetanus,

dressings and antibiotics.

For the Emergency Room

- Life-saving drugs and special pharmacologic agents

in sufficient stock to permit timely replacements from

the nearest pharmacy service.

Examples:

Cardiac/CNS stimulants, depressants, anticonvul

sants


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Sedatives/tranquilizers

Analeptics

Local anesthetics

Steroids

Coronary vasodilators

Anti-asthma agents - bronchodilators

Drugs for hypertension oral and parenteral)

Anti-ulcer drugs

Plasma expanders

Replacement water/electrolyte solution

Oxytoxics

- There shall be available stock of the following sup-

plies:

Intravenous infusion sets

Syringes

Masks

Sterile specimen containers

10 Formalin

Glass slides

Disinfectants

Splints

Ice bags, packs

Oxygen with gauge


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- There shall be at least a week s supply of basic

necessities and supplies in the event of natural or

man-made disasters such as floods,

fir

typhoons,

and earthquake which can lead to an emergency

situation affecting public health:

Water containers or jugs with potable or

chlorinated water

Disinfectants Lysol, Clorox)

Portable IV stands

Emergency bag with provisions

Medicine bag with prescriptions and medicines

Extra linens

Antitetanus serum

Kerosene lamps

Portable emergency lights

For Inpatient Service

- Medicines shall be available in sufficient quantity for

the duration of a patient s confinement.

- Routine immunization and other needs for normal

neonatal postpartum care shall be provided for by the

hospital.

adiology nit

This is not a requirement for a primary-category hospital;

however, if the hospital opts to provide one within the

hospital premises, the following guidelines shall be ob

served.

As a general rule, in the evaluation of a patient s condi

tion, more so when examinations have to be done else

where, the patient or a responsible family member shall

be made aware and informed of the reasons, ad

vantages, and the cost of these examinations.


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When a small hospital affiliates with another in the use of

its facilities, expertise, and ancillary services, a regular

monthly or quarterly) meeting between affiliating units

shall be held to tackle problems and work out improve

ments in the network.

Feedback relating to specific critical or problematic

cases shall be instantaneous and automatic whether by

telephone, messenger, personal, or other means of com

munication.

- Requests for X-ray shall be signed and shall include

the following information:

Patients n me age, sex, status, and address

Date of request, pertinent clinical data, and ex

amination requested

Tentative diagnosis

Clinical unit shall have written schedules including

required patient preparation and rates of x-ray pro

cedures.

- Follow-up examination requests shall include:

Date of last x-ray examination

Nature and result of the previous x-ray examina

tion being monitored.

Previous clinical findings if any

For Outpatients

- The hospital shall affiliate with a unit which is not

more than four hours away by usual means of

transportation.

- When the hospital decides to set up its own x-ray

facility, there shall be available corresponding man

power competencies and facilities to support such ad

ditional services. Only qualified personnel shall be al

lowed to operate the x-ray equipment.


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In house service may be set up at a

level

which will

depend on the needs of the community and com-

petence and skills of available manpower. Only

qualified personnel will be allowed to operate the x-

ray equipment.

For Inpatients

Patients requiring serial x ray for their diagnosis and

monitoring shall be referred out when no in house ser-

vice is available.

NURSING S RVI

Every hospital shall have a nursing service responsible for the

planning organizing directing and control of the service which

shall be capable of providing comprehensive quality nursing care.

l nning Planning shall be based on the type of agen-

cy the services it offers its philosophy and its objec-

tives. It shall be congruent with the overall development

plan of the hospital.

The nursing service shall have established policies stand-

ards and procedures to ensure conformity and consis-

tency with pre established regulations:

Approved personnel and nursing policies are in writ-

ing communicated and kept up to date.

Procedure manuals are available in each clinical area

which shall be reviewed/revised periodically.

A mechanism for assessing personnel performance

and quality of nursing care shall be developed and es-

tablished.

Policies procedures standards and evaluation sys-

tems are included in nursing personnel orientation.

Needs in each patient care area are assessed and

determined by the collective suggestion of nurses in

that re

Each care unit shall have a list of essential equipment

it is responsible for.


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Stock of basic emergency medicines shall be main-

tained in each area.

rganizing the ursing Service

The Chief Nurse or

his/her designate

s ll

be responsible for the organiza-

tion and administration of the Nursing Service. He/she

shall be directly responsible to the Chief of Hospital/Medi-

cal Director/Administrator.

rganizational structure depends on the category

of hospital. It shall establish a harmonious working

relationship with the other services of the hospital and

clearly defines the responsibilities for each level of

nursing personnel.

Staffing The Nursing Service shall develop and

maintain a staffing pattern that will meet the needs of

the patients and standards of the profession and as-

sure adequate provision of care at all times.

The number of nursing personnel shall be in accord-

ance with licensing requirements of the Bureau of

Licensing and Regulation Department of Health.

ob descriptions Job descriptions shall be clear

and in writing. The seven cardinal functions of a

professional nurse shall be followed:

Undertaking responsible nursing care and super-

vision of medical communicable psychiatric minor

surgical pediatric obstetric patients involving

management of nursing care requiring the ap-

plication of principles based upon the biological

psychological physical and social sciences.

Observation of symptoms of physical mental con-

ditions and needs requiring evaluation or applica-

tion of principles based upon the biologic physi-

cal and behavioral sciences.

Accurate reporting and recording of facts includ-

ing evaluation of the whole case.

Supervision of other personnel contributing to the

nursing care of patients.

Execution of nursing procedures and techniques.


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Direction and education to secure physical and

mental care.

Application and execution of written legal orders of

physicians concerning treatment and medications,

including the application of hypodermic and in

tramuscular injections.

_

u lific tions of nursing personnel

.: .,/ r

The chief nurse or his/her designate must be a

registered nurse, preferably a holder of a Bachelor

of Science degree in Nursing with at least one

year of experience and satisfactory performance.

The staff nurse shall be a registered nurse,

preferably a holder of a Bachelor of Science de

gree in Nursing.

Nursing attendants shall be at least a high school

graduate, preferably registered midwives.

irecting the Nursing Service - The Nursing Service shall

provide the mechanism whereby organizational goals

and objectives are achieved to the highest extent pos

si le

_ Directions must be reasonable, clear, and complete.

- Effective supervision shall be provided to ensure at

tainment of the nursing service objectives.

- Intra- and inter-departmental coordination shall be ob

served.

_ A staff development program shall be provided to en

hance nursing personnel s knowledge, skills, and at

titudes.

Orientation to introduce them to their new job

In-service education in specific areas to increase

knowledge and develop proper attitude.

Continuing education beyond the basic curriculum.


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7/25/2019 Oper

operations in hospital

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