TECHNICAL REQUIREMENTS



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| |Department of Health |

| |Bureau Of Health Facilities And Services (BHFS) |

| | ASSESSMENT TOOL FOR LICENSURE OF HOSPITALS |

OUTLINE OF CONTENTS

I. GENERAL INFORMATION(page 2)

II. HOSPITAL ADMINISTRATION

A. Services

1. Administrative Service (pages 3-8)

1. Human Resource

2. Accounting

3. Budget and Finance

4. Billing and Claims

5. Procurement

6. Property and Supply Management

8. Linen and Laundry

1.9 Housekeeping

7. Nutrition and Dietary

8. Security Services

9. Ambulance Services

10. Central Information Management

11. Medical Records (Including Dental Records)

12. Medical Social Services

13. Nutrition and Dietetics

14. Pharmacy

1. Patients Rights and Organizational Ethics (pages 9-10)

2.

3. Patient Care (pages 11-13)

4. Implementation of Care (pages 13-15)

5. Evaluation of Care (page 15)

6. Leadership and Management (pages 16-17)

7. External Services (page 17)

8. Human Resource Management (page 17-18)

9. Data Collection, Management and Use

(pages18-19)

10. Safe Practice and Environment including

Patient and Staff Safety (pages 20-25)

11. Maintenance of Environment of Care (pages

25-27)

12. Infection Control (pages 28-32))

13. Energy and Waste Management (page 33)

14. Improving Performance (page 34)

IICC

III. CLINICAL SERVICES (pages 35-36)

IV. PERSONNEL

POSITION STAFFING REQUIREMENT(pages 37-43)

1. Top Management Personnel Qualification

Standard

2. Administrative

3. Clinical

4. Nursing

5. Ancillary

IV.

A.

B.

C.

IV. EQUIPMENT AND INSTRUMENTS (pages44-51)

List of Equipment and Instrument Requirement

1. Administrative

2. Clinical

1. Emergency Room

2. Outpatient Care

3. Operating Room

4. Recovery Room

5. High Risk Pregnancy Unit

6. Delivery Room

7. Neonatal Intensive care Unit

8. Intensive Care Unit

3. Nursing Unit/Ward

4. Isolation Room

5. Central Supply and Sterilization Unit/ Room

6. Physical Medicine and Rehabilitation Unit

7. Dialysis Clinic

8. Ambulatory Surgical Clinic

9. Dental Clinic

10. Dietary

V. PHYSICAL PLANT REQUIREMENT(52-56)

Required rooms/areas/offices

VI.HOSPITAL PROGRAMS (pages 57-59)

1. Blood Services

2. Newborn Screening

3. Mother-Baby Friendly Hospital Initiative

4. Health Promotion and Disease Prevention

5. Generics Act

6. Health Emergency Management Services

A.

B.

C.

VII. HOSPITAL COMMITTEES (page 60)

VII. HOSPITAL OPERATIONS CRITERIA (page 61)

I.

II.

VIII. SIGNATURE PAGE (page 62)

I. GENERAL INSTRUCTIONS:

1. Check to make sure that you have the complete tool with a total of sixty-three (63) pages and copies of the SOE,SOM and NOV Forms.

2. Assign sections of the tool to corresponding team members.

3. To properly fill-out this tool, the Regulatory Officer shall make use of: (INTERVIEWS, ( REVIEW OF DOCUMENTS, (OBSERVATION and (VALIDATION of findings.

4. If the corresponding items are present or available, place a ✔on each of the appropriate boxes alongside each corresponding item. If not, put an X instead.

5. The REMARKS column shall document relevant observations both positive and negative, including innovations and initiatives undertaken by those responsible in the facility.

6. Make sure to fill-in the blanks with the needed information. Do not leave any items blank; write N.A. if not applicable.

7. (Sh shaded cell means that specific items are not applicable to the hospital level.

8. (means the service can be outsourced but must be inside hospital premises.

9. The Team Leader shall at the end of the inspection or monitoring visit, make sure that the team members complete their respective tool section and proceed to accomplish the Summary of Evaluation (SOE) or Summary of Monitoring (SOM) Form and if warranted, the Notice of Violation (NOV) Form.

10. The Team Leader shall ensure that all team members write down their printed names, designation and affix their signatures and indicate the

date of inspection or monitoring,all at the last page of the Assessment Tool, on the SOE and SOMForms and if warranted, also on the NOV Form.

11. The Team Leader shall make sure that the Head of the facility or, when not available, the next most senior or responsible officer affix his/her signature on the same aforementioned pages and indicate the position, to signify that inspection or monitoring results were discussed during the exit conference and a copy of the SOE or SOM and, only if warranted, that of the NOV, were received.

12. This shall also serve as self-assessment tool for facility owners and monitoring tool.

II. GENERAL INFORMATION:

Name of Hospital:

Address:

(Number & Street) (Barangay/District)

(Municipality/City) (Province & Region)

Telephone No../ Fax No.

E-mail Address:

License No (for renewal):

Date Issued Expiry Date:

Hospital Category: (Level 1 (Level 2 (Level 3

Philhealth Accreditation:Center of: ( Safety ( Quality ( Excellence

Classification According to Ownership: ( Government ( Private

No. of: Authorized Bed Capacity Implementing Beds

Name of Owner or Governing Body (if corporation):

Name of Hospital Administrator, Medical Director or Chief of Hospital

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| |ADMINISTRATIVE AND FINANCE SERVICE: The AFS shall ensure adequate and timely financial and direct support services to all hospital units. | | | |

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| |Administrative Group: |●Documented and | | |

|1.1.1 |Human Resource Management |implementable policies and | | |

| |There shall be a comprehensive human resource management plan which includes recruitment, selection, promotion, separation, welfare and benefits in accordance with applicable laws. |procedures | | |

| | |Approved documented | | |

| | |policies, guidelines and | | |

| | |procedures on: | | |

| | |a) Staffing plan |● Complete, updated and | |

| | |b) Recruitment and |easily retrievable | |

| | |Selection |individual personnel file | |

|1.1.1.a | |c) Hiring/Appointment |● Evidence of continuous | |

|1.1.1.a.1 | |d) Orientation & Staff |improvement | |

| | |Development | | |

| | |e) continuing education, | | |

| | |and | | |

| | |training | | |

| | |Approved documented | | |

| | |policies, guidelines and | | |

| | |procedures on | | |

| | |a) Staffing plan | | |

| | |b) Recruitment and | | |

| | |Selection | | |

| | |c) Hiring/Appointment | | |

| | |d) Orientation & Staff | | |

| | |Development | | |

| | |e) continuing education, | | |

| | |and training | | |

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| 2.1.1| | | | |

| |anizational policies and procedures respect and support patients' right to quality care and their responsibilities in that care. |Informed consent is |All patient charts have | |

| | |obtained from patients |signed consent. | |

| | |prior to initiation of | | |

| | |care.  | | |

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| 2.2.1| ACCESS - Goal: The organization is accessible to the community that it aims to serve. | | | |

| 2.2.1.a |3.Physical Access to the |Entrances and exits are |Presence of entrances and |

| |organization and its |clearly and prominently |exits that are readily |

| |services is facilitated and|marked, free of any |accessible and free from |

| |is appropriate to patients'|obstruction and readily |obstruction.   |

| |needs. |accessible. | |

| |6.The organization uniquely identifies all patients including newborn infants, and creates a specific patient chart for each patient that is readily accessible to authorized personnel. |All patients are correctly |All patients are correctly | |

|2.2.2.a | |identified by their patient|identified by their | |

| | |charts. |charts.  | |

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| 2.2.3.a |7.Each patient's physical, psychological and social status is assessed. |An appropriately |All patients have |  |

| | |comprehensive history and |comprehensive history and | |

| | |physical examination is |PE within 24 hours from | |

| | |performed on very patient |admission. | |

| | |within 24 hours from | | |

| | |admission.  The history | | |

| | |includes present illness, | | |

| | |past medical, family, | | |

| | |social and personal | | |

| | |history. | | |

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| 2.4.1 |16. The discharge plan is | |All charts have discharge |

| |part of the patient's care| |plans |

| |plan and is documented in | | |

| |the patient chart. | | |

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| |17.The organization regularly reviews and updates its policies, guidelines and procedures |

|2.5.1.a | |

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| |18.Terms of reference, membership and procedures are defined for the meetings of all committees within the organization. Minutes of meetings are recorded and approved. |

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|2.5.1.b | |

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| 3.1.1.a |21. Planning ensures that appropriately trained and qualified (and where relevant, |

| |credentialed) staff are available to undertake the type and level of activity |

| |performed by the organization. This includes those who are consulted when suitable expertise is |

| |not available within |

| |the organization |

| | Goal:  Collection and aggregation of data are done for patient care, management of services, education and research. |

| |RECORDS MANAGEMENT |

| |Goal:  Integrity, safety, access and security of records are maintained and statutory requirements are met. |

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|4.2 | |

| |Medical Record | | |

|4.2.1 | | | |

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|6.1.1.a |26.The |The organizational |

| |organization plans|environment complies |

| |a safe and |with structural |

| |effective |standards and safety |

| |environment of |codes as prescribed by |

| |care consistent |law. |

| |with its mission, | |

| |services, and | |

| |with laws and | |

|6.1.1.b |regulations. | |

| | |There are management |

| | |plans which address |

| | |safety, security, |

| | |disposal and control of |

| |27.The |hazardous materials and |

| |organization plans|biological wastes |

| |a safe and | |

| |effective | |

| |environment of |Emergency and disaster |

| |care consistent |preparedness, fire |

| |with its mission, |safety, radiation safety|

| |services, and with|and utility systems. |

| |laws and | |

| |regulations. | |

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| 7.1.1 |34.The organization routinely collects and evaluates information to improve the safety and adequacy of the environment of care |An |Presence of incident |

| | |inci|reporting |

| | |dent|system/sentinel event |

| | |repo|monitoring system (which|

| | |rtin|may include nosocomial |

| | |g |infections, unexpected |

| | |syst|deaths, adverse drug |

| | |em |reactions, flood |

| | |iden|transfusion reactions, |

| | |tifi|falls, etc).  |

| | |es | |

| | |pote| |

| | |ntia| |

| | |l | |

| | |harm| |

| | |s, | |

| | |eval| |

| | |uate| |

| | |s | |

| | |caus| |

| | |al | |

| | |and | |

| | |cont| |

| | |ribu| |

| | |ting| |

| | |fact| |

| | |ors | |

| | |for | |

| | |the | |

| | |nece| |

| | |ssar| |

| | |y | |

| | |corr| |

| | |ecti| |

| | |ve | |

| | |and | |

| | |prev| |

| | |enti| |

| | |ve | |

| | |acti| |

| | |on. | |

| 8.1.1.a |38.An interdisciplinary infection control program ensures the prevention and control of infection in all services. | |Presence of an Infection|

| | | |Control |

| | | |Committee (ICC) with |

| | | |defined goals, |

| | | |objectives, strategies |

| | | |and priorities or for a |

| | | |primary hospital -  a |

| | | |designated doctor and |

| | | |nurse in-charge of |

| | | |infection control.  |

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| 9.1.1 |

| 10.1.1 |

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| |2.1 Level 1 (With Consulting Specialists in the four major specialties plus Anesthesia) |

| |General Medicine | | | | |

|General Pediatrics | | | | |

| |Obstetrics and Gynecology | | | | |

|Surgery | | | | |

| |Anesthesia | | | | |

|Emergency | | | | |

| |Outpatient Service | | | | |

|2.2. Level 2 |2.2 Level 2 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus Anesthesia) |

|Departmentalized Clinical Care | | | | |

| | Medicine | | | | |

| Pediatrics | | | | |

| |Obstetrics and Gynecology | | | | |

| |Surgery | | | | |

| |Anesthesia | | | | |

|Emergency Service | | | | |

| |Outpatient Service | | | | |

|2.3. Level 3 (With Medical Specialists who are Fellows/Diplomates in the four major specialties plus and Anesthesia and other specialties and sub-specialties present). |

| |Specialty Clinical Care | | | | |

| |- Dept. of Medicine | | | | |

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|- Dept. of Pediatrics | | | | |

| |- Dept. of Obstetrics and Gynecology | | | | |

|- Dept. of Surgery | | | | |

| |- Dept. of Anesthesia | | | | |

| - General Dentistry | | | | |

| |Sub-specialty Critical Care | | | | |

| |- Intensive Care | | | | |

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| - High Risk Pregnancy care | | | | |

| | - Neonatal Intensive care | | | | |

| |Emergency Service | | | | |

|Outpatient Service | | | | |

| | Accredited Residency Training Program for Physicians in the four major | | | | |

| |departments namely: | | | | |

|Medicine | | | | |

| |Surgery | | | | |

|Obstetrics and gynecology | | | | |

| |Pediatrics | | | | |

| |Nursing Services: |

| |General Nursing ( for all levels) | | | | |

| |Highly Specialized Critical Care and Management in the | | | | |

| |following areas: (for levels 2 and 3) | | | | |

| |Medicine | | | | |

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| |Pediatrics | | | | |

| |Obstetrics and Gynecology | | | | |

| |Surgery and Anesthesia | | | | |

| ● In areas with other Specialties (aside from the five) and | | | | |

|Subspecialties, there should be corresponding | | | | |

|Nursing care. | | | | |

Ancillary Services

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|( Clinical Laboratory | | | | |

|Category of laboratory must be Secondary for level 1, Tertiary for Level 2 And for level 3, Tertiary with histopathology. | | | | |

|( Radiology | | | | |

|Category of Radiology must be 1st level for Level 1, 2nd level with mobile Unit for Level 2, and 3rd level for level 3. | | | | |

| 4.3 ( Pharmacy | | | | |

| Other Services | | | | |

|( Dental Services ( for all levels) | | | | |

|( Ambulatory Surgical Clinic (for level 3) | | | | |

|( Dialysis ( for level 3) | | | | |

|Physical Medicine and Rehabilitation Services (for level 3) | | | | |

|Respiratory Unit for level 2 and 3. | | | | |

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|Verifier: |

|( Documents review, ( Observe,( Interview staff & (Validate |

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|CODE |POSITION STAFFING |

|10.1 |REQUIREMENT I: |

| |(Top Management Positions) |

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|11.4.1 |Pharmacist (full-time,registered); |Adequate |Adequate |Adequate | |

| 11.4.2|Pathologist |1 |1 |

| | |Level 1 |

| |STANDARD REQUIREMENT | |

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|CODE | | |

| | 1.ADMINISTRATIVE | |

|12.1.1 | | |

| 12.1.1.1 | Computer with Internet Access |1 |

| | Oven |1 |1 |

| 13.1.1.1 | Bag-valve-mask unit |

| 13.2.1.1 |1. Clinical Weighing Scale |1 |

| 13.3.1.1 |1. Air-conditioning Unit |

| 13.4.1.1 |1. Air-conditioning Unit |

| 13.6.1.1 |1. Air-conditioning Unit |1 |

| 13.7.1.1 |1. Cardiac Monitor |

| | Air-conditioning Unit |

| |Bag-valve-mask unit |

| |Ultrasound | | |1 | | |

| |2.Blood transfusion | | | | | |

|42x2 | | | | | | |

| |3.HIV/AIDS Core Team | | | | | |

|42x3 | | | | | | |

| |4.Waste Management | | | | | |

|42x4 | | | | | | |

|42x5 |5.Patient Safety | | | | | |

|40x6 |6.Infection Control | | | | | |

|40x7 |7.Pharmacologic/Therapeutics | | | | | |

| |8.Health Emergency/ | | | | | |

|428 |Crisis Management | | | | | |

|42x9 |9.CQI | | | | | |

| |10.Tissue | | | | | |

|42x10 |(for levels 2 and 3 only) | | | | | |

| |11.Ethics | | | | | |

|42x11 |(for levels 2,and 3 only) | | | | | |

| |12.Grievance | | | | | |

|42x12 | | | | | | |

| |Other committees, please | | | | | |

| |specify | | | | | |

|42x13 | | | | | | |

| | |Verifier: (Documents review and ( Interview staff |

| | |SERVICES (levels 1 & 2) / DEPARTMENT (level 3) |

|CODE |D.HOSPITAL OPERATIONS: | |

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|43 | | |

| | |OPD |

|Signature over Printed Name |Signature over Printed Name |Signature over Printed Name |

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|_______________________________ |_______________________________ |_______________________________ |

|Position |Position |Position |

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|_______________________________ |_______________________________ |_______________________________ |

|Date |Date |Date |

|_______________________________ |_______________________________ |________________________________ |

|Signature over Printed Name |Signature over Printed Name |Signature over Printed Name |

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|_______________________________ |_______________________________ |________________________________ |

|Position |Position |Position |

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|_______________________________ |_______________________________ |________________________________ |

|Date |Date |Date |

CONCURRED BY:

|_______________________________ |

|Signature over Printed Name |

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|_______________________________ |

|Position/Designation |

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|_______________________________ |

|Date |

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