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)
1.1. Human Resource
1.2. Accounting
1.3. Budget and Finance
1.4. Billing and Claims
1.5. Procurement
1.6. Property and Supply Management
1.8
Linen and Laundry
1.9
Housekeeping
1.7. Nutrition and Dietary
1.8. Security Services
1.9. Ambulance Services
1.10. Central Information Management
1.11. Medical Records (Including Dental
Records)
1.12. Medical Social Services
1.13. Nutrition and Dietetics
1.14. Pharmacy
2. Patients Rights and Organizational Ethics
(pages 9-10)
3. Patient Care (pages 10-13)
4. Implementation of Care (pages 13-15)
5. Evaluation of Care (page 16)
6. Leadership and Management (pages 16-17)

7.
8.
9.
10.
11.
12.
13.
14.

External Services (page 17)

Human Resource Management (page 18)
Data Collection, Management and Use
(pages18-19)
Safe Practice and Environment including
Patient and Staff Safety (pages 20-25)
Maintenance of Environment of Care (pages
26-27)
Infection Control (pages 28-32))
Energy and Waste Management (page 33)
Improving Performance (page 34)

III. PERSONNEL
POSITION STAFFING REQUIREMENT(pages 35-43)
1. Top Management Personnel Qualification
Standard
2. Administrative
3. Clinical
4. Nursing
5. Ancillary
IV. EQUIPMENT AND INSTRUMENTS (pages44-52)
List of Equipment and Instrument Requirement
1. Administrative
2. Clinical
2.1. Emergency Room
2.2. Outpatient Care
2.3. Operating Room

2.4. Recovery Room

2.5. High Risk Pregnancy Unit
2.6. Delivery Room
2.7. Neonatal Intensive care Unit
2.8. 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(53-57)
Required rooms/areas/offices
VI.HOSPITAL PROGRAMS (pages 58-60)
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
VII. HOSPITAL COMMITTEES (page 61)
VII. HOSPITAL OPERATIONS CRITERIA (page 62)
VIII. SIGNATURE PAGE (page 63)
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 1 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

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)
(Municipality/City)

(Barangay/District)
(Province & Region)

Telephone No../ Fax No.

E-mail Address:
License No (for renewal):
Date Issued
Hospital Category:

Expiry Date:
Level 1 Level 2

Level 3

Philhealth Accreditation:Center of: Safety Quality Excellence

Classification According to Ownership: Government
No. of: Authorized Bed Capacity

Private

Implementing Beds

Name of Owner or Governing Body (if corporation):

Assessment Tool for

Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 2 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

Name of Hospital Administrator, Medical Director or Chief of Hospital

Assessment Tool for

Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 3 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

DOH MONITORING

INDICATOR

DOH INSPECTION

CRITERIA

SELF-ASSESSMENT

STANDARDS

EVIDENCE
DMINISTRATION:
esponsive to the requirements of quality health service delivery, health regulation, health financing and good governance.
ADMINISTRATIVE AND
FINANCE SERVICE: The
AFS shall ensure adequate
Documented and
and timely financial and
implementable policies and
direct support services to all procedures
hospital units.
Approved documented policies,
guidelines and procedures on:
Administrative Group:
a) Staffing plan
Human Resource
b) Recruitment and
Complete, updated and
Management
Selection
easily retrievable
There shall be a
c) Hiring/Appointment
individual personnel file
comprehensive human
d) Orientation & Staff
Evidence of continuous
resource management plan
Development
improvement
which includes recruitment,
e) continuing education, and
selection, promotion,
training
separation, welfare and
Approved documented policies,
benefits in accordance with
guidelines and procedures on
applicable laws.
a) Staffing plan
b) Recruitment and Selection
c) Hiring/Appointment
d) Orientation & Staff
Development
e) continuing education, and
training

AREA

REMARKS

Assessment Tool for

Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 4 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

f)
g)
h)
i)

Performance Evaluation
Rotation/Transfer
Succession Plan
Merit, Promotion, Awards
& Incentives
j) Resignation, Termination
and Retirement
k) Physical Examination
record of schedule of duties
appointment/employment
contract, if valid
updated health certificate (as
required)
orientation plan/program of
new employees implemented
record of schedule of duties
appointment/employment
contract, if valid
updated health certificate (as
required)
orientation plan/program of
new employees implemented
Financial Management
Group
Accounting
There shall be a systematic
recording of all financial
transactions, preparation of
financial statements and
relevant reports, and maintenance and safekeeping of
Books of Accounts.
Budget
There shall be a
consolidation and
preparation of the Budget
Proposal, Work and
Financial/ Operational
Plans including its
implementation and

documented and
implementable policies and
procedures

documented and
implementable policies and
procedures

Verifier:
Documents review,
Observe
Interview staff,
Validate
List of personnel
check if
Current

Verifier:
Documents review,
Interview staff,
Validate

Verifier:
Documents review,
Interview staff,
Validate
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 5 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

Billing and Claims

there shall be a system of
billing of patients and
processing of claims

documented and implementable

policies and procedures

Procurement:
There shall be a
comprehensive plan of
systematic management of
procurement and
acquisition of supplies,
materials,
healthcare equipment,
vehicles, services,
infrastructure work and
other required logistics for
the effective and efficient
delivery of quality services

Policies, guidelines and

procedures on requisition,
purchase, issuance and
inventory; disposal of nonfunctional equipment,
instruments, supplies, expired
drugs and medicines and
reagents are in place.

Property and Supply

Management:
There shall be a systematic
way of receipt, storage,
issuance and conduct of
inventory .

documented and implementable

policies and procedures

Proof of transactions
Documents are readily
Available

Linen and Laundry

There shall be adequate
supply of clean linens for
patients and other hospital
units.

Sorting of soiled and

contaminated linens in
designated areas
Systematic washing of laundry
with safeguard against spread of
infection
Disinfection of laundry

Policies, procedures and

guidelines in cleaning and
washing of soiled linens

Housekeeping
There shall be provision
and maintenance of clean,
safe and sanitary facilities

Verifier:
Documents review,
Interview staff,
Validate
Documents are readily
available

Verifier:
Documents review,
Observe
Interview staff
Validate

Look for approved Work

and Financial Plan and its
implementation

Adequate
housekeeping
supplies.

evidence of continuous
review of policies and
procedures

Verifier:
Documents review,
Interview staff,
Validate

Verifier:
Documents review,
Interview staff,
Validate

Verifier:
Documents review,
Interview staff,
Validate
Assessment Tool for
Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 6 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0

Assessment Tool for

Licensure of Hospitals
Revision: 00
Effectivity date: 10/01/12
Page 7 of 7
DOH-CHD3-LRED- SOP-01-01-Form1-Rev.0