2.

PATIENTS RIGHTS AND ORGANIZATIONAL ETHICS

2.1.1 All patient charts have signed consent.
2.1.2 Presence of facilities consistent with clinical service capability based on DOH license in accordance
with the hospitals level (e.g. level 1 surgical capability, level 2 ICU, level 3 teaching and training hospital).

List of services available

2.2

PATIENT CARE
2.2.1. a Presence of entrances and exits that are readily accessible and free from obstruction.
2.2.1. b Presence of directional signages to locate service areas.
Directional signs are prominently posted. Check ER, OPD, wards and lobby
2.2.1.c Presence of alternative passageways (ramps and elevators) that are prominently marked and free
from obstruction for patients with special needs
2.2.2.a All patients are correctly identified by their charts.
2.2.3.a All patients have comprehensive history and PE within 24 hours from admission.
2..2.3.b All patient charts have progress notes by doctors.
2.2.3.c All patients for surgery have undergone pre-operative anesthetic assessment.
2.3.1 Proof of monitoring of the implementation of the policies and procedures on quality control of
diagnostic examinations
2.3.2.a All drugs are administered in a timely, safe, appropriate and controlled manner to the right patient
2.3.2.b All doctors, dentists, nurses and pharmacists have updated licenses
2.3.2.c Proof that the prescriptions or orders are verified before medications are administered.
2.3.2.e All charts have proper documentation of drug administration
2.4.1All charts have discharge plans
2.5.1.a Strategically Posted Vision and Mission of all the Services
Approved Manual of Operations and/ or Written Policies, Guidelines and Procedures on Clinical
Services Offered
2.5.1.bStrategically Posted Functional and Organizational Chart with Photos Showing Names and
Relationship by Positions Proof of the creation of all committees within the organization which
includes the terms of reference for membership
2.5.1.c Presence of evaluation and monitoring activities to assess management and organizational
performance
2.6.1 Presence of MOA/ contract for all out-sourced services (e.g. dialysis unit, dietary, laboratory,
radiology).
(Outsourced are services/ facilities provided by third party but are inside the hospital)
3.1 Human Resource Management
3.1.1.a Presence of policies and procedures for credentialing and privileging of staff
3.1.1.b Staff to bed ratio for licensed doctors, registered nurses and midwives/nursing aides follow

the DOH prescribed ratio.

4.1 DATA COLLECTION, AGGREGATION AND USE
4.2.1.a Presence of policies and procedures on systematic filing, retrieval, retention, storage, disposal
and management of medical records. Patients chart contents include the following:
-Doctors Progress Notes
-Informed Consent
-Problem List
-Medication and Treatment Record
-Laboratory and X-ray Reports
-Dietary Assessment Clinical and Graphic Record of Vital Signs (TPR sheet)
-Personal History and Physical Examination records
-Newborn Record and Physical Maturity Rating, if warranted
-Doctors Progress Notes
-Medication and Treatment Record
-Laboratory and X-ray Reports
-Dietary Assessment Nurses Progress Notes
-Records of Transfer/Referral to another Physician or Health Facility
-Inpatient Referral/Consultation Notes of Other Physicians
-Final Diagnosis
-Advance Directive, if any

Presence of procedures to protect records and patients charts against loss, destruction, tampering
and unauthorized access or use

6.1 SAFE PRACTICE AND ENVIRONMENT

6.1.1.b Presence of a management plan addressing safety, security, disposal and control of hazardous
materials and biologic wastes, emergency and disaster preparedness, fire safety, radiation safety and utility
systems.
6.1.1.c Presence of operating manuals of the medical equipment.
6.1.1.d Proof of implementation of the policies, procedures and safety programs on
6.1.1.e Proof of the implementation of the policies and procedures for the safe and efficient use of medical
equipment.
6.1.1.f Presence of adequate space, lighting and ventilation in compliance with structural requirements (for
patient safety and privacy).
6x1.1.g Presence of policies and procedures on risk identification, assessment and control.
7.1

MAINTENANCE OF THE ENVIRONMENT OF CARE

7.1.1Presence of incident reporting system/sentinel event monitoring system (which may include nosocomial
infections, unexpected deaths, adverse drug reactions, flood transfusion reactions, falls, etc).
7.1.2Presence of generator/emergency light, water system, adequate ventilation or air conditioning.
7.1.3Proof of training of the staff who is in charge of the maintenance of the equipment.

8.1 INFECTION CONTROL

8.1.1.a 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.
8.1.1.b Presence of an infection control program ensuring prevention and control of infections on all services
8.1.2.a Presence of coordinated system-wide procedure for isolation of nosocomial infections.
8.1.2.b Presence of coordinated system-wide procedure for case containment of nosocomial infections
8.1.2.c Presence of coordinated system-wide procedure for asepsis.
8.1.3.a Presence of policies and procedures on the prevention and treatment of needle stick injuries and
safe disposal of needles.
8.1.3.b Presence of program on prevention of transmission of airborne infections and risks from patients with
signs and symptoms suggestive of tuberculosis or other communicable diseases .
8.1.4Presence of policies and procedures on cleaning, disinfecting, drying, packaging and sterilizing of
equipment, instruments and supplies. (Refer to Annex__ Sterilization Guidelines in Hospital Setting)
8.1.5Presence of policies and procedures on reporting of infections to personnel and public health agencies

Presence of policies, procedures and guidelines for safe reuse of items which comply with relevant
statutory requirements.

9.1 ENERGY AND WASTE MANAGEMENT