PART-1
POLICIES & PROCEDURES
1. Policies and procedures in patients’ rights (c/o DOH dept. memorandum no. 2017-0061)
2. Policies & procedures for medicine/pedia/ob/surgeon/anesthesia dept.
3. Protocols & pathways
4. Policies & procedure manual for all service/dept/unit (nursing/admin/medical)
5. Policies & procedures of committees (proof of creation of committees/ minutes of meeting)
a. Credential/privilege
b. Health care waste management
c. Patient safety
d. Infection prevention control
e. Antimicrobial stewardship
f. Pharmacologic and therapeutic
g. Emergency and disaster preparedness
h. CQI
i. Department & communication technology
6. Presences of evaluation and monitoring activities to assist mgt. and perform
7. Operational performance-accomplishment report or other annual reports
8. Policies & procedures for hiring credentialing & privileging staff
9. Job descriptions for staff
10. Annual plan on training activities including resource and budget
11. Policies &procedures on record storage and disposal (needs logbooks)
12. Proof of submission on the online health facility statistical reporting system (ohfsrs)
13. Policies and procedures on filing & retrieval of charts
14. Policies procedure on protection of records against loss destruction & tamping and unauthorized
access & in maintaining confidentiality, provided roles & responsibilities
EMR electronic medical records
1. Presences of infection prevention & control committee of defined roles & responsibilities with
IPCC function & activities/ minutes of the meeting
2. IPC manual/policies on antimicrobial use/ reports of infection control activities (outbreaks,
training, investigation)
3. Policies & procedures on disposition of dead bodies with dangerous communicable diseases
4. Policies & procedures on isolation/occupational health & safety program employees
5. Policies on timely referral and care reporting on highly transmissible and notifiable injection
disease
6. Policies & procedures on reporting notifiable disease CTB chart needs
7. Presences of incident reporting system /sectional event monitoring system
(patients’ safety) for (eg. Hospital acco. Infection/adverse extorted or BT, fall)
8. Presence of quality improvement program (Q1)
9. Presence of customer satisfaction survey-filled up forms w/monthly analysis-action taken
10. Policies & procedures and universal newborn screening (logbook of NB)
11. Logbook of NB test for hearing
12. Proof of rooming-in and breastfeeding/MBF hospital, MBF workplace – certificate
13. List of family planning acceptors OPD/OBward
14. Records of NB given BCG and HEP.B first done
15. Policies & procedures on anti-smoking (NO SMOKING SIGNAGED at HALLWAYS, WARD OPD
OFFICES)
16. Proof of implementation of hospital emergency mgt. plan (fire drill & earthquake drill) (ENT
PLANS POSTED at HALLWAYS & ROOMS)
17. NTP- proof of implementation of national TB program=presences of hospital TB referral
logbook/list of TB care
18. Proof of allocation of charity beds to incident atleast 10% of bed capacity
19. Policies and procedures on handling cares of patients for discharge w/computed hospital bills
20. Policies and procedures on the implementation of RA 10932 rendering emergency care &
admission to indigent patients/ a copy of RA 10932 posted in a visible area
21. Proof of implementation of act no.3753 and presidential degree 766 logbook shaming proof of
submission of accomplished birth/death certificates to local health registry/properly filled waiver
if they opt to file for thermal
Part-II
22. Policies and procedures on prevention and treatment on needle stick injuries and safe disposal of
needles
23. Policies and procedures on cleaning /disinfecting, drying, packaging and sterilizing of equipment
instruments & supplies
Part-III (admin & Dietary)
24. Logbook for packaging and sterilizing equipment instrument & supplies
25. Policies and procedures in dietary/monthly menu
26. Policies & procedures on security of patient’s visitors & hospital staff
27. Policies & procedures on proper disposal
28. Housekeeping/sanitation/ proof of implementation
29. Policies & procedures on maintenance (equipment & building)
30. Building maintenance program
31. Check presence of MSDS (material safety data sheet) in lab & engineering
32. Interview staff manner of waste segregation & disposal; safe storage and disposal of reagents and
disposal of waste water
33. Policies & procedures addressing safety/security/disposal control of hazardous materials and
biologic wastes/emergency & disaster preparedness
34. Policies & procedures for quality entries/ corrective and preventive maintenance program for
medical equipment
35. Presence of appointed personnel in charge of security
36. Presence of generated emergency light, water system, adequate ventilation
37. Check circuit of water analysis for last 6 months/prevention & correction maintenance logbook
38. Policies & procedure in preventive and corrective maintenance & plan for replacement
39. Training of staff in charge of maintenance if in hours-certificate/if outsource MOA/contract
license & permits for LGU DENR- generated permit
40. Policies & procedures on water disposal mgt.
a. Sources of member on guideline in waste segregation, collection, Rx & disposal
b. Contracts w/handler if applicable
41. Observe/segregation of waste/ labelling of bins/proper mgt. of temporary storage area prior to
hauling of disposal/recyclable waste staging area
