Benchbook Self Assessment Manual 1 Protected

Orientation of Hospitals on
Benchbook Self-Assessment
and Accreditation Process

MANUAL I

PHILIPPINE HEALTH INSURANCE CORPORATION
Manual 1

Table of Contents

I. GUIDELINES FOR THE HOSPITALS 2

Appendix A . 8

Appendix B ... 10

Appendix C ... 11

II. BENCHBOOK SELF ASSESSMENT AND SURVEY
TOOLS. 12

Patients Rights.. 12

Patient Care 17

Leadership and Management 44

Human Resource Management . 48

Information Management 55

Safe Practice and Environment . 59

Improving Performance ... 72

III. THE BENCHBOOK ACCREDITATION PROCESS
(Self-Assessment). 75

GUIDELINES FOR THE HOSPITALS
Accomplishing the Benchbook Self-Assessment and Survey Tool

I. COMPONENTS OF THE TOOL

The Benchbook Self-Assessment and Survey Tool is divided into seven performance areas: (1) Patient
Rights and Organizational Ethics, (2) Patient Care, (3) Leadership and Management, (4) Human
Resource Management, (5) Information Management, (6) Safe Practice and Environment, and (7)
Improving Performance. Each performance area is divided into sub-areas, except for Patient Rights and
Improving Performance. These sub-areas are broken down into several standards with one or several
criteria to each standard; one or several indicators to each criterion; and one or several evidence to each
indicator.

The tool contains the list of goals, standards, criteria, indicators and evidence under each performance
area. It is divided into 15 sections representing 3 process areas (document review, chart review and
leadership interview) and 12 hospital areas (wards, ER, OPD, ICU, OR, pharmacy, laboratory, imaging,
medical records, facilities and maintenance, human resources and others).

The indicators are appropriated into the 15 sections of the self-assessment and survey tool. A particular
indicator may be found in one or several sections where the indicator is applicable.

The self-assessment/survey tool has eight columns (see appendix a). The first column, CODE, contains
the unique alphanumeric code for each indicator and tags for the core indicators. The second, third and
fourth columns contain the STANDARDS, CRITERIA and INDICATORS respectively. The standards and
criteria that appear in the self-assessment/survey tool are the same standards and criteria that were
published in the Benchbook on Performance Improvement of Health Services. (De la Pena, 2004)

The next two columns, labeled HOSP and PHIC, contain blank spaces, which shall be used to indicate
compliance or noncompliance to the evidence. The evidences are listed in the 7
th
column. Comments
and explanations may be written in the 8
th
column labeled REMARKS.

II. USERS

Hospital conducting self-assessment

The Benchbook Self-Assessment and Survey Tool will be used by the hospital during its conduct of the
self-assessment process. It allows the hospital to evaluate itself and discern clearly its strengths and
areas in which improvements can be made. For the self-assessment, the hospital has to accomplish the
Self-Assessment and Survey Tool and the score sheet.

PhilHealth Surveyors conducting accreditation survey

The Benchbook Self-Assessment and Survey Tool accomplished by the hospital will be submitted to
PhilHealth and will be used by the surveyors during the conduct of the accreditation survey. The two
columns labeled PHIC and SURVEYOR SCORE are intended for PhilHealth use.

III. PROCEDURE

Hospitals may employ the following procedure for conducting the self-assessment and accomplishing
the score sheet. This process is similar to the accreditation survey process to be conducted by
PhilHealth.

1. REVIEW THE STANDARDS

The hospital may start by reading the following components in the tool in order to understand the
requirements in the proper context:

Goal: declares the overall intent of the standards under it; pictures the desired-for situation
targeted by a performance improvement program
Standard: delineates the best possible condition that should exist in the organization for it to
attain quality performance; sets the maximum achievable performance expectations for activities
that affect the quality of care
Criteria: lays down specific actions that need to be done to meet the standard
Indicators: measurable variables or characteristics that can be used to determine the degree of
adherence to a standard or achievement of quality goals
Page 2 of 76
Core indicators : characteristics that should be present for a hospital to function as a
facility providing care, treatment and diagnosis in a manner that is safe and efficient for
the patients and its staff
Evidence: proof of compliance to the indicator in the form of a document, through interview or
observation

2. ORGANIZE THE SELF-ASSESSMENT TEAM

The hospital should come up with a team tasked to conduct its self-assessment. It may assign only
an individual or hire consultants to do the job depending on its preferred approach or as may be
permitted by its resources.

Hospitals may also adopt a process similar to the PHIC accreditation survey. The survey will be done
by a team of at least three surveyors regardless of the level of care (primary, secondary or tertiary).
One member of the team should have the capability of evaluating charts and understanding the
medical process (surveyor A), preferably a doctor or a nurse. The rest of the team (surveyor B and
C) shall be composed of allied medical professionals or other technical staff. The surveyors will be
assigned different sections of the tool. Each surveyor will handle a different process or hospital area.
The suggested distribution of areas is as follows:

Hospital Areas covered Range of evidences
Surveyor A
(Doctor/Nurse)
Wards (medical, surgical,
pediatric and OB), ER,
ICU
Chart review, Document
review, Leadership
interview
Surveyor B
(Technical Staff)
Imaging, Laboratory,
Facilities and
Maintenance, Other
areas
Document review.
Leadership interview
Surveyor C
(Technical Staff)
HR, Medical records,
OPD, OR, Pharmacy
Document review,
Leadership interview

The PhilHealth survey will take a maximum of 3 days for a tertiary hospital, 2 days for a secondary
hospital and one day for a primary hospital.

Tertiary Hospital
Surveyor A Surveyor B Surveyor C
Opening Conference
Document Review Day 1
Leadership Interview
Chart review Imaging HR
Medical ward Laboratory Medical records
Surgical/OB ward Facilities and
maintenance
Pharmacy Day 2
Pediatric ward OR
ICU Other areas OPD
ER
Surveyor meeting
Day 3
Exit conference

Secondary Hospital
Opening Conference
Document Review
Chart review Imaging HR
Day 1
Medical ward/ICU Laboratory Medical records
Surgical/OB ward Facilities and
maintenance
Pharmacy
Pediatric ward OR
ER Other areas OPD
Surveyor meeting
Day 2
Exit conference
Page 3 of 76

Primary Hospital
Opening Conference
Document Review
Chart review Imaging/Laboratory HR
Ward Facilities and
maintenance
Medical records
ER Other areas Pharmacy
OPD
Surveyor meeting
Exit conference

3. ANALYZE EVIDENCES

The self-assessment team may proceed by analyzing the evidence/s in their assigned hospital areas
and determine compliance to the indicator. As evidences include documents, interview and
observation, the hospital should analyze them in the manner PhilHealth will analyze them during the
actual accreditation survey. With documentary evidences for example, the hospital should perform its
own document review i.e. patient chart review, policy reviews, etc. For interviews and observation,
the hospital may conduct them on patients, their staff, or leaders in order to make an appropriate self-
assessment. It may also employ the data-gathering and sampling techniques used by PHIC
surveyors on particular indicators.

As some indicators need to be assessed in several hospital areas or by several types of evidence,
hospitals should refer to Column 5 of the score sheet labeled AREA which lists all the possible
hospital/process areas where the indicators may be evaluated.

4. ACCOMPLISH THE SCORE SHEET

The self-assessment team is in charge of checking for the evidence in the hospital areas. In the
score sheet, compliance is marked with a check and noncompliance with an x,. Compliance and
non-compliance is inputted in the 5
th
and 6
th
columns (HOSP and PHIC) of the self-
assessment/survey tool. Any additional comments shall be written in the 8
th
column (REMARKS).

Towards the end of the survey, the team will meet and consolidate their findings. The summary of
the findings will be documented in the score sheet (see appendix b). The score sheet lists all the
indicators successively, arranged into performance areas as shown in the Benchbook. It also
consists of eight columns.

The task of the self-assessment team is to consolidate the findings from the different areas into one
result and record this in the score sheet. The hospital must meet all elements/requirements of the
evidence in all applicable hospital areas in order to say that compliance to the evidence is achieved.

After consolidating all the evidences, the assessment team has to decide on the score for the
indicator. The following scale is used for scoring the indicators:

1 =0% compliance to the indicator
2 =1 - 49 % compliance to the indicator
3 =50 99 % compliance to the indicator
4 =100 % compliance to the indicator

For core indicators (see figure 1), compliance may either be all or nothing. Thus, the hospitals may
only get a score of 1 or 4. For non-core indicators, the scoring depends on whether the indicator is
qualitative or quantitative.

Page 4 of 76

Figure 1. Example of a core indicator 1.1.a.1 All patient charts have signed consent. Notice that
the only possible scores for this indicator are 1 (0% compliance) and 4 (100% compliance).

Quantitative indicators require computation, usually of the proportion of a sample that met a certain
requirement e.g. Percentage of charts with progress notes by doctors (see figure 2). The formula for
computation is reflected in the evidence. The resulting percentage is verified against the scale to get
the actual score for that indicator.

Figure 2. 2.3.2.c.2 Percentage of charts with progress notes by nurses

Qualitative indicators, on the other hand, do not require a randomly selected sample. Rather, it
involves compliance to the listed evidence. The self-assessment team, upon consolidating the
findings from the different hospital, computes for the proportion of the listed evidence that the hospital
has complied with. In 1.1.b.1 for example (figure 3), there are four listed evidences. If the hospital
has all the enumerated policies i.e. 4 out of the 4 evidences, then that is 100%. Following the scale,
the score of the hospital for 1.1.b.1 is 4. If for example, the hospital only had 2 of the enumerated
policies i.e. 2 of the 4 evidences or 50%, again, using the scale, the hospital would get a score of 3.

Figure 3. 1.1.b.1 Presence of policies and procedures to identify and address patients rights: right to
care, right to consent, freedom of choice, rights of incompetent patients.

5. COMPUTE THE OVERALL SCORES

After finalizing the scores for all the indicators, the overall score of the hospital may now be
computed. To start, the indicator scores need to be averaged per criterion. The averaging includes
the scores for the core indicators.

The criteria and the indicators for each criterion must be identified. The
CODE will be of use in identifying which indicators belong to which criterion.
For Patient Rights and Organizational Ethics and Improving Performance, the
code is only four characters (e.g. 1.1.b.1). The first character represents the
performance area (e.g. 1.1.b.1). The second character represents the
standard (e.g. 1.1.b.1. The third character, a letter, represents the criterion
(e.g. 1.1.b.1) and the last character, the indicator (e.g. 1.1.b.1).

Page 5 of 76

The five-character alphanumeric code for Patient Care, Leadership and
Management, Human Resource Management, Information Management and
Safe Practice and Environment represents the performance area, sub-area,
standard, criterion (letter code) and indicator respectively.

There are a few standards that
do not have a criterion. The
criterion is assigned x as the
letter code. In these cases, the
standard will serve as the
criterion. All indicators under
that standard will then be
averaged to get the criterion
score.

Figure 4 shows a few examples
of such indicators. Standard
7.4 and 7.5 both have only one
indicator each while the
standard 7.6 has 3 indicators
7.6.x.1, 7.6.x.2 and 7.6.x.3

The computation of criterion
scores is illustrated in the
following example:

In figure 5, 1.1.a.1 under
Patient Rights and
Organizational Ethics is the
lone indicator for the criterion
whereas 1.2.a.1, 1.2.a.2 and
1.2.a.3 all belong to just one
criterion. Thus, the aggregation
for the sample scores will be as
follows:

Aggregated criterion score =
(score for indicator 1 +score for
indicator 2 + +score for
indicator n) n

*(n is the number of indicators
for the criterion)

1.1.a.1 =4
1.1.b.1 =1
1.1.c.1 =3
1.1.d.1 =3
(1.2.a.1 +1.2.a.2 +
1.2.a.3) 3 (#of
indicators for the
criterion) =(3 +3 +4) 3
=3.33
1.2.b.1 =3
(1.3.a.1 +1.3.a.2) 2 =
(3 +2) 2 =2.5
1.3.b.1 =2

Figure 4
Figure 5.
Sample score
sheet
Page 6 of 76
Scores for the performance area can then be computed as follows:

Performance area score (%) =(Sum of all criterion scores Maximum possible score for the
performance area) x 100

Maximum possible score =Number of criteria for the performance area x 4 (maximum score)

With the computed performance area scores and percentage compliance to CORE indicators (which
should be 100%), the hospital may now refer to the Table of Accreditation Awards. The Table of
Accreditation Awards lists the percentage compliance needed for each award. The hospital may
apply for the award where their scores the application form and in the Benchbook Self-Assessment
Summary (Appendix C).

Accreditation
Award
Criteria
Center of Safety
Compliance to 100% of CORE indicators
+
60 % compliance to each of the following:
Patients Rights and Organizational Ethics
Safe Practice and Environment
Patient Care
Center of Quality
+
75 % compliance to each of the following:
Patients Rights and Organizational Ethics
Patient Care
Information Management
Human Resource Management
Leadership and Management
Center of Excellence
+
90% compliance to each of the 7 performance areas

Page 7 of 76
NOT FOR CIRCULATION
BENCHBOOK for HOSPITALS
Self Assessment and Survey Tool
SECTION 1 - DOCUMENT REVIEW
1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients' rights and ethically relating with patients and other organizations
1.1.b.1 Organizational policies and
procedures respect and support
patients' right to quality care and
their responsibilities in that care.
Policies and procedures
which identify and address
patients rights and
responsibilities are
documented and
monitored.
Presence of policies and
procedures to identify and
address patients' rights:
right to care, right to consent,
freedom of choice, rights of
incompetent patient (ex.
minors)
__
__
__
__
__
__
__
__
DOCUMENT REVIEW
1. Policies and procedures on patients' rights: right to care
2. Policies and procedures on patients' rights: right to consent
3. Policies and procedures on patients' rights: freedom of choice
4. Policies and procedures on patients' rights: rights of incompetent
patients (minors)
1.1.d.1 Organizational policies and
The hospital protects
patients and respects their
rights during research
involving human subjects
procedures to protect patients
and respect their rights during
research involving human
subjects
__
__
__
__
DOCUMENT REVIEW
Policies and procedures on conduct of research involving patients:
benefits and risks, informed consent, etc.
INTERVIEW
If hospital has done or has an ongoing research study involving patients:
Ask leaders/researcher during leadership meeting regarding recruitment
of participants, informed consent, confidentiality, etc
1.2.a.1 The organization encourages and
promotes opportunities to involve
patients and their families in their
care.
Policies and programs to
educate patients and
families on how to take a
more pro-active role in
health care decision
making are documented,
monitored and evaluated
for their effectiveness.
Presence of policies
regarding active participation
of patients and families in
health care decisions
__
__
__
__
__
__
__
__
DOCUMENT REVIEW
1. Policies on patient education
2. Policies on family education
3. Policies on patient involvement in care decision-making
4. Policies on family involvement in care decision-making
care.
Proof of ongoing policy
review to monitor and
evaluate the effectiveness of
the program on patient
education
__ __
DOCUMENT REVIEW
Monitoring reports related to patient or family education program/policy
STANDARDS CRITERIA INDICATOR REMARKS HOSP PHIC EVIDENCE CODE
1 of 43
Appendix A
Page 8 of 76
NOT FOR CIRCULATION
Self Assessment and Survey Tool
SECTION 2 - LEADERSHIP INTERVIEW
subjects
__
__
__
__
DOCUMENT REVIEW
INTERVIEW
1.3.b.1 The organization documents and
follows policies and procedures
for addressing patients' needs for
confidentiality, privacy, security,
religious counseling and
communication.
The hospital systematically
determines, monitors and
improves the extent to
which patients' needs for
confidentiality, privacy,
security, counseling and
communication are
addressed.
Presence of patient feedback
mechanism on addressing
patients' needs for
security, religious counseling
and communication
__
__
__
__
DOCUMENT REVIEW
Any reports on patient feedback monitoring e.g. analysis of patients'
suggestions, complaints and other feedback or patient satisfaction
survey result
INTERVIEW
Ask leaders about their patient feedback mechanism and/or their patient
satisfaction survey
1.5.b.1 The organization's personnel
discharge their functions
according to codes of ethical
behavior and other relevant
professional and statutory
standards.
The organization identifies
and monitors personnel
compliance with the code
of ethics relevant to their
respective disciplines.
procedures on monitoring
compliance of personnel with
codes of professional conduct
relevant to their respective
disciplines
__
__
__
__
__
__
DOCUMENT REVIEW
Policies and procedures on monitoring compliance to codes of
professional conduct relevant to their respective discipline
INTERVIEW
1. Ask leaders regarding their compliance with the codes of professional
conduct e.g. advertisement of services by doctors, sponsorship of
hospital activities by drug companies
2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging
and laboratory regarding their compliance with the codes of professional
Note : Proof of compliance may include: the establishment of an Ethics
Committee that will regularly review these codes, undertake education
of staff on ethical conduct, recommend regulatory policies and
disciplinary measures
STANDARDS CRITERIA INDICATOR REMARKS HOSP PHIC EVIDENCE CODE
1 of 14
Appendix A
Page 9 of 76
Benchbook for Hospitals Score Sheet
1.1.a.1
core __ __
DOCUMENT
Patient charts - sample charts of patients currently admitted. If hospital is
departmentalized, get samples during tour of the different departments.
Formula: No. of patient charts with signed consent / no. of patient charts
reviewed x 100
Sample size:10% or 10 charts whichever is lower
Note: *Informed consent - includes a patient-doctor discussion of the ff
issues: the nature of the decision or procedure; reasonable alternatives to
the proposed intervention; the relative risks, benefits, and uncertainties
related to each alternative; assessment to patient understanding; and
patient's acceptance or refusal of the intervention.
Wards 1
4
1
4
1.1.b.1
__
__
__
__
__
__
__
__
DOCUMENT REVIEW
patients (minors)
Document review 1
2
3
4
1
2
3
4
1.1.c.1
__
__
__
__
DOCUMENT or OBSERVATION
Written statements of patient rights and responsibilities given to patients or
Information Education Campaign (IEC) materials on patient rights and
responsibilities such as posters, flyers, pamphlets, audio-visual
presentation, etc. Check the following areas: admitting section, ER,
wards and OPD.
INTERVIEW
Ask patients from ER, wards or OPD what their rights and responsibilities
are
ER
Wards
OPD
Others - admitting
section
1
3
4
1
3
4
1.1.d.1
__
__
__
__
DOCUMENT REVIEW
INTERVIEW
Ask leaders/researcher during leadership meeting regarding recruitment of
participants, informed consent, confidentiality, etc
Document review
Leadership meeting
1
3
4
1
3
4
1.2.a.1
__
__
__
__
__
__
__
__
DOCUMENT REVIEW
Document review 1
2
3
4
1
2
3
4
1.2.a.2
__ __
CHART REVIEW
Patient charts from medical records - check the nurses' notes/doctor's
orders for health education, advice and home instructions
Formula: Number of charts with health education, advice and home
instructions/ Number of charts reviewed
Sample size: 10 charts from the medical records or 10% whichever is
lower
Chart review 1
2
3
4
1
2
3
4
1.2.a.3
__ __
DOCUMENT REVIEW
Document review 1
4
1
4
1.2.b.1
__
__
__
__
__
__
DOCUMENT REVIEW
Policies and procedures on involvement of patients and families in making
care decisions on ethical issues to include the ff:
Right of unconscious patients
Right to dignity
Right to appropriate care based on religious and personal beliefs etc.
INTERVIEW
1. Ask the doctors and nurses in the ER, wards or ICU on how they
involve the patients' families on making care decisions with ethical issues
2. Ask the patient or patient's family (ER, wards or ICU) if the
doctor/hospital staff involves them in making care decisions with ethical
issues e.g. In medicine ward, you may ask about advance directives, truth
telling to the dying, diet (Muslims, vegetarian). In ICU, ask about proxy
consent. In surgery and OB wards - procedures involving reproductive
tract (BTL, hysterectomy, oophorectomy, sexual reassignment)
Document review
ER
Wards
ICU
1
2
3
4
1
2
3
4
1.3.a.1
__
__
__
__
__
__
__
__
__
__
DOCUMENT REVIEW
1. Policies and procedures that address patients' needs for confidentiality
2. Policies and procedures that address patients' needs for privacy
3. Policies and procedures that address patients' needs for security
4. Policies and procedures that address patients' needs for religious
counseling
5. Policies and procedures that address patients' needs for
communication
Note: Take note of the provisions of the policies for use in interview during
survey of wards, ER, imaging and laboratory
Document review 1
2
3
4
1
2
3
4
CODE
SELF-
ASSESSMENT
SCORE
SURVEYOR
SCORE
REMARKS HOSP PHIC EVIDENCE SECTION
Scoring:
1: 0% compliance to the indicator
2: 1 - 49% compliance to the indicator
3: 50 - 99% compliance to the indicator
4: 100% compliance to the indicator 1 of 23
Appendix B
Page 10 of 76

B
B
B
E
E
E
N
N
N
C
C
C
H
H
H
B
B
B
O
O
O
O
O
O
K
K
K
S
S
S
E
E
E
L
L
L
F
F
F
-
-
-
A
A
A
S
S
S
S
S
S
E
E
E
S
S
S
S
S
S
M
M
M
E
E
E
N
N
N
T
T
T
S
S
S
U
U
U
M
M
M
M
M
M
A
A
A
R
R
R
Y
Y
Y
(This form must be accomplished by the hospital.)

Name of hospital
DOHLicenseNo.
Category Primary Secondary Tertiary
Classification Government Private
Address
Province
Region
Accreditation
status applied for
CenterofSafety CenterofQuality CenterofExcellence

Self-assessment scores per area Compliance(%)
Patient Rights and Organizational Ethics
Patient Care
Leadership and Management
Human Resource Management
Information Management
Improving Performance

Compliance to core indicators
Number of core indicators complied with
Percentageofcompliance

Appendix C
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MASTER LIST
NOT FOR CIRCULATION
1.1.a.1
core
Organizational policies and
Informed consent is
obtained from patients
prior to initiation of care.
All patient charts have signed
consent
CORE
DOCUMENT
Patient charts - sample charts of patients currently admitted. If hospital
is departmentalized, get samples during tour of the different
departments.
Formula: No. of patient charts with signed consent / no. of patient charts
reviewed x 100
Sample size: 10% or 10 charts whichever is lower
Note: *Informed consent - includes a patient-doctor discussion of the ff
issues: the nature of the decision or procedure; reasonable alternatives
to the proposed intervention; the relative risks, benefits, and
uncertainties related to each alternative; assessment to patient
understanding; and patient's acceptance or refusal of the intervention.
Wards
1.1.b.1 Organizational policies and
which identify and address
patients rights and
documented and
monitored.
procedures to identify and
address patients' rights:
right to care, right to consent,
freedom of choice, rights of
incompetent patient (ex.
minors)
DOCUMENT REVIEW
patients (minors)
Document review
1.1.c.1 Organizational policies and
Patients receive written
statements of their rights
and responsibilities.
Proof that patients are
informed of their rights and
responsibilities through IEC
materials; e.g., posters, flyers,
pamphlets, audio-visual
presentation, etc.
DOCUMENT or OBSERVATION
Written statements of patient rights and responsibilities given to patients
or Information Education Campaign (IEC) materials on patient rights and
responsibilities such as posters, flyers, pamphlets, audio-visual
presentation, etc. Check the following areas: admitting section, ER,
wards and OPD.
INTERVIEW
Ask patients from ER, wards or OPD what their rights and
ER
Wards
OPD
Others - admitting
section
subjects
DOCUMENT REVIEW
INTERVIEW
Document review
Leadership
interview
REMARKS EVIDENCE SECTION CODE STANDARDS CRITERIA INDICATOR
1 of 63
Page 12 of 76
MASTER LIST
NOT FOR CIRCULATION
care.
Presence of policies
regarding active participation
of patients and families in
health care decisions
DOCUMENT REVIEW
Document review
care.
Percentage of charts with
health education, advice and
home instructions
CHART REVIEW
Patient charts from medical records - check the nurses' notes/doctor's
orders for health education, advice and home instructions
Formula: Number of charts with health education, advice and home
instructions/ Number of charts reviewed
Sample size: 10 charts from the medical records or 10% whichever is
lower
Chart review
care.
Proof of ongoing policy review
to monitor and evaluate the
effectiveness of the program
on patient education
DOCUMENT REVIEW
Document review
2 of 63
Page 13 of 76
MASTER LIST
NOT FOR CIRCULATION
1.2.b.1 The organization encourages and
care.
Patients and their families
are involved in making
care decisions with ethical
issues, such as
withholding resuscitation,
foregoing life-sustaining
treatment, end-of-life care,
etc.
procedures on involvement of
patients and families in
making care decisions on
ethical issues
such as withholding
resuscitation, foregoing life-
sustaining treatment, end-of-
life care, etc.
DOCUMENT REVIEW
Policies and procedures on involvement of patients and families in
making care decisions on ethical issues to include the ff:
Right of unconscious patients
Right to dignity
Right to appropriate care based on religious and personal beliefs etc.
INTERVIEW
1. Ask the doctors and nurses in the ER, wards or ICU on how they
involve the patients' families on making care decisions with ethical
issues
2. Ask the patient or patient's family (ER, wards or ICU) if the
doctor/hospital staff involves them in making care decisions with ethical
issues e.g. In medicine ward, you may ask about advance directives,
truth telling to the dying, diet (Muslims, vegetarian). In ICU, ask about
proxy consent. In surgery and OB wards - procedures involving
reproductive tract (BTL, hysterectomy, oophorectomy, sexual
reassignment)
Document review
ER
Wards
ICU
1.3.a.1 The organization documents and
communication.
Hospital staff is aware of
and follows policies and
procedures in addressing
patients needs for
security, counseling, and
communication.
procedures that address
patients' needs for
and communication
DOCUMENT REVIEW
confidentiality
2. Policies and procedures that address patients' needs for privacy
3. Policies and procedures that address patients' needs for security
4. Policies and procedures that address patients' needs for religious
counseling
communication
Note : Take note of the provisions of the policies for use in interview
during survey of wards, ER, imaging and laboratory
Document review
3 of 63
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MASTER LIST
NOT FOR CIRCULATION
communication.
Hospital staff is aware of
and follows policies and
procedures in addressing
patients needs for
security, counseling, and
communication.
Proof of hospital staff
awareness and compliance
with the policy in addressing
patients needs for
security, religious counseling,
and communication.
DOCUMENT
Security logs (ER, entrance)
INTERVIEW
1. Ask patients from the wards, ER and imaging if they feel secured
2. Ask patients from the wards, ER and imaging if their privacy is
respected
3. Ask staff regarding provisions of the policy addressing needs for
privacy, confidentiality, religious counseling and communication
OBSERVATION
1. Observe if patients privacy is respected in all areas of the hospital
e.g.. partitioning in patients room for those who will undergo procedures
and examination that require privacy.
2. The structures of emergency room and OPD allow for auditory and
visual privacy.
3. Observe if all areas in which patients receive care are secured.
Observe the vicinity (outside the building).
Wards
ER
Imaging
Laboratory
1.3.b.1 The organization documents and
communication.
The hospital systematically
determines, monitors and
improves the extent to
which patients' needs for
security, counseling and
communication are
addressed.
Presence of patient feedback
mechanism on addressing
patients' needs for
and communication
DOCUMENT REVIEW
Any reports on patient feedback monitoring e.g. analysis of patients'
suggestions, complaints and other feedback or patient satisfaction
survey result
INTERVIEW
Ask leaders about their patient feedback mechanism and/or their patient
satisfaction survey
Document review
Leadership
interview
1.4.a.1 The organization systematically
elicits, monitors and acts upon
feedback from patients, their
families, visitors and
communities.
for routinely determining
and improving the level of
patient satisfaction with all
relevant aspects of care
are documented and
monitored.
Presence of policies for
routinely determining and
improving the level of patient
satisfaction
DOCUMENT REVIEW
1. Policies for routinely determining and improving the level of patient
satisfaction
2. Patient satisfaction questionnaire/survey or patient satisfaction
survey results or documentation of actions to address the identified gaps
Document review
1.4.b.1 The organization systematically
elicits, monitors and acts upon
feedback from patients, their
families, visitors and
communities.
for addressing and
resolving patients
complaints are
documented and
monitored.
procedures for addressing
and resolving patients'
complaints
DOCUMENT REVIEW
1. Policies and procedures on addressing and resolving patients
complaints
2. Minutes of meetings that address/resolve patients' complaints or
patient satisfaction survey results
Document review
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1.5.a.1 The organization's personnel
standards.
relevant codes of
professional conduct and
other statutory standards
and informs its personnel
about these codes and
standards.
procedures on codes of
professional conduct
consistent with relevant
statutory standards
DOCUMENT REVIEW
Policies and procedures on codes of professional conduct
Policies and procedures on codes of professional conduct are consistent
with relevant statutory standards such as, but not limited to:
1. Codes of professional standards (PRC, PMA, PNA, PAMET, CSC,
DOLE, etc)
2. Patient detention (RA 9434) and
3. Anti-deposit law (RA 8344)
4. Sexual harassment law (RA 7877).
Document review
1.5.a.2 The organization's personnel
standards.
relevant codes of
professional conduct and
other statutory standards
and informs its personnel
about these codes and
standards.
Presence of programs on
improving staff awareness on
and other statutory standards
DOCUMENT REVIEW
Documents related to implementation of the program e.g. copy of
lectures on professional conduct and related topics
INTERVIEW
Ask staff (HR) about the programs on awareness on codes of
professional conduct and other statutory standards
Document review
HR
1.5.b.1 The organization's personnel
standards.
and monitors personnel
compliance with the code
of ethics relevant to their
respective disciplines.
procedures on monitoring
compliance of personnel with
relevant to their respective
disciplines
DOCUMENT REVIEW
Policies and procedures on monitoring compliance to codes of
professional conduct relevant to their respective discipline
INTERVIEW
1. Ask leaders regarding their compliance with the codes of professional
2. Ask doctors, nurses and other staff from wards, ER, OPD, imaging
and laboratory regarding their compliance with the codes of professional
Note : Proof of compliance may include: the establishment of an Ethics
Committee that will regularly review these codes, undertake education
of staff on ethical conduct, recommend regulatory policies and
disciplinary measures
Document review
Leadership
interview
Wards
ER
OPD
Imaging
Laboratory
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1.5.c.1 The organization's personnel
standards.
Procedures for resolving
ethical issues related to
professional practice or to
conflicts of interest are
based on the relevant
code of ethics and other
professional and legal
standards.
procedures for resolving
ethical issues related to
professional practice or to
conflicts of interest that are
based on the relevant code of
ethics and other professional
and legal standards
DOCUMENT REVIEW
1. Policies and procedures for resolving ethical issues related to
professional practice or to conflicts of interest
2. Policies and procedures for resolving ethical issues related to
professional practice or to conflicts of interest are based on relevant
codes of ethics and other professional and legal standards
3. Proof of compliance to the policies and procedures, which may
include the establishment of an Ethics Committee that will resolve issues
related to professional practice or to conflicts of interest or minutes of
meeting of the committee
INTERVIEW
Ask leaders how they handle ethical issues related to professional
practice or conflicts of interest
Document review
Leadership
interview
follows procedures for resolving
ethical issues as they arise from
patient care.
ethical issues that arise in
the course of providing
care are monitored for
their effectiveness.
procedures for resolving
ethical issues arising from
patient care
DOCUMENT REVIEW
Policies and procedures for resolving ethical issues arising from patient
care or reports or records of resolution of ethical dilemmas arising in the
course of providing care e.g. disclosure of treatment-related injuries or
adverse events
Document review
follows procedures for resolving
ethical issues as they arise from
patient care.
ethical issues that arise in
the course of providing
care are monitored for
their effectiveness.
Proof of monitoring of
policies/procedures for
resolving ethical issues
arising from patient care
DOCUMENT REVIEW
Annual reports of the Ethics Committee (if present) or any similar reports
on ethical issues by any hospital committee or body
Document review
2. PATIENT CARE
2.1. ACCESS
Goal: The organization is accessible to the community that it aims to serve.
2.1.1.a.1 The organization informs the
community about the services it
provides and the hours of their
availability.
Information detailing the
clinical services offered
and hours of their
availability is strategically
distributed and prominently
posted.
Presence of signages,
posters and other information
materials/media detailing the
clinical and ancillary services
offered and hours of
availability
OBSERVATION
1. Look for signage/s of services offered or presence of flyers, posters,
pamphlets about the services offered and the hours of their availability at
the ER, OPD, lobby and hospital perimeter
2. The hours of availability are indicated in the signage/s, flyers, posters
or pamphlets at the ER, OPD, lobby and hospital perimeter
3. "PhilHealth Accredited" signage, if applicable
ER
OPD
Other Areas: lobby,
hospital perimeter
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2.1.1.b.1
core
The organization informs the
availability.
Clinical services are
appropriate to patients'
needs and the former's
availability is consistent
with the organization's
service capability and role
in the community.
Presence of facilities
consistent with clinical service
capability based on DOH
license in accordance with the
hospitals level (e.g. level 2
surgical capability, level 3
ICU, level 4 teaching and
training hospital)
CORE
DOCUMENT REVIEW
1. List of services available
2. DOH License
OBSERVATION:
Look at the facilities, structure, manpower, equipment and supply.
Check if the service capability of the hospital is in accordance with the
hospital level
Document review
ER
OPD
ICU
OR/RR/PACU
2.1.1.b.2 The organization informs the
availability.
Clinical services are
appropriate to patients'
needs and the former's
availability is consistent
with the organization's
service capability and role
in the community.
Presence of services
addressing the endemic and
most common diseases in the
community
DOCUMENT REVIEW
1. Inpatient census
2. Outpatient census.
3. The hospital should have services that address the top ten diseases
in their census.
4. The hospital should have services in accordance to the 'Mother-Baby
Friendly Hospital Initiative"
5. The hospital should have services for newborn screening
INTERVIEW
Interview leaders regarding availability of services for endemic and most
common diseases in the community based on their census
Document review
Leadership
interview
2.1.1.c.1 The organization informs the
availability.
The community is aware of
clinical services offered
and times of availability
Percentage of patients who
are aware of the services
provided by the hospital
INTERVIEW
Ask patients or relatives/caregivers from ER and OPD if they are aware
of the clinical services offered and times of availability
Note: Ask only about the services relevant to the patient or caregiver.
Formula: Number of respondents who are aware of the services/
number of respondents X 100
Sample size: Rule of 10 (10 patients or 10% whichever is lower)
ER
OPD
2.1.2.a.1
core
Physical access to the
organization and its services is
facilitated and is appropriate to
patients' needs.
Entrances and exits are
clearly and prominently
marked, free of any
obstruction and readily
accessible.
Presence of entrances and
exits that are readily
accessible and free from
obstruction
CORE
OBSERVATION
1. Entrance and exit signs. Check ER, OPD, wards, ICUs, OR, imaging
and laboratory
2. Entrances and exits are accessible and free from any obstruction
Note: Exit signs should be luminous or illuminated and prominently
marked. There should be exit signs in major areas of the hospital and
all doors leading to the outside.(Reference: RA 6541 Building Code of
the Philippines)
ER
OPD
Wards
ICU
OR/RR/DR/PACU
Imaging
Laboratory
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2.1.2.b.1
core
patients' needs.
Directional signs are
prominently posted to help
locate service areas within
the organization.
Presence of directional
signages to locate service
areas
CORE
OBSERVATION
Directional signs are prominently posted. Check ER, OPD, wards and
lobby.
NOTE: For smaller hospitals, look for labels/signages in major areas
including comfort rooms.
ER
OPD
Wards
Other Areas -
Lobby
2.1.2.c.1
core
patients' needs.
Alternative passageways
for patients with special
needs (e.g. ramps) are
available, clearly and
prominently marked and
free of any obstruction
Presence of alternative
passageways (ramps,
elevators) that are
prominently marked and free
from obstruction for patients
with special needs
CORE
OBSERVATION
1. There are alternative passageways for patients with special needs.
Check ER, OPD, wards and other areas
2. They are prominently marked and
3. They are free from obstruction.
ER
OPD
Wards
Other Areas
2.1.2.d.1 Physical access to the
patients' needs.
Major service areas have
nearby waiting facilities
that are clean, well-lit,
adequately ventilated and
equipped with appropriate
fixtures and furniture
Presence of waiting facilities
that are clean, well-lit,
adequately ventilated and
equipped with appropriate
fixtures and furniture
OBSERVATION
1. Waiting area/room/facility are provided in the ER, OPD, imaging,
laboratory, ICU and other areas
2. Waiting facilities are clean:
3. Waiting facilities are well-lit
4. Waiting facilities are adequately ventilated and
5. Waiting facilities are equipped with appropriate fixtures and furniture
ER
OPD
Imaging
Laboratory
ICU
Other Areas
2.1.2.e.1 Physical access to the
patients' needs.
The organization
documents, follows
policies and procedures,
and provides resources for
the safe and efficient
direction of patients, their
families and visitors and
staff traffic.
Policies and procedures for
the safe and efficient direction
of patients, their families and
visitors and staff traffic are
followed
DOCUMENT REVIEW
Policies and procedures for the safe and efficient direction of patients,
their families and visitors and staff traffic.
Note: Take note of the provisions of the policies for use in interview
during survey of wards, ER, OPD, ICU, OR, imaging and laboratory.
INTERVIEW
Ask nurses and staff regarding policies and procedures for the safe and
efficient direction of patients, their families and visitors. Verify if answer
is consistent with written hospital policy.
OBSERVATION
The staff, patients and visitors follow the policies and procedures.
Visiting hours posted may be considered; may also be found in hospital
manual
Document review
ER
OPD
Wards
ICU
OR/RR/DR/PACU
Imaging
Laboratory
Other Areas
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2.1.2.f.1 Physical access to the
patients' needs.
Patients, their visitors and
staff can efficiently and
safely move within the
confines of the
organization.
Presence of safe and
spacious hallways/
passageways
OBSERVATION
Patients, visitors and staff can efficiently and safely move within the
confines of the organization (e.g. non-slippery floors, spacious
passageways, etc.)
ER
OPD
Wards
ICU
OR/RR/DR/PACU
Imaging
Laboratory
Other Areas
2.2. ENTRY
Goal: The entry process meet patient needs and are supported by effective systems and a suitable environment.
2.2.1.a.1 Patients receive prompt and
timely attention by qualified
professionals upon entry.
Patient waiting times are
routinely monitored,
evaluated and improved
based on standards and
procedures developed by
the organization.
Depending on their needs,
patients are seen within
the planned waiting period.
procedures on patient waiting
time
DOCUMENT REVIEW
Policies and procedures on patient waiting time
Document review
the organization.
Presence of monitoring
system for patient waiting
times
DOCUMENT REVIEW
Monitoring and evaluation reports on patient waiting time
Note: Hospitals should set the patient waiting time.
Document review
the organization.
have been attended to in
accordance with the hospital
policy
INTERVIEW
Interview patients from ER, OPD, imaging or laboratory regarding
waiting times. Verify the time the patient was seen from ER chart or
logbook from ER, OPD, imaging or laboratory
Formula: Number of patients who waited based on the prescribed
waiting time/total number of patients interviewed x 100
Sample size: Rule of 10
ER
OPD
Imaging
Laboratory
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2.2.1.b.1 Patient receive prompt and timely
attention by qualified
Patients are informed of
the cause of any delay in
the delivery of services.
Presence of policies on
informing patients for any
cause of delay in the delivery
of services
DOCUMENT REVIEW
Policies and procedures on informing patients for any cause of delay in
the delivery of services
Document review
2.2.1.b.2 Patient receive prompt and timely
Patients are informed of
the cause of any delay in
the delivery of services.
Percentage of patients
informed of the cause of any
delay
INTERVIEW
Ask patients from ER, OPD, wards, imaging or laboratory if they were
informed about possible causes of delay of care if applicable
Formula: Number patients informed of the cause of any delay in
delivery of services / number of patients with delayed provision of
services x 100
ER
OPD
Wards
Imaging
Laboratory
2.2.1.c.1 Patient receive prompt and timely
Patients are satisfied with
the actual waiting time.
satisfied with actual waiting
time
INTERVIEW
Ask patients from ER, OPD, imaging or laboratory if they are satisfied
with the waiting time
Formula: Number of patients satisfied with actual waiting time/total
number of patients interviewed x 100
Sample size: 10 patients or 10% whichever is lower
ER
OPD
Imaging
Laboratory
2.2.2.a.1 The organization documents and
follows policies and procedures,
and provides resources to ensure
proper patient triaging.
The staff follows policies
and procedures in
determining and
prioritizing patients' clinical
needs and in identifying
clinical services that will
best address them.
procedures in determining
and prioritizing patients
clinical needs and in
identifying clinical services
that will best address them
DOCUMENT REVIEW
1. Policies and procedures in determining and prioritizing patients'
clinical needs
2. Policies and procedures in identifying clinical services that will best
address patient's clinical needs
Document review
2.2.2.b.1 The organization documents and
The staff follows policies
and procedures in
determining admissibility
of patients or the need for
referral to other
organizations.
procedures in determining
and prioritizing admissibility of
patients or the need for
referral to other organizations
DOCUMENT REVIEW
1. Policies and procedures in determining and prioritizing admissibility
of patients or the need for referral to other organizations
2. Policies and procedures in determining and prioritizing the need for
referral to other organizations
3. ER/OPD logbook of admissions and referrals
INTERVIEW
Ask ER/OPD staff on procedures of admission and referrals
Note : identify personnel to be interviewed. May obtain chart from wards
and look for the chief complaint, determine admissibility and need for
referral.
Document review
ER
OPD
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2.2.2.c.1 The organization documents and
Patients are correctly and
efficiently assigned to the
clinical services
appropriate to their needs
correctly assigned to the
clinical services appropriate
to their needs
DOCUMENT
Patient chart from ward and ICU
Note: Determine if the service the patient is admitted to coincides with
the patient's chief complaint and working diagnosis.
Formula: Number of patients correctly assigned to the clinical services
appropriate to their needs / total number of patients interviewed x 100
Sample Size: Rule of 10
Wards
ICU
2.2.3.a.1 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
identified by their patient
charts
procedures for correctly
identifying patients by their
chart
DOCUMENT REVIEW
Policies and procedures for correctly identifying patients by their chart
Footnote: to uniquely identify a patient may mean making the patient
number a lifetime number.
Document review
2.2.3.a.2
core
The organization uniquely
identified by their patient
charts
identified by their charts
CORE
DOCUMENT and INTERVIEW
Patient chart from ER, ward, OPD and ICU and verify with patient if
he/she really is the person indicated in the chart
Formula: Number of charts correctly identified with patient / total
number of charts reviewed x 100
Sample size: 10 charts or 10% whichever is lower
ER
OPD
Wards
ICU
2.2.3.b.1 The organization uniquely
The patient charts contain
identifiers unique to each
patient
unique identifiers for each
patient
DOCUMENT
Patient chart from ER, OPD, wards and ICU
Note: Review patients charts and look for patients complete name,
address, birthday, demographic data (sex, age, civil status), hospital
number. For newborns, look for parents' names and footprint of the
baby, attending physician, room number
Formula: Number of charts with unique identifiers/Number of charts
reviewed x 100
ER
OPD
Wards
ICU
2.2.3.c.1 The organization uniquely
Patient charts are
appropriately and
systematically indexed to
facilitate retrieval and
storage and to avoid
duplication or loss
Percentage of charts properly
indexed
OBSERVATION
Look at how the charts in the OPD, wards and medical records are
indexed and arranged in the chart tray
Formula: Number of charts properly indexed/Number of charts
reviewed x 100
OPD
Wards
Medical Records
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2.2.4.a.1 The health professional
responsible for the care of the
patient obtains informed consent
for treatment.
Prior to admission,
patients and/or their
families are appropriately
informed by authorized
qualified personnel of their
disease, condition or
disability, its severity, likely
prognosis, benefits and
possible adverse effects of
various treatment options,
and the likely costs of
treatment.
admitted who are
appropriately informed by
authorized qualified
personnel of their disease,
condition or disability, its
severity, likely prognosis,
benefits and possible adverse
effects of various treatment
options and the likely costs of
treatment
INTERVIEW
Ask patient/family from the wards/ICU if they were appropriately
informed by authorized qualified personnel (doctor, nurse or other allied
medical staff) about the following: their disease, condition or disability,
its severity, likely prognosis, benefits and possible adverse effects of
various treatment options and the likely cost of treatment
Formula: Number of patients/families who were appropriately informed
by authorized qualified personnel/Total number of patients/families
interviewed x 100
Wards
ICU
2.2.4.b.1 The health professional
responsible for the care of the
patient obtains informed consent
for treatment.
Patient and/or their
families demonstrate
knowledge of their
prognosis, benefits, and
various treatment options,
and the likely costs of
treatment.
Percentage of
patients/relatives who have
knowledge about their
prognosis, benefits, and
various treatment options and
the likely costs of treatment
INTERVIEW
Ask the patients/relatives from wards or ICU about the following: their
disease, condition or disability, its severity, likely prognosis, benefits,
and possible adverse effects of various treatment options and the likely
costs of treatment
Formula: Number of patients/relatives who have knowledge about their
disease/total number of patients /relatives interviewed x 100
Sample size: 10 patients or 10% whichever is lower
Wards
ICU
2.2.5.a.1 Planning for discharge begins
upon entry into the organization
and ensures a coordinated
approach to discharge and
continuing management.
Patients and/or their
families are informed of
the expected (barring any
complications)
approximate duration of
treatment, the extent or
frequency of
reassessment, the likely
outcomes and their need
for follow-up care after
discharge
Percentage of
patients/relatives who were
informed of the approximate
duration of treatment, the
extent or frequency of
reassessment, the likely
outcomes and their need for
follow up care after discharge
INTERVIEW
Ask patients/relatives if any member of the health care team has
informed them of the following: approximate duration of treatment, extent
or frequency of reassessment, likely outcomes and need for follow up
care after discharge.
Note : The surveyor should look for patients who are admitted within the
last 48h and are not yet for discharge
Formula: Number of patients or their relatives who were informed of
approximate duration of treatment , etc/total number of patients or
relatives interviewed x 100
Wards
ICU
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2.2.5.b.1 Planning for discharge begins
upon entry into the organization
and ensures a coordinated
approach to discharge and
continuing management.
Patients and/or their
families are informed of
the need for and
availability of resources to
continue care after
discharge
Percentage of patients and/or
their families informed of the
need and availability of
resources to continue care
after discharge
INTERVIEW
Ask patients and/or relatives if they were informed of the need and
availability of resources to continue care after discharge
Formula: Number of patients and/or relatives informed of the need and
availability of resources to continue care after discharge/total number of
patients and/or relatives interviewed
Wards
ICU
2.3. ASSESSMENT
Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care.
2.3.1.a.1
core
Each patient's physical,
psychological and social status is
assessed.
An appropriately
comprehensive history and
physical examination is
performed on every patient
within 24 hours from
admission. The history
includes present illness,
past medical, family, social
and personal history.
All patients have
comprehensive history and
PE within 24 hours from
admission
CORE
DOCUMENT
Patient chart from wards or ER
NOTE: comprehensive history includes present illness, review of
systems, past medical, family and personal history
Formula: Number of charts with comprehensive history and PE within
24 hours from admission/number of charts reviewed x 100
Wards
ER
2.3.1.b.1 Each patient's physical,
psychological and social status is
assessed.
Whenever appropriate,
mental status
examinations,
psychological evaluations
and nutritional and
functional assessments
are performed on the
patient.
Percentage of charts that
have mental status
examinations, psychological
evaluations, nutritional or
functional assessments
performed among patients
who need such evaluations
CHART REVIEW
Patient charts from medical records
Note: Review charts and look for records of mental status examination,
psychological evaluations, nutritional and functional assessments, as
applicable
Formula: Number of patients who underwent mental status
examination, psychological evaluation, nutritional and functional
assessment/Number of patients who should have undergone such
examinations or assessments x 100
Chart review
2.3.2.a.1 Appropriate professionals
perform coordinated and
sequenced patient assessment to
reduce waste and unnecessary
repetition.
Based on collaboratively
developed policies and
procedures, qualified
personnel conduct initial
assessments in an
efficient and systematic
manner to avoid repetition.
procedures on conducting
initial assessments in an
manner
DOCUMENT REVIEW
Policies and procedures on conducting initial assessments in an efficient
and systematic manner
Document review
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2.3.2.a.2 Appropriate professionals
repetition.
Based on collaboratively
developed policies and
procedures, qualified
personnel conduct initial
assessments in an
manner to avoid repetition.
Proof that health
professionals who conduct
initial assessmenst are
qualified
INTERVIEW
1. Ask the staff from the ER and wards who did the initial assessments.
Verify if the identified staff is qualified.
2. Ask the patient from the ER and wards who did the initial
assessments. Verify if the identified staff is qualified.
ER
Wards
2.3.2.b.1 Appropriate professionals
repetition.
The order of assessment
is determined by the
patient's prioritized needs
Proof that order of
assessment was determined
by the patient's prioritized
needs
INTERVIEW
Ask health care professional, e.g.. physician, nurse, PT, etc. how he/she
assessed the patient and relate it to the needs of the patient
Note: The patient's prioritized needs are based on the priority medical
needs as determined by the health care professional.
ER
Wards
ICU
2.3.2.c.1
core
Appropriate professionals
repetition.
Previously obtained
information is reviewed at
every stage of the
assessment to guide
future assessments
All patient charts have
progress notes by doctors
CORE
CHART REVIEW
Patient chart from medical records
Note: The progress notes should be done regularly and documented in
the patient chart either as separate 'progress notes' sheets or side
notes in the doctor's order sheets.
Formula: Number of charts with progress notes by attending health
care professional/total number of charts reviewed x 100
Chart review
2.3.2.c.2 Appropriate professionals
repetition.
Previously obtained
information is reviewed at
every stage of the
assessment to guide
future assessments
progress notes by nurses
CHART REVIEW
Note: Look for nurses' progress notes
Formula: Number of charts with progress notes by attending health
care professional/total number of charts reviewed x 100
Chart review
2.3.3.a.1 Assessments are performed
regularly and are determined by
patient's evolving response to
care.
During the course of
management, qualified
personnel re-assess the
patients' physical and
psychological conditions
according to the patient's
needs.
Proof that re-assessment is
conducted by qualified
personnel according to the
patient's needs
CHART REVIEW
Note: Check if the health professional doing the re-assessment is
licensed and qualified.
Chart review
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2.3.3.b.1 Assessments are performed
care.
Re-assessment is done
whenever the patients'
condition take an
unexpected turn.
progress notes during
instances when patient needs
reassessment
CHART REVIEW
Note: Ask for charts with unexpected outcomes/turn of events, e.g.
adverse events, morbidities, mortalities.
Formula: Number of charts with progress notes/total number of charts
reviewed x 100
Chart review
2.3.3.c.1 Assessments are performed
care.
Re-assessment results in
a review of the patients'
management.
Proof that re-assessment
results in a review of the
patients' management
CHART REVIEW
Note : Look at the progress notes and doctor's orders. Look for the
reassessments done. These should be followed correspondingly by
doctor's orders pertaining to the management of the patient (e.g.
continue present management, an order for an additional medication,
diagnostic or referral)
Chart review
2.3.3.d.1 Assessments are performed
care.
Qualified personnel give
patients for surgery pre-
operative physical and pre-
anesthetic assessment.
procedures regarding pre-
operative and pre-anesthetic
assessment
DOCUMENT REVIEW
1. Policies and procedures regarding pre-operative assessment e.g..
cardio-pulmonary clearance
2. Policies and procedures regarding pre-anesthetic assessment
Document review
2.3.3.d.2 Assessments are performed
care.
Percentage of patients for
surgery who have undergone
pre-operative
physical/medical assessment
CHART REVIEW
Patient chart from medical records (surgery patients)
Note : Look for pre-operative assessment, e.g.. Cardio-pulmonary
clearance
Formula: Number of patients with pre-operative assessments performed
by qualified personnel / Number of patients for surgery reviewed x 100
Chart review
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2.3.3.d.3
core
Assessments are performed
care.
All patients for surgery have
undergone pre-operative
anesthetic assessment
CORE
CHART REVIEW
Note: Look for pre-operative anesthetic evaluation in the patient chart.
Pre-operative assessment should be done for patients requiring more
than local anesthesia.
Formula: Number of patients with pre-operative assessments performed
by qualified personnel / Number of patients for surgery reviewed x 100
Chart review
2.3.3.e.1 Assessments are performed
care.
The status of post-
operative patients is
assessed upon admission
into, during confinement
and upon discharge from
the recovery area
have undergone post-
operative assessment upon
admission into, during
confinement and upon
discharge from the recovery
area
CHART REVIEW
Formula: Number of patients with post-operative assessments / Number
of patients for surgery reviewed x 100
Chart review
2.3.4.a.1 Assessments are documented
and used by the health care team
to ensure effective
communication and continuity of
care.
Legible written records of
the initial and ongoing
assessments are
accomplished for each
patient and kept in the
patient chart
legibly written entries of the
initial and ongoing
assessments
CHART REVIEW
Note: Look at progress notes, side notes or doctor's orders. To test for
legibility, ask the staff nurses to read the entries of the doctors.
Formula: Number of charts with legibly written entries of the initial and
ongoing assessments/total number of charts reviewed x 100
Chart review
2.3.4.b.1 Assessment are documented and
used by the health care team to
ensure effective communication
and continuity of care.
Medical records are stored
in an area that is safe and
accessible to all members
of the health care team,
and whenever appropriate,
to external providers
Presence of safe and
accessible area for keeping of
medical records
OBSERVATION
Safe and accessible area for keeping of medical records in the wards,
ER, OPD and ICU. Records should be safe from unauthorized access.
ER
OPD
Wards
ICU
2.3.5.a.1 Diagnostic examinations
appropriate to the provider
organization's service capability
and usual case mix are available
and are performed by qualified
personnel.
for the standard
performance, monitoring
and quality control of
diagnostic examinations
are documented and
monitored
procedures for the standard
performance, monitoring and
quality control of diagnostic
examinations
DOCUMENT REVIEW
1. Policies and procedures for the standard performance of diagnostic
examinations
2. Policies and procedures for the monitoring of diagnostic
examinations
3. Policies and procedures for the quality control of diagnostic
examinations
Document review
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2.3.5.a.2
core
Diagnostic examinations
personnel.
for the standard
performance, monitoring
and quality control of
diagnostic examinations
are documented and
monitored
Proof of monitoring of the
implementation of the policies
and procedures on quality
control of diagnostic
examinations
CORE
DOCUMENT REVIEW
Monitoring reports, e.g.. utilization review of diagnostics exams done,
audit reports, manual of procedures, or DOH monitoring reports e.g..
Quality control diagnostic reports (QC reports on softwares, calibration of
diagnostic equipment, film reject analysis, etc.)
Document review
2.3.5.b.1 Diagnostic examinations
personnel.
for accessing and referring
patients to approved
external providers when
diagnostic services are not
available within the
provider organization are
documented and
monitored
procedures for accessing and
referring patients to approved
external providers
DOCUMENT REVIEW
Policies and procedures on accessing and referring patients to approved
external providers (outside laboratories, imaging, etc)
Document review
2.3.5.b.2 Diagnostic examinations
personnel.
for accessing and referring
patients to approved
external providers when
diagnostic services are not
available within the
provider organization are
documented and
monitored
Presence of monitoring
system on the implementation
of referral to approved
external providers
DOCUMENT REVIEW
Logbooks for monitoring referral to approved external providers,
monitoring reports or documented actions or Monitoring reports on
documented actions e.g. memos
Note : Hospitals without policies on referral get an automatic score of 1.
Document review
2.3.6.a.1 Assessments of patients with
special needs are determined by
policies and procedures that are
consistent with legal and ethical
requirements.
identify patients with
special needs and the
specific types of
assessment appropriate to
their needs
procedures that identify
patients with special needs
and the specific type of
assessment appropriate to
their needs
DOCUMENT REVIEW
1. Policies and procedures that identify patients with special needs
2. Policies and procedures that identify the specific type of assessment
appropriate to the needs of patients with special needs
Note : For hospitals not handling patients with special needs, their
policies should clearly indicate this.
Footnote: Patients with special needs include infants, school-aged
children, adolescents, the elderly and the disabled, victims of alleged
sexual abuse or violence, patients with emotional or behavioral disorder,
patients with drug dependencies or alcoholism
Document review
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2.4 CARE PLANNING
Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals.
2.4.1.a.1 The care plan addresses patient's
relevant clinical, social, emotional
and religious needs.
The plan, aside from
delineating responsibilities,
includes goals to be
achieved, services to be
provided, patient
education strategies to be
implemented, time frames
to be met, resources to be
used.
Presence of
adopted/developed protocols,
CPGs or pathways containing
goals to be achieved,
services to be provided,
patient education strategies to
be implemented, time frames
to be met and resources to be
used
DOCUMENT
Adopted/developed protocols, CPGs or pathways containing
goals to be achieved
services to be provided
patient education strategies to be implemented
time frames to be met
resources to be used
Footnote : Clinical pathways derived from clinical practice guidelines
and other types of clinical evidence should be developed or
implemented for the top 10 cases of admissions and/or consultations
Wards
ICU
ER
OPD
2.4.2.a.1 The care plan is consistent with
scientific evidence, professional
standards, cultural values,
medico-legal and statutory
requirements.
The care plan is
developed by a multi-
disciplinary team of health
professionals within the
organization
Proof of involvement of a
multidisciplinary team in the
formulation of
adapted/developed protocols,
CPGs or pathways
DOCUMENT REVIEW
Documents (memos, issuances, orders) stating the involvement of a
multidisciplinary team (doctors, nurses, dietitians, social worker and
other medical and paramedical staff) in the development of protocols,
guidelines or pathways
Document review
2.4.2.b.1 The care plan is consistent with
requirements.
The care plan is
developed following
search and appraisal of
published scientific
literature
Proof that evidence-based
approach was used in
developing/adopting the
protocols, CPGs or pathways
DOCUMENT REVIEW
1. Documents (memos, issuances, orders) stating that evidence based
approaches (systematic literature search and appraisal using accepted
tools) were used in adopting/developing the protocols, CPGs and
pathways.
2. Minutes of meetings on development/adoption of the protocols,
guidelines or pathways
Document review
2.4.2.c.1 The care plan is consistent with
requirements.
Expert judgment, practice
standards and patients
values are considered in
developing care plans.
Proof that practice standards
and when necessary, expert
judgment and patient's values
are considered in the care
plan
DOCUMENT
Patient chart from wards or ICU - doctor's orders
Review management if based on practice standards or if expert
judgment (specialists) and patient values were considered as needed
INTERVIEW
Ask doctors their basis for their management, whether they use practice
guidelines, protocols, journal articles or books.
Wards
ICU
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2.4.3.a.1 The organization ensures that
information about the patient's
proposed care is clear and readily
accessible to designated
multidisciplinary health care
providers and other relevant
persons.
Care planning is
documented in the patient
chart.
Presence of documentation of
care plan in the patient chart
DOCUMENT
Documentation of care plan in patient chart (from wards, ICU, ER or
OPD) - Look at the following:
1. Detailed clinical history
2. SOAP format
3. Admitting orders
4. Doctor's orders
5. Nurses notes
6. Medication sheet
7. TPR sheet
8. Laboratories
ER
OPD
Wards
ICU
2.4.3.b.1 The organization ensures that
information about the patient's
proposed care is clear and readily
accessible to designated
multidisciplinary health care
providers and other relevant
persons.
Clinical pathways,
algorithms and problem-
oriented notes in SOAP
format are incorporated in
the medical record
Presence of clinical
pathways, algorithms or
problem-oriented notes in
SOAP format in the medical
record
DOCUMENT
Clinical pathways, algorithms or problem-oriented notes in SOAP format
should be incorporated in the chart/medical record
Wards
2.5 IMPLEMENTATION OF CARE
Goal: Care is delivered to ensure the best possible outcomes for the patients.
2.5.1.a.1 Care is delivered in a timely, safe,
appropriate and coordinated
manner, according to care plans.
In the management of
clinical pathway-covered
conditions, the order and
timing of treatments follow
the pathway
procedures on
implementation/ compliance
to pathways
DOCUMENT REVIEW
Policies and procedures on implementation/compliance to clinical
pathways
Document review
2.5.1.a.2 Care is delivered in a timely, safe,
In the management of
clinical pathway-covered
conditions, the order and
timing of treatments follow
the pathway
clinical pathway-based
management
DOCUMENT
Ask for charts with clinical pathway-covered conditions.
Formula: Number of charts managed according to clinical
pathways/total number of charts reviewed
Wards
2.5.1.b.1 Care is delivered in a timely, safe,
Orders for treatments are
implemented within time
intervals established by
the organization
procedures on time intervals
to act on orders for treatment
DOCUMENT REVIEW
Policies and procedures on time intervals to act on orders for treatment
e.g. doctors orders must be carried out within 30 minutes; time intervals
for IV medications
Document review
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2.5.1.b.2 Care is delivered in a timely, safe,
Orders for treatments are
implemented within time
intervals established by
the organization
Proof that orders for
treatment are implemented
within time intervals
established by the
organization
DOCUMENT REVIEW
Monitoring reports, if none, ask for patient charts and look at the doctors
orders and medication sheet
INTERVIEW
1. Ask nurses regarding time intervals established by the hospital and
how they are implemented
2. Ask patients regarding time intervals of treatment e.g. what time
usually are medications given, etc.
Note : If hospital has no policy on time intervals to act on orders of
treatment, automatic score of 1.
Document review
2.5.1.c.1 Care is delivered in a timely, safe,
Referrals to other
specialties are made
according to established
pathways or guidelines
referrals made according to
pathways or guidelines
CHART REVIEW
Patient charts - Verify if orders for referrals (or nonreferrals) are
consistent with related CPGs and clinical pathways

Formula: Number of charts with referral made according to pathway/
number of charts with referrals x 100
Chart review
2.5.1.d.1 Care is delivered in a timely, safe,
Results of referrals are
communicated to relevant
members of the health
care team and are
considered in the
management.
results of referral
communicated to relevant
health care team and are
considered in the
management
CHART REVIEW
Patient charts - Check charts if results of referrals are communicated to
relevant members of the health care team and if these are considered in
the management
Formula: Number of charts with referral communicated to relevant
health care team and considered in the management/ number of charts
with referrals x 100
Chart review
2.5.2.a.1 Rights and needs of patients are
considered and respected by all
the staff.
Patients receive
explanations on the nature
of a test or treatment, the
need for it prior to
administration, its likely
effects and side effects,
and what patients can do
to cope with them
received explanation on the
nature, necessity, effects, and
side effects and how to cope
with them
INTERVIEW
Ask patient if he/she received explanations on the nature of a test or
treatment, the need for it prior to admission, its likely effects and side
effects, and what patients can do to cope with them
Formula: Number of patients who received explanation on the nature,
necessity, effects, and side effects and coping with side effects of a test
or treatment/ number of patients interviewed x 100
Wards
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2.5.2.b.1 Rights and needs of patients are
the staff.
Patients wish to decline
tests or treatments is
respected
Presence of policy on test or
treatment refusal
DOCUMENT REVIEW
Policy on refusal of test or treatment
Document review
2.5.2.b.2 Rights and needs of patients are
the staff.
Patients wish to decline
tests or treatments is
respected
Percentage of patients whose
wish to decline tests or
treatments was respected
INTERVIEW
Ask patients who wish to decline tests if their wish was respected.
Formula: Number of patients whose wish to decline tests or treatments
were respected/ number of patients interviewed who declined tests or
treatments x 100
Note : If there are no patients (who wish to decline test) around, ask for
charts from the medical records section and look for HAMA, DNR,
refuse IV, refuse BT, unnecessary drugs or procedures. The signed
waiver could be in the doctors orders, progress notes or waiver forms.
Wards
ICU
2.5.3.a.1 Care is coordinated to ensure
continuity and to avoid
duplication.
that determine the extent
of duplicate assessments
and treatments performed
by trainees respect
patients rights, and are
documented and
monitored.
procedures on duplicate
assessments and treatments
performed by trainees
DOCUMENT REVIEW
1. Policies and procedures indicating extent of duplicate assessments
and treatments performed by trainees
2. Policies and procedures indicating the extent of duplicate
assessments and treatments performed by trainees respect patients'
rights
Document review
2.5.3.a.2 Care is coordinated to ensure
continuity and to avoid
duplication.
that determine the extent
of duplicate assessments
and treatments performed
by trainees respect
patients rights, and are
documented and
monitored.
Proof that the policies and
procedures on duplicate
are monitored
DOCUMENT REVIEW
Monitoring reports in compliance to policies and procedures on duplicate
INTERVIEW
Interview management or QA team on how they monitor compliance to
the policies
Document review
Leadership
interview
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2.5.4.a.1 Appropriate personnel educate
patients and/or their families to
help them understand patients'
diagnosis, prognosis, treatment
options, health promotion and
illness prevention strategies.
The organization
documents and
implements policies and
procedures, and provides
resources to promote
interactive, appropriate
and relevant educational
programs for patients.
procedures on promoting
interactive, appropriate and
relevant educational
programs for patients
DOCUMENT REVIEW
Policies and procedures promoting interactive, appropriate and relevant
educational programs for patients
Document review
The organization
documents and
Proof of individual patient
education by appropriate
health care professional
DOCUMENT
Look at the doctor's orders in the patient chart for the documentation of
patient education (wards).
Note : The word 'advised' is sufficient proof of compliance.
INTERVIEW
Ask patient if they were advised/educated by any of the health care
team. Cross refer to patient's chart if relevant and appropriate
Note : Health care professionals are not limited to doctors only. It also
includes nurses, physical therapists, dentists, etc.
OPD
Wards
The organization
documents and
Proof of provision of
resources for patient
educational programs
DOCUMENT REVIEW
Approved budget to support patient educational programs
OBSERVATION
Presence of materials, equipment, structures to support the patient
educational programs e.g.. LCD, posters, venue
Document review
Wards
Other Areas
2.5.4.b.1 Appropriate personnel educate
Patients are aware of their
roles and responsibilities
in their health care
are aware of their roles and
responsibilities in their care
INTERVIEW
Ask patients their role and responsibilities in their health
Formula: Number of patients aware of their roles and responsibilities in
their care/number of patients interviewed x 100
OPD
Wards
2.5.5.a.1 Drugs are administered in a
standardized and systematic
manner in the provider
organization.
Drugs are administered in
a timely, safe, appropriate
and controlled manner
procedures on drug
administration
DOCUMENT REVIEW
Policies and procedures on drug administration
Document review
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2.5.5.a.2
core
Drugs are administered in a
organization.
Drugs are administered in
All drugs are administered in
and controlled manner to the
right patient
CORE
CHART REVIEW
Patient chart from the medical records
For the timeliness of drug administration, check the hospital policy. If
hospital does not have policy, frequency of drug administration in the
chart should be checked and validate it thru patient interview
Formula: Number of drugs administered to the right patient at the
correct time, manner, and route/number of drugs x 100.
Sample size: 10 drugs (may come from different charts)
Note: Surveyor may also check for administration of any of the
following: antibiotics, anticonvulsants, MgSO4, KCl drip and other drips,
calcium gluconate, sodium bicarbonate, etc. For oral medications, do
direct observation
Chart review
2.5.5.b.1 Drugs are administered in a
organization.
The provider organization
documents and follows
policies and procedures
and allocates resources
for the training,
supervision, and
evaluation of professionals
who administer drugs
procedures for training,
supervision and evaluation of
professionals who administer
drugs
DOCUMENT REVIEW
1. Policies and procedures for training of professionals who administer
drugs
2. Policies and procedures for supervision of professionals who
administer drugs
3. Policies and procedures for evaluation of professionals who
administer drugs
Document review
organization.
for the training,
supervision, and
Presence of resources
allocated for training,
drugs
DOCUMENT REVIEW
1. Budget allocated for training, supervision and evaluation of
professionals who administer drugs
2. Training plan, training modules/materials, evaluation forms
Note : Use organizational chart as guide/reference.
OBSERVATION
Observe presence of related structures present, e.g.. training room,
conference room, libraries
Document review
Other areas
organization.
for the training,
supervision, and
Proof of training, supervision,
and evaluation of
drugs
DOCUMENT REVIEW
1. Reports on performance monitoring of professionals who administer
drugs
2. Evaluation reports of professionals who administer drugs
3. Proof of training, e.g.. certificates of training
INTERVIEW
Ask leaders how the supervision of professionals who administer drugs
are conducted
Document review
Leadership
interview
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2.5.5.c.1
core
organization.
Only qualified personnel
order, prescribe, prepare,
dispense and administer
drugs
All doctors, nurses and
pharmacists have updated
licenses
CORE
INTERVIEW
Randomly check the licenses of doctors, nurses and pharmacists if they
are updated
Formula: Number of doctors, nurses and pharmacists with updated
licenses/number of doctors, nurses and pharmacists interviewed x 100
Wards
Pharmacy
ER
OPD
2.5.5.c.2 Drugs are administered in a
organization.
order, prescribe, prepare,
dispense and administer
drugs
orders for drug administration
that were made by licensed
doctors
CHART REVIEW
Doctor's orders in patient chart from the medical records
Orders that were made by interns should be countersigned by licensed
residents or consultants
Formula: Number of charts with orders for drug administration made by
licensed doctors/number of charts reviewed x 100
Chart review
2.5.5.d.1 Drugs are administered in a
organization.
Regular review of
prescription orders is
undertaken by
appropriately trained staff
to ensure safe and
appropriate use of drugs
Proof of regular review of
prescription orders being
undertaken by appropriately
trained staff to ensure safe
and appropriate use of drugs
DOCUMENT REVIEW
1. Policy on regular review of prescription orders
2. Evaluation reports by nurses/doctors in the floors, clinical pharmacist
or therapeutics committee or minutes of meeting of the therapeutics
committee
INTERVIEW
Ask leaders about utilization review activities, audit/peer review, other
activities where appropriateness and safety of drug use are discussed
Footnote: This is to ensure that prescriptions are written correctly (e.g..
in generic form), and that precautions for drug-drug and drug-food
interactions have been adequately addressed.
Document review
Leadership
interview
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2.5.5.e.1
core
organization.
Prescriptions or orders are
verified and patients are
identified before
medications are
administered
Proof that prescriptions or
orders are verified before
medications are administered
CORE
DOCUMENT
Procedures on verification of prescriptios and orders
INTERVIEW
Ask staff how they verify orders from doctors prior to drug administration
OBSERVATION
Observe if staff verifies the prescriptions or orders for drugs with the
doctor and the drug against the doctor's order
Note : This is on a case to case basis; includes the route of
administration (slow IV) and other precautionary measures/instruction
e.g.. ANST
Wards
ER
ICU
2.5.5.e.2
core
organization.
Prescriptions or orders are
verified and patients are
identified before
medications are
administered
Proof that patients are
correctly identified prior to
administration of medications
CORE
INTERVIEW
Verify from patients if they were correctly identified prior to drug
administration
OBSERVATION
Observe if the staff verifies the identity of patient prior to administration
of medications
Wards
ER
ICU
2.5.5.f.1 Drugs are administered in a
organization.
Telephone orders are
countersigned by the
ordering physician not later
than standards set by the
organization and based on
statutory requirements
procedures regarding
telephone orders
DOCUMENT REVIEW
Policies and procedures regarding telephone orders
Document review
2.5.5.f.2 Drugs are administered in a
organization.
Telephone orders are
countersigned by the
ordering physician not later
than standards set by the
organization and based on
statutory requirements
Percentage of telephone
orders countersigned by
ordering doctor within the
standard time interval
DOCUMENT
Look at the telephone orders in the charts. Take note of the time of
receipt of order and time of countersigning; validate with hospital
standard/policy
Note : All telephone orders should be countersigned within 24 hours or
within the time set by the hospital
Formula: Number of countersigned telephone orders/number of
telephone orders x 100 (should be applied per chart; overall rating for
the indicator will be the mean of ratings)
Wards
ICU
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2.5.5.g.1 Drugs are administered in a
organization.
Discontinued or recalled
drugs are retrieved and
safely disposed of
procedures on retrieval and
safety disposal of drugs
DOCUMENT REVIEW
1. Policies and procedures on retrieval of drugs
2. Policies and procedures on safety disposal of drugs
Document review
2.5.5.g.2 Drugs are administered in a
organization.
Discontinued or recalled
drugs are retrieved and
safely disposed of
Proof that policies and
procedures on retrieval and
safety disposal of drugs are
followed
DOCUMENT
Look for documents such as memos, issuances or receipts showing that
recalled or discontinued drugs are either returned to
manufacturers/distributors or disposed of properly.
INTERVIEW
Ask staff the actual practice of retrieval and safe disposal of recalled or
discontinued drugs.
OBSERVATION
Ask staff to show where they dispose recalled, discontinued or expired
drugs.
Pharmacy
Wards
2.5.5.h.1 Drugs are administered in a
organization.
Drugs are selected and
procured based on the
organization's usual case
mix and according to
that are consistent with
scientific evidence and
government policies.
procedures on selection and
procurement of drugs,
consistent with scientific
evidence and government
policies
DOCUMENT REVIEW
1. Policies and procedures on drug selection and procurement
2. Policies and procedures on drug selection and procurement are
consistent with scientific evidence
3. Policies and procedures on drug selection and procurement are
consistent with government policies e.g.. National Drug Policy
INTERVIEW
Ask the members of therapeutics committee regarding manner of
selection and procurement of drugs
OBSERVATION
Observe actual supply of drugs in the pharmacy in accordance with the
organization's policies
Document review
Leadership
interview
Pharmacy
2.5.5.i.1
core
organization.
Drug administration is
properly documented in
the patient chart
All charts have proper
documentation of drug
administration
CORE
CHART REVIEW
Medication sheet in patient chart from medical records
Formula: Number of charts with proper documentation of drug
administration/total charts reviewed x 100
Sample size: rule of 10
Chart review
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2.5.5.j.1 Drugs are administered in a
organization.
for detecting, reporting and
monitoring adverse effects
are documented and
monitored
procedures for detecting,
reporting and monitoring
adverse effects
DOCUMENT REVIEW
1. Policies and procedures for detecting adverse effects
2. Policies and procedures for reporting adverse effects
3. Policies and procedures for monitoring adverse effects
Document review
2.5.5.j.2 Drugs are administered in a
organization.
for detecting, reporting and
are documented and
monitored
Proof of compliance to
policies and procedures for
detecting, reporting and
DOCUMENT REVIEW
1. Forms for reporting incidents, adverse drug events, sentinel events or
adverse events
2. Regular monitoring reports on adverse events
Document review
2.5.6.a.1 Treatment procedures are
performed in a standardized and
systematic manner in the provider
organization.
Treatment procedures are
performed in a timely,
safe, appropriate and
controlled manner
Presence of policies on
treatment procedures
DOCUMENT REVIEW
1. Policies on treatment procedures, clinical pathways, CPGs,
flowcharts or algorithms
2. For hospitals with operating rooms: WHO surgical safety checklist is
included in the policies on treatment procedures
Document review
2.5.6.a.2 Treatment procedures are
organization.
performed in a timely,
safe, appropriate and
controlled manner
Proof that treatment
procedures are performed in
DOCUMENT
1. Review patient chart and verify appropriateness of treatment
procedures.
2. For hospitals with operating rooms: WHO surgical safety checklist is
incorporated in the charts of surgery patients
INTERVIEW
1. Ask staff how they ensure performing treatment procedures in a
timely manner.
2. Ask staff how they ensure performing procedures in a safe and
controlled manner
3. Ask patients/caregivers how certain procedures such as IV insertion,
catheterization were done?
Note : Treatment procedures include but are not limited to
appendectomy, CS, hydration for AGE, suturing, excision, incision and
drainage, thoracotomy, chest tube insertion, IV insertion
Wards
ICU
OR/RR/DR/PACU
ER
2.5.6.b.1 Treatment procedures are
organization.
documents and reviews
for the training,
supervision, and
who perform procedures.
procedures for training,
professionals who perform
the procedures
DOCUMENT REVIEW
1. Policies and procedures for training of professionals who perform the
procedures
2. Policies and procedures for supervision of professionals who perform
the procedures
3. Policies and procedures for evaluation of professionals who perform
the procedures
Document review
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organization.
for the training,
supervision, and
Presence of resources
allocated for training,
procedures
DOCUMENT REVIEW
1. Budget allocated for training, supervision and evaluation of
professionals who perform procedures
2. Training plan, training modules/materials, organizational chart,
evaluation forms
OBSERVATION
Observe related structures present, e.g.. training room, conference
room, libraries
Document review
Other areas
organization.
for the training,
supervision, and
Proof of training, supervision,
and evaluation of
the procedures
DOCUMENT REVIEW
1. Reports on performance monitoring of professionals who perform the
procedure or evaluation reports
2. Proof of training, e.g.. certificates of training
INTERVIEW
Validate with leaders regarding supervision of performance of
procedures and training.
Document review
Leadership
interview
2.5.6.c.1 Treatment procedures are
organization.
order, plan, perform and
assist in performing
procedures
orders for treatment
procedures performed by
qualified personnel
DOCUMENT
Verify from patient chart if the orders for treatment procedures were
performed by qualified personnel
Formula: Number of charts with orders for treatment procedures
performed by qualified personnel/number of charts reviewed x 100
Wards
ICU
2.5.6.d.1 Treatment procedures are
organization.
Orders are verified and
patients are identified
before treatment
procedures are performed.
Proof that orders are verified
and patients are identified
before procedures are
performed
INTERVIEW
Ask patients from ER, Wards, OR/RR/DR or ICU if they were properly
identified prior to performance of procedures
OBSERVATION
Observe if staff verifies the orders for procedures with the doctor and
how the staff identify the patients e.g.., arm banding
ER
Wards
OR/RR/DR
ICU
2.5.6.e.1 Treatment procedures are
organization.
legibly and accurately
documented in the patient
chart by qualified
personnel.
legible and accurate
documentation of treatment
procedures by qualified
personnel
DOCUMENT
Verify from doctor's orders in patient chart the legibility and accuracy of
documentation of treatment procedures. Ask the nurse/hospital staff to
read the orders from the chart.
Formula: Number of charts with legibly and accurately documented
treatment procedures / total number of charts reviewed with procedures
x 100
Wards
ICU
ER
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2.5.6.f.1 Treatment procedures are
organization.
Medical devices and
equipment are used,
maintained, stored and
disposed based on
technical specifications.
Proof that medical devices
and equipment are used
maintained, stored and
disposed based on technical
specifications.
DOCUMENT
1. Policies and procedures on use and maintenance of medical devices
2. Policies and procedures on storage and disposal of medical devices
3. Schedule of equipments maintenance check, calibration of
equipment
4. Logbook on preventive maintenance
INTERVIEW
Ask personnel how they use, maintain, store and dispose medical
devices
Document review
Facilities and
Maintenance
Imaging
Laboratory
2.5.6.g.1 Treatment procedures are
organization.
Medical devices and
equipment are selected
and procured based on
organizations case mix,
staff expertise, service
capability and according to
government policies
selection and procurement of
medical devices and
equipment based on
organizations case mix, staff
expertise, service capability,
government policies
DOCUMENT REVIEW
1. Policies and procedures on selection and procurement of medical
devices and equipment
devices and equipment are based on organization's case mix, staff
expertise, and service capability
devices and equipment are consistent with scientific evidence
devices and equipment are consistent with government policies
Document review
2.5.6.g.2 Treatment procedures are
organization.
Medical devices and
equipment are selected
organizations case mix,
staff expertise, service
capability and according to
government policies
Proof that medical devices
and equipment are selected
organization's case mix, staff
expertise, service capability
and according to policies and
procedures that are
consistent with scientific
evidence and government
policies
DOCUMENT REVIEW
List of equipment procured the previous year/s. Check if procured
according to policies and procedures.
INTERVIEW
Ask management team regarding basis for procurement of the listed
equipment
Document review
Leadership
interview
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2.5.7.a.1 The care of patients with special
needs is governed by policies
and procedures that are
consistent with legal and ethical
requirements
The care of patients with
special needs is governed
by policies and procedures
legal and ethical
requirements
procedures that govern care
of patients with special needs
DOCUMENT
Policies and procedures that govern care of patients with special needs
Examples: care of pregnant patients in radiology department, care of
victims of sexual or child abuse in the ER
Footnote: Patients with special needs include infants, school-age
children, adolescents, the elderly and the disabled, victims of alleged or
suspected sexual abuse or violence, patients with emotional or
behavioral disorders, patients with drug dependencies or alcoholism.
Document review
2.6 EVALUATION OF CARE
Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients.
2.6.1.a.1 Data relating to processes and
outcomes of patient care are
analyzed to provide information
for care improvement.
The organization routinely
collects process and
outcomes data from its
provision of patient care
Proof of data collection
related to processes and
outcomes of care
DOCUMENT REVIEW
Process and outcomes data reports such as but not limited to:
1. medical audit reports
2. morbidity and mortality reports
3. hospital infection data
4. adverse event reports
5. evaluation reports of diagnostics, procedures and treatment
6. other reports: disposition data, variance reports, etc
Document review
2.6.1.b.1 Data relating to processes and
The organization provides
resources for the formal
and collaborative
evaluation of care using
analysis of process and
outcomes data
Presence of budget or
resource allocation for CQI
activities that makes use of
analysis of process and
outcomes data
DOCUMENT REVIEW
1. Budget or resource allocation for collection of data related to process
and outcomes of care such as the following: medical audit, morbidity
and mortality reports, adverse event and hospital infection data, etc
2. Budget or resource allocation for analysis of data related to process
and outcomes of care such as: medical audit, mortality and morbidity
conferences, etc
INTERVIEW
Ask QA committee what are the resources provided by the organization
for CQI activities
Document review
Leadership
interview
2.6.1.c.1 Data relating to processes and
Results of evaluation of
care are fed back to the
health care providers
concerned
Proof that results of
evaluation of care are fed
back to health care providers
concerned
DOCUMENT REVIEW
Documents showing that results of evaluation of care are fed back to
concerned health care providers such as issuances, memos or reports
INTERVIEW
Verify with health care providers if they were given the results of the
evaluation of care
Document review
Wards
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2.6.1.d.1 Data relating to processes and
Results of evaluation of
care are routinely
presented and discussed
in meetings of top
management
Proof that results of
evaluation of care are
routinely presented and
discussed in meetings of top
management
DOCUMENT REVIEW
Documents showing that results of evaluation of care were presented
and discussed in meetings of top management such as issuances,
memos, directives, excerpts/minutes/agenda of meetings
INTERVIEW
Ask management team if the QA committee presents and discusses the
results of evaluation
Document review
Leadership
interview
2.6.2.a.1 The health care team takes
action to address any
improvements required.
Evaluation of care leads to
formal and collaborative
performance improvement
activities that harness the
resources of appropriate
services
Presence of collaborative
performance improvement
activities that harness the
resources of appropriate
services
DOCUMENT REVIEW
Policies /memo/ letters regarding any collaborative performance
improvement activities as a result of evaluation of care
INTERVIEW
Verify with health care team if there are performance improvement
activities as a stemming from results of evaluation of care.
Document review
Leadership
interview
2.6.3.x.1 Quality improvement activities are
documented, enable continuous
quality improvement and
incorporate the following
elements:
* Monitoring, assessment,
analysis and evaluation of
activities
* Appropriate and timely action
*Evaluation of the effectiveness
of any action taken
*Feedback of evaluation results
Proof of documentation of QI
activities
DOCUMENT REVIEW
Minutes of QA committee meetings, reports, memoranda/ orders/policies
emanating from resolution of cases
INTERVIEW
Ask leaders on QI activities, specific cases brought to the attention of the
QC/QT
Document review
Leadership
interview
2.6.3.x.2 Quality improvement activities are
documented, enable continuous
quality improvement and
elements:
* Monitoring, assessment,
activities
* Appropriate and timely action
*Evaluation of the effectiveness
of any action taken
*Feedback of evaluation results
Proof that QI activities
elements:
*Monitoring, assessment,
activities
*Appropriate and timely action
*Evaluation of the
effectiveness of any action
taken
*Feedback of evaluation
results
DOCUMENT REVIEW
Reports of CQI activities
INTERVIEW
Validate with QA committee members regarding the (4) elements of CQI
activities
Document review
Leadership
interview
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2.7. DISCHARGE
Goal: Care is coordinated between the organization and other health care providers in the community to ensure that the needs of the patient are continuously met.
2.7.1.x.1
core
The discharge plan is part of the
patient's care plan and is
documented in the patient chart.
All charts have discharge
plans
CORE
CHART REVIEW
Patient chart from medical records, look at the discharge orders. It
should contain all of the following:
1. May go home order
2. Home medications (if applicable)
3. Follow up visits/schedule
4. Home care/advise
Formula: Number of charts with discharge plans/number of charts
reviewed x 100
Note : Discharge plan is not synonymous with discharge summary
Chart review
2.7.2.x.1 The organization provides
information about continuing
management plan to the patient
and relevant health care
providers in a manner that
maintains patient confidentiality
and privacy.
Proof that the patients are
informed of the continuing
management plan while
maintaining confidentiality
and privacy
INTERVIEW
Ask patients how they were informed of the continuing management
plan, may ask about home medications (if applicable), follow up
visits/schedule and other home care/advise. Use chart of the patient as
reference during interview.
Wards
ICU
2.7.2.x.2 The organization provides
information about continuing
management plan to the patient
and relevant health care
providers in a manner that
maintains patient confidentiality
and privacy.
Proof that the relevant health
care providers are informed of
the continuing management
plan while maintaining
confidentiality and privacy
INTERVIEW
Ask staff how they inform other health care providers regarding
continuing management plans for referred patients. Use chart of patient
as reference during interview.
Wards
ICU
2.7.3.x.1 The organization arranges
access to other relevant
community health services in a
timely manner, and ensures that
patients are aware of appropriate
services before discharge.
Proof that the organization
arranges access to other
relevant community health
services in a timely manner
DOCUMENT
Patient chart - check for discharge orders and arrangements, referral
forms to community health services (e.g. RHU, CHO)
Footnote: Examples of other relevant community health services
include, but are not limited to, RHUs, Botika sa Barangay, etc.
INTERVIEW
Ask staff how such arrangements are made, who is in charge, what
facilities they make arrangements with for provision of health care
services; validate answers to such with the patients
Wards
ICU
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2.7.3.x.2 The organizations arranges
access to other relevant
community health services in a
timely manner, and ensures that
patient are aware of appropriate
services before discharge.
ensures that patients are
aware of the appropriate
services in the community
before discharge.
INTERVIEW
Ask patients if they are aware of the appropriate services in the
community before discharge
Wards
ICU
2.7.4.x.1 Patients understand the
discharge plans and their
responsibilities for continuing
management.
understand their discharge
plans
INTERVIEW
Ask patients about their knowledge and understanding of the care plan
and their responsibilities for continuing management
Formula: Number of patients who understand their discharge plans and
responsibilities for continuing management / total number of patients for
discharge interviewed x 100
Note : Interview patients for discharge. If there are no in-patients for
discharge, interview patients from the OPD or ER.
Wards
ICU
3. LEADERSHIP AND MANAGEMENT
3.1 THE MANAGEMENT TEAM
3.1.1.x.1 The provider organization's
management team provides
leadership, acts according to the
organization's policies and has
overall responsibility for the
organization's operation, and the
quality of its services and its
resources
Presence of organizational
structure
DOCUMENT REVIEW
Organizational structure/chart or manual of operations
OBSERVATION
Observe if the organizational structure/chart is posted conspicuously in
appropriate areas (Lobby)
Document review
Other Areas
(Lobby)
3.1.1.x.2 The provider organization's
management team provides
leadership, acts according to the
organization's policies and has
overall responsibility for the
organization's operation, and the
quality of its services and its
resources
Percentage of staff aware of
their leadership team
INTERVIEW
Ask 10 staff to identify the management team (hospital director or chief
of hospital or chief health officer together with the administrative officer
or administrator and service/department heads)
Formula: Number of staff aware of their leadership/total number of staff
interview x 100
ER
OPD
Wards
Imaging
Laboratory
Pharmacy
HRD
Other Areas
Goal: The organization effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health outcomes, and is responsive to patient's and
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3.1.2.x.1 The organization's management
ensures the presence of effective
working relationships within the
organization, with the community,
and with other relevant
organizations and individuals.
Presence of staff satisfaction
survey which includes
interpersonal relationships
DOCUMENT REVIEW
Reports on the results of staff satisfaction survey, and should include the
following: analysis, conclusion and recommendation
Document review
3.1.2.x.2 The organization's management
ensures the presence of effective
working relationships within the
organization, with the community,
and with other relevant
organizations and individuals.
Presence of activities that
promote team building/good
working relationship
DOCUMENT REVIEW
1. Documentation of team building activities
Examples: christmas party, sports activities, outing, etc.
2. Community outreach program
Examples : medical mission, charity service, special clinic, community
service
Document review
3.1.3.x.1
core
Terms of reference, membership
and procedures are defined for
the meetings of all committees
within the organization. Minutes
of meetings are recorded and
approved.
Proof of the creation of all
committees within the
organization which includes
the terms of reference for
membership
CORE
DOCUMENT REVIEW
Proof of the creation of all committees which includes the terms of
reference for membership e.g. memo, office order, etc
INTERVIEW
Ask leaders what the committees in their hospital are and ask for the
order that created these committees
Document review
Leadership
interview
3.1.3.x.2 Terms of reference, membership
and procedures are defined for
the meetings of all committees
within the organization. Minutes
of meetings are recorded and
approved.
Presence of recorded minutes
of the meetings for all
committees within the
organization
DOCUMENT REVIEW
1. Minutes of meetings for Quality Assurance Committee (level 1, 2, 3
and 4)
2. Minutes of meetings for Therapeutics Committee (level 2, 3 and 4)
3. Minutes of meetings for Infection Control Committee (level 3 and 4)
4. Minutes of meetings for other committees
Note: Level I hospitals may not necessarily have TC or infection
committee, but there should at least be 2 persons looking at the use of
therapeutic drugs & infection control
INTERVIEW
Committee members to validate the above activities
Document review
Leadership
interview
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3.1.4.x.1
core
The organization's management
team regularly assesses its own
performance and the
performance of the organization.
Presence of evaluation and
monitoring activities to assess
management and
organizational performance
CORE
DOCUMENT REVIEW
Documentation of evaluation activities to assess management and
organizational performance such as monthly, quarterly, semestral or
annual reports as applicable
INTERVIEW
1. Ask the management team about priorities for performance
improvement that relate to hospital wide activities and patient outcomes
2. Ask management team how targets are set
Document review
Leadership
interview
3.1.5.a.1 The organization develops and
procedures which cover the major
services and aspects of
operations.
The organization develops
its mission, vision and
corporate goals based on
agreed-upon values.
Presence of written mission,
vision, and goals
DOCUMENT REVIEW
1. Written vision
2. Written mission
3. Written goals
Note: Content of the Vision, Mission & Goals should include
addressing the health needs of the community.
Document review
3.1.5.a.2 The organization develops and
operations.
The organization develops
its mission, vision and
corporate goals based on
agreed-upon values.
Proof that the mission and
vision were developed based
on agreed upon values
INTERVIEW
Ask the management team about how the vision and mission were
developed.
Note: Content of the Vision, Mission & Goals should include
addressing the health needs of the community.
Leadership
interview
3.1.5.b.1 The organization develops and
operations.
The organization's by-
laws, policies and
procedures support care
delivery and are consistent
with its goals, statutory
requirements, accepted
standards and its
community and regional
responsibilities.
Presence of written by-laws,
which are consistent with
goals, statutory requirements,
accepted standards and
community and regional
responsibilities
DOCUMENT REVIEW
1. Written by-laws
2. Policies and procedures
3. Written by-laws are consistent with goals, statutory requirements,
accepted standards and community and regional responsibilities
4. Policies and procedures are consistent with goals, statutory
requirements, accepted standards and community and regional
responsibilities
INTERVIEW
Ask leaders how their by-laws, policies and procedures were developed
Document review
Leadership
interview
3.1.5.c.1 The organization develops and
operations.
Policies and procedures,
aside from being complied
with, are reviewed and
revised as necessary.
Proof that policies and
procedures are reviewed and
revised as necessary
DOCUMENT REVIEW
1. Memos or issuances on review and/or revision of policies
2. Minutes of meetings on the review and/or revision of policies
INTERVIEW
Ask leaders how they review and revise policies and procedures
Document review
Leadership
interview
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3.1.5.d.1 The organization develops and
operations.
The organization
communicates its policies
and procedures to all
levels of the workforce.
Issuances on policies and
procedures are known to all
levels of the workforce
DOCUMENT REVIEW
1. Communication or dissemination plans for policies and procedures
2. Attendance to orientation/information dissemination activities
INTERVIEW
1. Ask leaders about how the vision/mission statement are
communicated to the hospital staff.
2. Ask leaders about how policies and procedures are communicated to
all levels of workforce.
3. Ask leaders and staff about their knowledge of organizations' by-
laws, policies and procedures
4. Ask staff (from different levels) about their knowledge of certain
Document review
Leadership
interview
ER
OPD
Wards
Pharmacy
HRD
Imaging
Laboratory
Other areas
3.1.5.d.2 The organization develops and
operations.
The organization
communicates its policies
and procedures to all
levels of the workforce.
Presence of a responsible
person for information
dissemination
DOCUMENT REVIEW
Proof of designation of a person responsible for information
dissemination
INTERVIEW
Ask leaders who the responsible person for information dissemination is
Document review
Leadership
interview
3.2 EXTERNAL SERVICES
Goal: The organization ensures that services provided by external contractors meet appropriate standards.
3.2.1.x.1
core
Documented agreements and
contracts cover external service
providers and specify that the
quality of services provided must
be consistent with appropriate set
standards.
Presence of MOA/contract for
all outsourced services (e.g.
dialysis unit, dietary,
laboratory, radiology)
CORE
DOCUMENT REVIEW
1. Contracts/MOA for outsourced services
2. Valid licenses of all providers of the outsourced services
OBSERVATION
Actual presence of the outsourced services within the hospital if
applicable
Note: The contracts/MOA should be updated. MOA is sufficient for
some hospitals where the outsourced services are not within the facility
Document review
Imaging
Laboratory
Other areas
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4. HUMAN RESOURCE MANAGEMENT
4.1 HUMAN RESOURCES PLANNING
Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals.
4.1.1.a.1 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.
The organization defines
the qualifications and
competencies of its staff.
Presence of job descriptions
indicating the qualifications
and competencies
appropriate to the personnel's
job functions, duties and
responsibilities
DOCUMENT REVIEW
J ob descriptions of personnel specifying the following:
1. functions
2. duties and responsibilities and the
3. required qualifications and competencies
Document review
4.1.1.b.1 Planning ensures that
the organization.
The organization
for hiring, credentialing,
and privileging of its staff.
procedures on hiring of staff
DOCUMENT REVIEW
Policies and procedures for hiring of staff
INTERVIEW
Ask appropriate personnel a certain procedure for hiring of staff.
Note: The surveyor can randomly pick out a doctor, a nurse, an admin
staff, both newly hired or old, and ask them the process of selection,
hiring and screening and performance appraisal; when was it last
conducted and by whom.
Document review
HRD
Wards
4.1.1.b.2
core
Planning ensures that
the organization.
The organization
for hiring, credentialing,
and privileging of its staff.
procedures for credentialing
and privileging of staff
CORE
DOCUMENT REVIEW
Policies and procedures for credentialing and privileging of staff
Document review
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4.1.2.a.1 Workload is monitored and
appropriate guidelines consulted
to ensure that appropriate staff
numbers and skill mix are
available to achieve desired
patient and organizational
outcomes.
Staff numbers and skill mix
are based on actual
clinical needs.
Presence of human resource
inventory system
DOCUMENT REVIEW
List of personnel, staffing pattern, or documents related to the HR
inventory system
Note: The hospital may document and analyze information like daily
patient loads, utilization rates and services, turn-around times to
determine staff size and mix.
INTERVIEW
Ask appropriate personnel (e.g. HR manager) how the right number and
mix of competent staff are maintained to meet the needs of internal and
external clients.
Document review
Leadership
interview
HRD
4.1.2.a.2 Workload is monitored and
outcomes.
are based on actual
clinical needs.
Presence of performance
monitoring on attendance,
tardiness and absenteeism
DOCUMENT REVIEW
Employee report card or its equivalent (e.g.. DTR, logbook)
Document review
4.1.2.a.3
core
Workload is monitored and
outcomes.
are based on actual
clinical needs.
Staff to bed ratio for licensed
doctors, registered nurses
and midwives/nursing aides
follow the DOH prescribed
ratio.
CORE
DOCUMENT REVIEW
1. List of total number of licensed doctors, registered nurses and
midwives/ nursing aides based on HR records and
2. The schedule of duties for the previous and current month
3. Number of beds registered with DOH and actually being used.
OBSERVATION
Number of beds.
Document review
Wards
4.1.2.b.1 Workload is monitored and
outcomes.
Appropriate policies and
procedures are monitored
to temporarily compensate
for, and to definitively,
address inadequacies in
staff numbers or expertise.
Presence of HR contingency
plan e.g. recall system to
address inadequate staff due
to absences, leaves,
resignations and increased
patient load.
DOCUMENT REVIEW
HR contingency plan e.g. recall system to address inadequate staff due
to absences, leaves, resignations and increased patient load
INTERVIEW
Ask HR, Wards and ER staff:
1. What happens when one staff is absent?
2. When one staff goes AWOL?
3. When there are too many patients?
4. What is the back up system to maintain appropriate number of staff?
Document review
HRD
Wards
ER
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4.1.2.b.2 Workload is monitored and
outcomes.
Appropriate policies and
procedures are monitored
to temporarily compensate
for, and to definitively,
address inadequacies in
staff numbers or expertise.
Proof of implementation and
monitoring of HR contingency
plan (e.g. recall system to
address inadequate staff due
to absences, leaves,
resignations and increased
patient load).
DOCUMENT REVIEW
1. Mandatory Monthly Hospital Report (take note of Maximum Bed
Occupancy Rate and Monthly NHIP Beneficiary Occupancy Rate
exceeding 100% to identify occasions of increased patient load);
2. Actual plan and monitoring report showing how the increased patient
load was addressed.
INTERVIEW
Ask HR, doctors, nurses and staff how the appropriate number of staff
was maintained and what monitoring procedure was made?
Document review
HRD
Wards
ER
Imaging
Laboratory
OR/RR/DR/PACU
4.2 STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES
Goal: Recruitment, selection, and appointment of staff comply with statutory requirements and are consistent with the organization's human resource policies.
4.2.1.a.1 Recruitment, selection,
appointment and reappointment
procedures ensure appropriate
competence, training, experience,
licensing and credentialing of all
appointees.
The organization defines,
disseminates and ensures
compliance with policies
and procedures governing
personnel recruitment,
selection and
appointments
defines, disseminates and
ensures compliance with
governing personnel
recruitment, selection and
appointments.
DOCUMENT REVIEW
1. Policies and procedures governing personnel recruitment, selection
and appointments.
2. Memos/endorsements reflecting the dissemination of policies and
procedures governing personnel recruitment, selection and
appointments.
3. Actions of the board/owner e.g. those reflected in its minutes,
resolutions, etc. showing that the organization ensures compliance to
policies and procedures on personnel recruitment, selection and
appointments.
INTERVIEW
Interview HR and wards staff for validation if the organization's policies
and procedures on personnel recruitment, selection and appointments
are actually being implemented.
Document review
HRD
Wards
4.2.1.b.1 Recruitment, selection,
appointees.
The recruitment and
selection process is open
& transparent, is
consistent with legal and
ethical requirements, and
allows a fair and unbiased
evaluation of the
qualifications and
competencies of all
applicants
Proof that recruitment and
selection are consistent with
the policies of the CSC (for
government) or the
organization.
DOCUMENT REVIEW
Corporate policy on recruitment, selection and appointment of staff
INTERVIEW
1. Ask leaders and staff on the process of hiring, re-hiring and firing. It
should be known to all staff and managers.
2. Ask staff from wards, ER, OPD, HRD, imaging, laboratory, facilities
and maintenance and other areas for what conditions will lead to their
firing
3. Ask staff regarding the process of their selection
Document review
Wards
ER
OPD
HRD
Imaging
Laboratory
Facilities and
Maintenance
Other areas
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4.2.1.c.1 Recruitment, selection,
appointees.
Relevant staff members
participate in the
development and
implementation of
personnel recruitment,
selection and appointment.
Presence of representation of
relevant staff in the
development and
implementation of personnel
recruitment, selection and
appointment policies
DOCUMENT REVIEW
1. Special/Office Orders or similar issuances defining the membership
of the body/committee/group tasked to develop and implement
personnel recruitment, selection and appointment;
2. Proof/minutes of meetings
3. Attendance of members
INTERVIEW
Ask leaders which team screens and appoints people and how members
of the team are selected.
Document review
Leadership
interview
4.2.1.d.1 Recruitment, selection,
appointees.
Selection and appointment
and evidence of staff
compliance with selection
or appointment standards
are documented
Proof of documentation
reflecting staff compliance
with selection and
appointment standards.
DOCUMENT REVIEW
Committee reports on selection and appointment
Document review
4.2.1.e.1 Recruitment, selection,
appointees.
Relevant licenses are
routinely monitored for
renewal.
Percentage of randomly
selected professional
personnel with updated
licenses
OBSERVATION
Ask personnel from each area to present their current licenses or PRC
claim stub for PRC cards that are still being processed
Formula: Number of professionals with updated licenses/number of
professionals randomly selected x 100
Sample size: At least 10 professional staff or 10% of the total
professional staff
ER
OPD
Wards
ICU
OR/RR/DR
Imaging
Laboratory
Pharmacy
Other areas
4.2.1.f.1 Recruitment, selection,
appointees.
Evidence of continuing
staff education and
training is routinely
monitored and assessed.
Presence of system to
monitor and assess
continuing education and
training of staff
DOCUMENT REVIEW
1. Certificates of attendance to trainings and formal continuing
education for personnel;
2. Monitoring reports on CME and training of staff
Document review
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4.2.2.a.1 Upon appointment, staff
members receive a written
statement of their accountabilities
and responsibilities that specifies
their role and how it contributes
to the attainment of the goals and
maintaining quality of care. The
statements are reviewed when
necessary.
Written job descriptions
are given to and discussed
with all newly-appointed
staff members.
Proof that newly appointed
staff are given written job
descriptions and the
corresponding
orientation/briefing.
DOCUMENT
Written job descriptions signed by the newly appointed personnel.
INTERVIEW
1. Interview newly-hired staff to determine if they received their written
job description
2. Ask staff if the job descriptions were discussed with them particularly
on their accountabilities and responsibilities that specifies their role and
how it contributes to the attainment of the goals and maintaining quality
of care
Note: Newly-hired personnel is defined as those who are
appointed/hired within the previous 6 months. If no newly appointed
staff is available, the surveyor may interview the most recently hired
staff.
HRD
4.2.3.a.1 Staff members are accountable
for the care and services they
give and for the discharge of their
delineated responsibilities.
The organization ensures
that staff accountabilities
and responsibilities are
consistent with their
qualifications, training,
experience, registration
and licensure.
Percentage of doctor(s),
nurse(s) and staff with job
functions, accountabilities
and responsibilities matching
their credentials, training and
experience.
DOCUMENT REVIEW
Written job description and/or relevant document defining the job
functions, accountabilities and responsibilities of personnel and the
corresponding credentials, training and experience required and match
this with the credentials of the doctor/nurse/staff chosen for the job.
Formula: Number of staff with job description matching their credentials,
training and experience/number of staff interviewed x 100
Document review
4.2.4.a.1 All services are provided by staff
members with appropriate
qualifications, experience or
training.
All doctors, nurses and
midwives providing clinical
care have current licenses
and documented evidence
of appropriate training and
experience.
Percentage of doctors, nurses
and midwives with valid
licenses
DOCUMENT
PRC License and all appropriate certifications of training
Formula: Number of doctors, nurses and midwives with current licenses
and certifications of training/number of doctors, nurses and midwives x
100
ER
OPD
Wards
ICU
OR/RR/DR
Imaging
Laboratory
Pharmacy
4.2.4.b.1 All services are provided by staff
training.
All administrative,
business and technical
services staff have current
licenses and documented
evidence of appropriate
training and experience
Percentage of personnel
performing administrative
functions with current licenses
and/or documented evidence
of appropriate training and
experience
DOCUMENT
PRC License or related documents (e.g.. certificate of training)
Formula: Number of administrative staff with current licenses/ number of
administrative staff who should have license x 100
Medical Records
HRD
Other areas
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training.
All administrative,
performing business functions
with current licenses and/or
documented evidence of
appropriate training and
experience
DOCUMENT
Note: Certificate of training will do since in small hospitals. Sometimes it
is the owner who possesses a different license is doing the work due to
his/her training certificate for the present job.
Example of business staff: accountant
Formula: Number of business staff with current licenses/number of
business staff who should have license x 100
HRD
Other areas
training.
All administrative,
performing technical functions
with current licenses and/or
documented evidence of
appropriate training and
experience
DOCUMENT
Note: Example of technical staff: engineer

Formula: Number of technical staff with current licenses /number of
technical staff who should have license x 100
Facilities &
Maintenance
Imaging
Laboratory
Other areas
4.3 STAFF TRAINING AND DEVELOPMENT
Goal: A comprehensive program of staff training and development meets individual and organizational needs.
4.3.1.a.1 There are relevant orientation,
training and development
programs to meet the educational
needs of management and staff.
The organization assesses
the educational needs of
management and staff
and identifies and/or
provides resources to
meet those needs
Presence of Training Needs
Assessment (TNA) System
DOCUMENT REVIEW
TNA report or its equivalent
Document review
4.3.1.a.2 There are relevant orientation,
The organization assesses
the educational needs of
management and staff
and identifies and/or
provides resources to
meet those needs
Presence of annual plan on
training activities
DOCUMENT REVIEW
Annual plan (including resource/budgetary allocation) on training
activities
Document review
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4.3.1.b.1 There are relevant orientation,
for orientation of new
management and staff are
documented and
monitored
procedures for the orientation
of new employees on general
hospital policies
DOCUMENT REVIEW
Policies and procedures on orientation of new employees to general
hospital policies
INTERVIEW
Randomly pick newly hired doctor, nurse, admin staff and ask them how
they were oriented.
Document review
Wards
ER
OPD
HRD
Imaging
Laboratory
Facilities and
Maintenance
Other areas
4.3.1.c.1 There are relevant orientation,
The organization
evaluates the
effectiveness of training
and development
programs to ensure that
they meet organizational,
community and individual
needs.
Presence of an evaluation
system of the training and
development program.
DOCUMENT REVIEW
Evaluation reports on the training and development program
Document review
4.3.1.c.2 There are relevant orientation,
The organization
evaluates the
effectiveness of training
and development
programs to ensure that
they meet organizational,
community and individual
needs.
Presence of end-of-training
assessment report
DOCUMENT REVIEW
End of training assessment report or its equivalent
Document review
4.3.2.a.1 The organization clearly defines
and ensures compliance with the
lines of authority and supervision.
New personnel - including
trainees, volunteers, new
graduates and external
contractors- are
adequately supervised by
qualified staff
Proof that new personnel are
adequately supervised
DOCUMENT
Organizational chart
INTERVIEW
Ask new personnel about the lines of authority and supervision and if the
supervision is adequate
HRD
4.3.2.b.1 The organization clearly defines
and ensures compliance with the
lines of authority and supervision.
The staff are provided with
a documented job
description outlining
accountabilities and
responsibilities.
Percentage of staff provided
with job description outlining
their accountabilities and
responsibilities
DOCUMENT REVIEW
Written job descriptions with conforme
Formula: Number of written job descriptions with conforme/number of
written job descriptions reviewed
Document review
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5. INFORMATION MANAGEMENT
5.1 DATA COLLECTION, AGGREGATION AND USE
Goal: Collection and aggregation of data are done for patient care, management of services, education and research.
5.1.1.a.1 Relevant, accurate, quantitative
and qualitative data are collected
and used in a timely and efficient
manner for delivery of patient
care and management of
services.
the relevant aspects of its
operations from which data
will be collected
procedures on data collection
relevant to delivery of patient
services
DOCUMENT REVIEW
Policies and procedures on data collection relevant to delivery of patient
care and management of services
Document review
5.1.1.b.1 Relevant, accurate, quantitative
services.
data sets, data generation,
collection and aggregation
methods and the qualified
staff who are involved in
each stage
Presence of annual statistical
reports and other additional
hospital statistics as
determined by the
management
DOCUMENT REVIEW
1. Annual Hospital Statistical Reports
2. Annual reports submitted to the DOH
3. MMHR submitted to PhilHealth
4. Other additional statistics as determined by the management or
hospital forms that serve as data aggregation instruments or data sets
and methods in preparation for statistical reports
Document review
5.1.1.b.2 Relevant, accurate, quantitative
services.
data sets, data generation,
collection and aggregation
methods and the qualified
staff who are involved in
each stage
Presence of qualified staff
involved in data definition,
generation, collection and
aggregation
DOCUMENT REVIEW
1. Proof of training/seminar or certificate on records management of
staff involved in data definition
2. Document (memo or issuance) designating a staff for data definition,
generation, collection and aggragation
INTERVIEW
Interview staff regarding their qualifications and functions
Document review
Medical records
5.1.1.c.1 Relevant, accurate, quantitative
services.
policies and procedures to
monitor and improve the
accuracy, completeness
and reliability of relevant
qualitative and quantitative
data relating to its
operations.
procedures to monitor and
improve the accuracy,
completeness and reliability
of relevant qualitative and
quantitative data relating to its
operations
DOCUMENT REVIEW
1. Policies and procedures to monitor the accuracy, completeness and
reliability of relevant qualitative and quantitative data relating to its
operations
2. Policies and procedures to improve the accuracy, completeness and
reliability of relevant qualitative and quantitative data relating to its
operations
Document review
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5.1.1.d.1 Relevant, accurate, quantitative
services.
The organization provides
resources and
opportunities to enable
management and staff to
use data in their decision
and policymaking
activities.
Presence of budget or
resources needed to collect,
maintain, process and
analyze data
DOCUMENT REVIEW
Plans, which include the budget for procurement of computers, software
and other resources (including training for data management), research
outputs, reports or budget execution report showing that such budget
has been disbursed
INTERVIEW
Ask leaders the content of plans and actual activities pertaining to
collection, maintenance, processing and analysis of data
OBSERVATION
Presence of computers, software, personnel, storage area for hard
copies of records
Document review
Leadership
interview
Medical records
5.1.1.e.1
core
Relevant, accurate, quantitative
services.
on record storage,
retention and disposal are
documented and
monitored
Policy on record storage,
safekeeping, retention and
disposal
CORE
DOCUMENT REVIEW
Policies and procedures on record storage, safekeeping and
maintenance, retention and disposal
Note: Policies and procedures on records management are updated
every 5 years
Document review
5.1.2.a.1 The collection of data and
reporting of information comply
with professional standards,
statutory and PhilHealth
requirements.
The organization collects
and submits reports
required by DOH and
PhilHealth
Compilation of DOH and
PhilHealth reports
DOCUMENT REVIEW
1. MMHR - Submitted every 10th day of the succeeding month
2. DOH reports - annual statistical reports
Note: For annual reports, look for the reports of the previous year, for
quarterly reports, previous quarter
Document review
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5.1.3.a.1 Every patient has a sufficiently
detailed patient chart to facilitate
continuity of care, and meet
education, research, evaluation
and medico-legal and statutory
requirements.
Care providers document
management details in the
patient chart. All entries
are promptly
accomplished, accurate,
legible, dated and duly
signed by the care
providers whose
designations are clearly
indicated
Percentage of properly
accomplished patient records
CHART REVIEW
Patient charts from medical records (surgical and medical cases)
Formula: Number of properly accomplished patient records/Number of
records retrieved
Sample size: 10 charts or 10%, whichever is lower
Scoring for properly accomplished charts
1. legibility 2. date, time & signature
3. completeness of entries (SOAP, review of systems, medication
treatment)
Note: Documentation in patient charts should be sufficiently detailed to
enable any member of the health care team to understand care plans
and care provision. Clinical pathways are excellent means to achieve
this.
Chart review
5.1.3.b.1 Every patient has a sufficiently
detailed patient chart to facilitate
continuity of care, and meet
education, research, evaluation
and medico-legal and statutory
requirements.
Patient charts are routinely
checked for completeness
and accuracy, and action
is taken to improve their
quality
Proof that charts are checked
for completeness and
accuracy
DOCUMENT REVIEW
Checklist for the completeness of the chart accomplished by the records
officer or other proof that charts are routinely checked for completeness
and accuracy.
Document review
5.1.4.a.1 Data in the patient charts are
coded and indexed to ensure the
timely production of quality
patient care information and
reports to PhilHealth.
Data from the patient
charts are routinely
collected, aggregated and
reported for use in quality
improvement activities, for
administrative purposes
and for mandatory
reporting to the
Department of Health and
PhilHealth
Presence of policies &
procedures on routine
collection, aggregation and
reporting of data from patient
charts for use in quality
improvement, administrative
purposes and for mandatory
reporting to Department of
Health and PhilHealth
DOCUMENT REVIEW
1. Policies & procedures on routine collection and aggregation of data
from patient charts for use in quality improvement, administrative
purposes and for mandatory reporting to Department of Health and
PhilHealth
2. Policies & procedures on routine reporting of data from patient charts
for use in quality improvement, administrative purposes and for
mandatory reporting to Department of Health and PhilHealth
Document review
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5.1.4.a.2 Data in the patient charts are
coded and indexed to ensure the
timely production of quality
patient care information and
reports to PhilHealth.
Data from the patient
charts are routinely
collected, aggregated and
reported for use in quality
improvement activities, for
administrative purposes
and for mandatory
reporting to the
PhilHealth
Proof that data collected and
aggregated from patient
charts are used for quality
improvement activities,
administrative purposes and
for mandatory reporting to the
PhilHealth
DOCUMENT REVIEW
Minutes of Quality Circle Meetings or Report/s on status of routine data
collection and aggregation from patient charts
INTERVIEW
Ask leaders on procedures on collection and aggregation of data from
patient charts for purposes of quality improvement activities,
administrative and mandatory reporting to DOH and PhilHealth
Document review
Leadership
interview
5.2 RECORDS MANAGEMENT
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met.
5.2.1.a.1
core
Clinical records are readily
accessible to facilitate patient
care, are kept confidential and
safe, and comply with all relevant
statutory requirements and codes
of practice.
When patients are
admitted or are seen for
ambulatory or emergency
care, patient charts
documenting any previous
care can be quickly
retrieved for review,
updating and concurrent
use
procedures on filing and
retrieval of charts
CORE
DOCUMENT REVIEW
Policies and procedures on systematic filing, retrieval and management
of medical records
Document review
5.2.1.a.2 Clinical records are readily
of practice.
When patients are
admitted or are seen for
ambulatory or emergency
care, patient charts
documenting any previous
care can be quickly
retrieved for review,
updating and concurrent
use
Percentage of charts
retrieved within the standard
time set by the organization
OBSERVATION
Ask the records keeper to retrieve a chart, then note the actual length of
time of retrieval
Formula: Number of charts retrieved within the time interval set by the
organization/Number of charts retrieved x 100
Note: If organization has not set a time interval, use 15 minutes.
Medical records
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5.2.1.b.1
core
Clinical records are readily
of practice.
The organization has
and devotes resources,
including infrastructure, to
protect records and patient
charts against loss,
destruction, tampering and
unauthorized access or
use. Only authorized
individuals make entries in
the patient chart
Presence of procedures to
unauthorized access or use
CORE
DOCUMENT REVIEW
Policies and procedures on records management for the entire hospital
to maintain privacy, accuracy and prevent loss and destruction
OBSERVATION
Observe nurses in the wards and records personnel on how they protect
patient chart against loss, tampering and unauthorized use
Document review
Wards
Medical records
5.2.1.b.2 Clinical records are readily
of practice.
The organization has
and devotes resources,
including infrastructure, to
unauthorized access or
use. Only authorized
individuals make entries in
the patient chart
Presence of logbooks for
borrowing and retrieval of
charts
DOCUMENT
Logbooks for borrowing and retrieval of charts
Medical records
6. SAFE PRACTICE AND ENVIRONMENT
6.1 PATIENT AND STAFF SAFETY
Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care.
6.1.1.a.1
core
The organization plans a safe
and effective environment of care
consistent with its mission,
services, and with laws and
regulations.
The organizational
environment complies with
structural standards and
safety codes as prescribed
by law
Presence of updated DOH
license to operate
CORE
DOCUMENT REVIEW
1. Updated DOH license
2. If facility has nuclear medicine, ask for the certificate issued by the
Philippine Nuclear Research Institute (PNRI)
Document review
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6.1.1.b.1
core
regulations.
There are management
plans which address
safety, security, disposal
and control of hazardous
materials and biological
wastes, emergency and
disaster preparedness, fire
safety, radiation safety and
utility systems.
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
CORE
DOCUMENT REVIEW
Management plan which includes policies, procedures and programs,
risk assessment, hazard surveillance among others that address the
following:
1. Safety
2. Security
3. Disposal and control of hazardous materials/biologic wastes
4. Emergency and disaster preparedness
5. Fire safety
6. Radiation safety
7. Utility systems
Note : The hospital must have plans for all the elements enumerated in
the criteria. Plans should have guiding policies and specific procedures
Document review
6.1.1.c.1 The organization plans a safe
regulations.
plans for the safe and
efficient use of medical
equipment according to
specifications
Presence of written plans on
the safe and efficient use of
medical equipment according
to specifications
DOCUMENT
Management plan which includes policies / procedures and programs
such as equipment maintenance programs for safe and efficient use of
medical equipment
Document review
6.1.1.c.2
core
regulations.
plans for the safe and
equipment according to
specifications
Presence of operating
manuals of the medical
equipment
CORE
DOCUMENT
Operating manuals for the medical equipment
ER
OPD
Wards
ICU
OR/DR/RR
Facilities and
maintenance
Imaging
Laboratory
Other areas
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6.1.2.a.1 The organization provides a safe
consistent with its mission and
regulations.
that address safety,
security, control of
hazardous materials and
biological wastes,
emergency and disaster
preparedness, fire safety,
radiation safety and utility
systems are documented
and implemented
procedures that address
safety, security, control of
biological wastes, emergency
and disaster preparedness,
fire safety, radiation safety
and utility systems and
existence of safety programs
on:
1. electrical safety
2. medical device safety
3. chemical safety
4. radiation safety
5. mechanical safety
6. water safety
7. combustible material safety
8. waste management
9. hospital safety program
(fire,emergency and disaster
preparedness)
DOCUMENT REVIEW
Policies and procedures that address the following:
1. Safety
2. Security
3. Control of hazardous material and biological wastes (including the
implementation of the gradual phase-out of mercury)
4. Emergency and disaster preparedness
5. Fire safety
6. Radiation safety
7. Utility systems safety
Existence of safety programs such as:
1. Electrical safety
2. Medical device safety
3. Chemical safety
4. Radiation safety
5. Mechanical safety
6. Water safety
7. Combustible material safety
8. Waste management
9. Hospital safety program (fire, emergency and disaster preparedness)
INTERVIEW
Ask about the frequency of the following:
1. Fire drill conducted in the past 12 months
2. Earthquake drill conducted in the past 12 months
Document review
Leadership
interview
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6.1.2.a.2
core
The organization provides a safe
regulations.
that address safety,
security, control of
biological wastes,
emergency and disaster
preparedness, fire safety,
radiation safety and utility
systems are documented
and implemented
Proof of implementation of
the policies, procedures and
safety programs on
1. electrical safety
2. medical device safety
3. chemical safety
4. radiation safety
5. mechanical safety
6. water safety
7. combustible material safety
8. waste management
9. hospital safety program
(fire, emergency and disaster
preparedness)
CORE
DOCUMENT REVIEW
1. Water safety - water analysis results for the past 6 months
2. Fire and emergency preparedness - check for exit plans, plans for
earthquake and other disasters
3. Control of hazardous materials - MOA/Contract of outsourced
services for waste management
INTERVIEW
1. Ask staff from ER, Wards, OPD, Laboratory, Pharmacy and Facilities
and maintenance on the manner of waste segregation and disposal
(general waste, liquid & solid waste, infectious & non-infectious,
hazardous & non hazardous)
2. Hospital safety programs
3. Mechanical safety program of the hospital
OBSERVATION
1. Electrical safety - check for exposed wires and sockets, "octopus
connections"
2. Emergency preparedness - check for evacuation plans, presence of
fire extinguishers
3. Control of hazardous waste - waste disposal system, segregation of
waste, proper labeling of waste receptacles,
4. Chemical safety - check safe storage and disposal of reagents
Document review
ER
OPD
Wards
Imaging
Laboratory
Pharmacy
Facilities and
maintenance
Other areas
For hospitals with radiologic facilities
DOCUMENT
1. Quality control programs and corrective and preventive maintenance
programs
2. Record of disposal of radiologic wastes
3. Preventive and corrective maintenance logbook
4. Film reject analysis test results
INTERVIEW
Ask staff about their role in the hospital waste management program
particularly manner of radiologic waste disposal
OBSERVATION
Observe if staff performs necessary precaution safety procedures such
as: red light is on while x-ray procedure is being done
Note: if not x-ray facility, may observe other areas with other mechanical
equipment e.g. generator (may look at the maintenance logbook,
elevators, gurneys
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6.1.2.b.1
core
regulations.
for the safe and efficient
use of medical equipment
according to specifications
are documented and
implemented
procedures for the safe and
equipment
CORE
DOCUMENT REVIEW
Policies and procedures on the safe and efficient use of medical
equipment (including the implementation of DOH AO#2008-0021on the
gradual phase-out of mercury)
Document review
6.1.2.b.2
core
regulations.
for the safe and efficient
use of medical equipment
according to specifications
are documented and
implemented
Proof of the implementation
of the policies and procedures
for the safe and efficient use
of medical equipment
CORE
DOCUMENT
1. Operating manual
2. Preventive and corrective maintenance logbook
3. Qualifications of staff handling medical equipment
INTERVIEW
1. Ask staff in the ER, ICU, wards, OR/RR/DR, facilities and
maintenance, imaging and laboratory about the policies and procedures
for use of medical equipment and their role in the implementation of
such policies and procedures.
2. Ask staff in the ER, wards, ICU and OR/RR/DR for the hospital's
program on the gradual phase-out of mercury
ER
ICU
Wards
OR/RR/DR
Facilities and
maintenance
Imaging
Laboratory
Other areas
6.1.2.c.1
core
regulations.
The design of patient
areas provides sufficient
space for safety, comfort
and privacy of the patient
and for emergency care
Presence of adequate space,
lighting and ventilation in
compliance with structural
requirements (for patient
safety and privacy)
CORE
OBSERVATION
Observe for the following:
1. Adequate space
2. Adequate lighting (lights are working, lighting is adequate enough for
conduct of general activities)
3. Adequate ventilation
ER
OPD
Wards
ICU
OR/RR/DR
Imaging
Laboratory
Pharmacy
6.1.2.d.1 The organization provides a safe
regulations.
All personnel understand
and fulfill their role in safe
practice
Percentage of personnel who
understand and fulfill their
role in safe practice
INTERVIEW
Ask personnel to describe their roles in safe practice
Examples: identify safety issues and ask personnel how he/she will
address this issue
Formula: Number of personnel who understands role in safe
practice/number of personnel interviewed x 100
ER
OPD
Wards
Pharmacy
Laboratory
Imaging
ICU
OR/RR/DR
Facilities and
maintenance
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6.1.2.e.1
core
regulations.
Risks are identified,
assessed and
appropriately controlled.
Where elimination or
substitution is not possible,
adequate warning and
protection devices are
used.
procedures on risk
identification, assessment
and control
CORE
DOCUMENT REVIEW
Policies and procedures on risk identification, assessment and control,
security risks, use of personal protective equipment, etc.
Document review
6.1.2.e.2 The organization provides a safe
regulations.
Risks are identified,
assessed and
appropriately controlled.
Where elimination or
substitution is not possible,
adequate warning and
protection devices are
used.
Presence of risk identification
and assessment system
DOCUMENT REVIEW
Risk assessment reports
OBSERVATION
1. Presence of warning signs where appropriate
2. Use of protective devices or personal protective equipment when
appropriate
Document review
ER
Wards
ICU
Laboratory
Imaging
Other areas
6.1.2.f.1 The organization provides a safe
regulations.
A coordinated security
arrangements in the
organization assures
protection of patients, staff
and visitors
Presence of policy regarding
facility security measures
DOCUMENT REVIEW
Policy on facility security measures
Document review
6.1.2.f.2
core
regulations.
A coordinated security
arrangements in the
organization assures
protection of patients, staff
and visitors
Presence of an appointed
personnel in charge of
security
CORE
DOCUMENT REVIEW
Contract of security agency or appointment of in-house security
or Appointment of person in charge of security
INTERVIEW
Ask the personnel in charge of security what the policies on security of
the hospital are
OBSERVATION
Presence of security guard/s or personnel in charge of security
Document review
Other areas
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6.1.3.a.1 The organization routinely
collects and evaluates
information to improve the safety
and adequacy of the environment
of care.
The effectiveness of safety
procedures and devices
are routinely tested,
monitored and improved
Proof of monitoring and
action to improve the
effectiveness of safety
procedures and devices
DOCUMENT REVIEW
1. Preventive maintenance programs for the equipment
2. Preventive and corrective maintenance logbooks
3. Incident reports regarding operation of medical devices
4. Logbook of quality control results
5. Record of length of time per exposure of personnel or film badge
report in radiology department
6. Document showing action to improve the effectiveness of safety
procedures
INTERVIEW
Ask staff in facilities and maintenance, imaging, laboratory, ICU and
OR/RR/DR about past problems regarding use of devices and what was
done to resolve these problems
Document review
Facilities and
maintenance
Imaging
Laboratory
ICU
OR/RR/DR
6.1.3.b.1
core
The organization routinely
of care.
An incident reporting
system identifies potential
harms, evaluates causal
and contributing factors for
the necessary corrective
and preventive action
Presence of incident reporting
system/sentinel event
monitoring system (which
may include nosocomial
infections, unexpected
deaths, adverse drug
reactions, blood transfusion
reactions, falls, etc)
CORE
DOCUMENT REVIEW
Incident/sentinel event reports or communications/ memoranda/orders
or proceedings on sentinel events
INTERVIEW
Ask leaders and staff from wards and ER how the incident reporting
system works
"Sentinel event" refers to injuries caused by medical management (and
not necessarily the disease process) that either caused death,
prolonged hospitalization or produced a disability during the time of
confinement or by the time of discharge.
Document review
Leadership
interview
Wards
ER
ICU
OR
6.1.3.b.2 The organization routinely
of care.
An incident reporting
system identifies potential
harms, evaluates causal
and contributing factors for
the necessary corrective
and preventive action
Proof that reported potential
harm are acted upon
DOCUMENT REVIEW
1. Incident/sentinel event reports
2. Written documents showing corrective and/or preventive actions
addressing the reported incidents e.g. memos, office orders, root cause
analysis etc.
INTERVIEW
Ask leaders how incidents/ adverse events/ sentinel events are handled
Document review
Leadership
interview
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6.2 MAINTENANCE OF THE ENVIRONMENT OF CARE
Goal: A comprehensive maintenance program ensures a clean and safe environment.
6.2.1.x.1
core
Emergency light and / or power
supply, water and ventilation
systems are provided for, in
keeping with relevant statutory
requirements and codes of
practice.
Presence of
generator/emergency light,
water system, adequate
ventilation or air conditioning.
CORE
DOCUMENT
Preventive and corrective maintenance logbooks for generator/
emergency light/ water tanks/ aircons
OBSERVATION
1. Presence of generator/emergency light, water tanks, adequate
ventilation or air conditioning
2. Test if faucets and water closets are working
3. Check if emergency light and generators are functional
Facilities and
maintenance
Other areas
6.2.2.x.1 Regular maintenance of grounds,
facilities and equipment in
keeping with relevant statutory
requirements, codes of practice,
or manufacturers' specifications
are done to ensure a clean and
safe environment.
Presence of written cleaning
schedules, logbooks and
checklists for grounds,
facilities and equipment
corrective and preventive
maintenance
DOCUMENT REVIEW
MOA/Contract for outsourced services for maintenance of equipment,
janitorial services, etc.
DOCUMENT
1. Cleaning schedule and checklist of facilities and equipment
2. Preventive and corrective maintenance logbook for equipment
OBSERVATION
Cleanliness of surroundings especially comfort rooms
Document review
Facilities and
maintenance
6.2.3.x.1
core
Equipment is serviced only by
people trained in the
maintenance of that equipment.
Registers and records of
equipment and related
maintenance are kept.
Proof of training of the staff
who is in charge of the
maintenance of the
equipment
CORE
DOCUMENT REVIEW
Proof of training of service personnel if in-house or Certificate of training,
attendance sheet, certificate of attendance, diploma, citation or
MOA/Contract for outsourced services (verify qualification of
technicians)
INTERVIEW
Ask about how equipment (generator, airconditioner, medical devices
and other equipment etc.) are maintained
Document review
Facilities and
maintenance
6.2.3.x.2 Equipment is serviced only by
people trained in the
maintenance of that equipment.
Registers and records of
equipment and related
maintenance are kept.
Presence of registers and
records of equipment and
related maintenance
DOCUMENT REVIEW
1. Preventive and corrective maintenance logbook for equipment
2. Operating manual
3. Equipment management plan which includes:
- who will maintain
- qualifications of those who maintain and
- schedule of maintenance
Document review
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6.2.4.x.1
core
Current information and scientific
data from manufacturers
concerning their products are
available for reference and
guidance in the operation and
maintenance of plant and
equipment.
Presence of operating
manuals equipment
CORE
DOCUMENT
Operating manual of generators, air conditioners and other non-medical
equipment
Facilities and
maintenance
Imaging
Laboratory
Other areas
6.3 INFECTION CONTROL
Goal: Risk of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced.
6.3.1.x.1
core
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
CORE
DOCUMENT REVIEW
1. ICC composition (for a primary hospital - proof of designation of a
doctor and nurse in-charge of infection control)
2. ICC functions and activities
3. Minutes of meeting, at least quarterly
activities
4. Statistics on nosocomial infections
INTERVIEW
Ask a member of the ICC regarding infection control program of the
hospital
Document review
Leadership
interview
6.3.1.x.2
core
An interdisciplinary infection
control program ensures the
infection in all services.
Presence of an infection
control program ensuring
infections on all services
CORE
DOCUMENT REVIEW
1. Policies and procedures on prevention and control of nosocomial
infection or Infection control manual
2. Policies on rational antimicrobial use based on the hospital
antibiogram in coordination with Microbiology Laboratory and Pharmacy
Therapeutics Committee
3. Reports of infection control activities e.g. training, outbreak
investigation, preventive programs
Document review
6.3.2.a.1 The organization uses a
coordinated system-wide
approach to reduce the risks of
nosocomial infections.
The organization
undertakes case finding
and identification of
nosocomial infections
Presence of program for case
finding and identification of
DOCUMENT REVIEW
1. Surveillance forms for nosocomial infection
2. Nosocomial Infection Case Reports
3. Hospital Acquired Infection Reports: semi annual infection rates,
antibiotic resistance pattern
Document review
6.3.2.b.1
core
The organization uses a
The organization takes
steps to prevent and
control outbreaks of
Presence of a coordinated
system-wide procedure for
isolation of nosocomial
infections
CORE
DOCUMENT REVIEW
Procedures on isolation of nosocomial infections
INTERVIEW
Ask staff in ER, wards and ICU the procedures on isolation
isolation - physical isolation of a patient with infection
Document review
ER
Wards
ICU
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6.3.2.b.2
core
case containment of
CORE
DOCUMENT REVIEW
Procedures on case containment of nosocomial infections
Note : case containment - means prevention of spread of infection
examples: reverse isolation, prophylaxis for exposed personnel,
vaccination, immunization
INTERVIEW
Validate from staff in ER, wards and ICU the procedures on case
containment
Document review
ER
Wards
ICU
6.3.2.b.3
core
asepsis
CORE
DOCUMENT REVIEW
Procedures on asepsis
INTERVIEW
Ask staff from ER, wards, laboratory and ICU about the approaches for
asepsis during diagnostic and treatment procedures
Document review
ER
Wards
ICU
Laboratory
6.3.3.a.1
core
infection the staff are exposed to
in the performance of their duties.
There are programs for
prevention and treatment
of needle stick injuries,
and policies and
procedures for the safe
disposal of used needles
are documented and
monitored
procedures on the prevention
and treatment of needle stick
injuries and safe disposal of
needles
CORE
DOCUMENT REVIEW
1. Policies and procedures for prevention and treatment of needle stick
injuries
2. Policies and procedures on proper handling and safe disposal of
sharps/needle sticks
INTERVIEW
Interview hospital staff on how they handle and dispose needles
OBSERVATION
Presence of receptacles for proper disposal of sharps
Document review
ER
Wards
ICU
Laboratory
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MASTER LIST
NOT FOR CIRCULATION
6.3.3.b.1
core
infection the staff are exposed to
in the performance of their duties.
There are programs for the
prevention of transmission
of airborne infections, and
risks from patients with
signs and symptoms
suggestive of tuberculosis
or other communicable
diseases are managed
protocols
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
CORE
DOCUMENT REVIEW
1. Infection control procedures on isolation and universal precaution
2. Program for the protection of healthcare workers e.g. personal
protective equipment (PPEs)
3. Policies on all patient admission/referral, isolation and timely case
reporting of highly transmissible and notifiable infectious disease e.g.
meningococcemia, SARS, avian flu, etc
4. Hand hygiene procedures
5. Environmental care and healthcare waste management
6. Procedures on recycling & reuse of equipment i.e. personal
protective equipment
INTERVIEW
Validate hospital policies on infection control such as use of PPEs,
isolation precautions and hand washing
OBSERVATION
1. Observe for use of gloves, surgical masks
2. Look for sinks or lavatories or designated areas for hand washing or
dispenser for sanitizers
3. Look for separate holding area/room for highly infectious cases
4. Ask a hospital staff to demonstrate hand washing technique
Document review
ER
Wards
ICU
Laboratory
6.3.4.x.1
core
Cleaning, disinfecting, drying,
packaging and sterilizing of
equipment, and maintenance of
associated environment, conform
to relevant statutory requirements
and codes of practice.
procedures on cleaning,
disinfecting, drying,
packaging and sterilizing of
equipment, instruments and
supplies
CORE
DOCUMENT REVIEW
1. Policies and procedures on cleaning, disinfecting, drying, packaging
and sterilizing of equipment, instruments and supplies
2. Policies on decontamination, disinfection, sterilization, disinfectants
for specific medical equipment/items and area
3. Housekeeping procedures in specific patient areas
Document review
6.3.5.x.1
core
When needed, the organization
reports information about
infections to personnel and public
health agencies.
procedures on reporting of
infections to personnel and
public health agencies
CORE
DOCUMENT REVIEW
Policies and procedures on reporting of infections to personnel and
public health agencies
Document review
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MASTER LIST
NOT FOR CIRCULATION
6.4 EQUIPMENT AND SUPPLIES
Goal: The provision of equipment and supplies supports the organization's role.
6.4.1.a.1 Planning of facilities and
selection and acquisition of
equipment and supplies involve
input from relevant staff and are
undertaken by appropriately-
qualified personnel.
Appropriate equipment
and supplies that support
the organizations role and
level of service are
provided. Consideration is
given to at least:
*the intended use
*cost benefits
*infection control
*safety
*waste creation and
disposal
*storage
acquisition of equipment and
supplies, considering the
intended use, safety, cost
benefit, storage, infection
control, waste creation and
disposal
DOCUMENT REVIEW
Procurement policy and plan which considers the following:
1. intended use
2. cost benefits
3. infection control
4. safety
5. waste creation and disposal
6. storage
Note : all elements must be present in the policies, if not - score is partial
INTERVIEW
Ask about the processes in selecting and acquiring equipment and
supplies (especially for LGU hospitals because procurement is
centralized at the provincial/municipal/ city level)
Document review
Leadership
interview
6.4.2.x.1 Specialized equipment is
operated according to
specifications and only by
appropriately -trained staff.
Proof that specialized
equipment is operated only by
a trained staff
DOCUMENT REVIEW
1. License if applicable
2. List of specialized equipment
3. Certificates of training, certificates of attendance, or equivalent
experience (at least 1 year) under a trained personnel
OBSERVATION
Identify specialized equipment that need only trained staff to operate
Example of specialized equipment : MRI, CT scan, ECG, 2d echo, x-ray,
respirator, ultrasound, anesthesia machine, endoscopes, etc
Document review
Imaging
Laboratory
Wards
ICU
OR/RR/DR
Other areas
6.4.3.x.1
core
Items designated by the
manufacturer for single use are
not reused unless the
organization has specific policies
and guidelines for safe reuse
which take into consideration
relevant statutory requirements
Presence of policies,
procedures and guidelines for
safe reuse of items which
comply with relevant statutory
requirements
CORE
DOCUMENT REVIEW
Policies and procedures on safe reuse of items
INTERVIEW
Ask heads and staff about the following:
1. Policy on reuse of items
2. SOPs on reuse
3. Reporting
4. Personnel in charge
Document review
Facilities and
maintenance
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6.5 ENERGY AND WASTE MANAGEMENT
Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability.
6.5.1.x.1
core
The handling, collection, and
disposal of waste conform to
relevant statutory requirements
Presence of licenses/permits/
clearances from pertinent
regulatory agencies
implementing among others
the following: RA 9003, RA
6969, RA 9275, PD 1586
DOH Hospital waste
management manual, RA
8749 (Clean Air Act)
CORE
DOCUMENT REVIEW
Pertinent licenses/permits from regulatory agencies (LGU, DENR, etc.)
Document review
6.5.2.x.1 The organization implements a
waste disposal program which
involves reuse, reduction an
recycling.
procedures on waste disposal
which involve reuse,
reduction and recycling
DOCUMENT REVIEW
1. Policies and procedures which involves reuse, reduction and
recycling in compliance with RA 9003 and DOH guidelines
2. Waste management program
3. MOA/contract of outsourced services for waste management
Document review
6.5.2.x.2
core
The organization implements a
waste disposal program which
involves reuse, reduction an
recycling.
Proof of implementation of
policies and procedures on
waste disposal
CORE
DOCUMENT REVIEW
1. Issuances - memos, guidelines on waste disposal
2. Contracts with waste handlers or disposal contractors, (if applicable)
3. Hospital policy that conforms to the joint DOH-DENR circular on
waste management for LGUs
INTERVIEW
Ask staff regarding SOPs on actual procedure waste disposal
OBSERVATION
1. Segregation of waste
2. Proper labeling of waste receptacles
3. Recyclable waste staging areas
4. Proper management of temporary storage areas prior to hauling for
disposal
Document review
ER
Wards
ICU
Pharmacy
Imaging
Laboratory
Facilities and
maintenance
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MASTER LIST
NOT FOR CIRCULATION
7. IMPROVING PERFORMANCE
7.1.x.1
core
The organization has a planned
systematic organization- wide
approach to process design and
performance measurement,
assessment and improvement.
Presence of Quality
Improvement Program
CORE
DOCUMENT REVIEW
1. Policy creating the QI program
2. Proof of meetings or similar documents of QA Committee activities
3. Policies and procedures on performance measurement and
improvement
INTERVIEW
Validation of QI activities thru interview of pertinent staff including
frontliners and Committee members
Document review
Leadership
interview
7.2.a.1 New process of care are
designed collaboratively based
on scientific evidence, clinical
standards, cultural values and
patient preferences.
There are resources
available for developing or
adopting clinical practice
guidelines
Proof that there are resources
available for developing or
adopting CPG
DOCUMENT REVIEW
Annual plan and budget showing funds allotted to CPG development or
adoption and implementation
INTERVIEW
Ask staff for presence of person knowledgeable of CPG appraisal
Document review
Leadership
interview
7.2.b.1 New processes of care are
Clinical practice guidelines
for the top 10 causes of
admissions and/or
consultations and
PhilHealth-adopted
guidelines are
disseminated and
monitored
Proof of dissemination of
PhilHealth-adopted CPGs for
the 10 conditions as
contained in HTA Forum (if
CPG is applicable in the
hospital)
DOCUMENT REVIEW
Documentation of dissemination of PhilHealth-adopted CPGs e.g.
Conferences- topics, meetings - look at the minutes, agenda, memos
and other issuances
OBSERVATION
CPGs or IEC materials available in the wards, nurses station, and
emergency room, doctors' offices/clinics
Document review
ER
OPD
Wards
admissions and/or
consultations and
PhilHealth-adopted
guidelines are
disseminated and
monitored
Proof of dissemination of
CPGs for the top 10 causes
of admission and/or
consultation
DOCUMENT REVIEW
Documentation of dissemination and monitoring of CPGs e.g.
Conferences- topics, meetings - look at the minutes, agenda, memos
and other issuances
OBSERVATION
CPGs or IEC materials available in the wards, nurses station, and
emergency room, doctors' offices/clinics
Document review
ER
OPD
Wards
admissions and/or
consultations and
PhilHealth-adopted
guidelines are
disseminated and
monitored
Proof of monitoring of CPG
dissemination
DOCUMENT REVIEW
1. Conduct of utilization review of drugs, procedures or diagnostic tests
based on CPG
2. Use of clinical pathways based on CPG
3. Conduct of medical audits using CPG as standard
Document review
Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of its internal and external clients.
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MASTER LIST
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7.3.x.1 Management is primarily
responsible for developing,
communicating, and
implementing a comprehensive
quality improvement program
throughout the organization and
delegating responsibilities to
appropriate personnel for its day-
to-day implementation.
Proof that the management is
primarily responsible for
developing, communicating
and implementing a
comprehensive quality
improvement program
throughout the organization
and delegating
responsibilities to appropriate
personnel for its day-to-day
implementation
DOCUMENT REVIEW
1. Memoranda/orders creating the QI team/Quality circle
2. Minutes of meetings/extracts of minutes relating to concerned topic,
documentation of activities
3. Monitoring reports on CPG use or similar QI activities
4. Designation of a point person for the QA program
INTERVIEW
Validate the activities by asking the management team or officer
involved in QA program
Document review
Leadership
interview
7.4.x.1 All service units and staff are
responsible for, and demonstrate
involvement in, performance
improvement that results in better
services in internal and external
clients.
Proof that all service units
and staff are responsible for,
and demonstrate involvement
in performance improvement
that results in better services
for internal and external
clients
DOCUMENT REVIEW
1. Policies or issuances on CQI Program
2. QA/CQI manual
3. Patient satisfaction survey results/ratings
4. Staff satisfaction survey
INTERVIEW
Validate the activities thru interview of any staff including the frontliners,
patients, external clients
Document review
ER
OPD
Wards
7.5.x.1 Managers and staff evaluate the
effectiveness of the quality
improvement program and take
action to address any
improvements required.
Proof of evaluation of the
quality improvement program
DOCUMENT REVIEW
1. Minutes or extracts of minutes of the management or Executive
Committee meetings
2. Memoranda, policies, orders emanating from the evaluation of QI
programs/activities
3. Monitoring and evaluation reports
Document review
7.6.x.1
core
The organization provides better
care service as a result of
continuous quality improvement
activities.
Presence of patient
satisfaction survey
CORE
DOCUMENT REVIEW
1. Patient satisfaction survey results
2. Patient satisfaction survey questionnaire (may check on the domains
and items)
Document review
7.6.x.2 The organization provides better
activities.
Proof of better patient
outcomes
DOCUMENT REVIEW
Documentation of better outcomes for patients as a result of CQI
activities e.g. declining trends of nosocomial infection, increase in
patient satisfaction ratings, in OB - increase in trend of trial labor vs. CS,
increase use of component blood vs. fresh whole blood, etc.
Document review
7.6.x.3 The organization provides better
activities.
Proof of better services
whether inpatient or
outpatient
DOCUMENT REVIEW
Documentation of better services e.g. reduction of turn-around-time for
diagnostic tests, OPD and ER services; increase in patient satisfaction
ratings, higher Benchbook assessment ratings for renewal application,
etc.
Document review
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NOT FOR CIRCULATION
7.7.x.1 Quality improvement activities
respect the confidentiality of data
regarding patients, staff and other
care providers.
Proof that QI activities respect
the confidentiality of data
regarding patients, staff and
other care providers.
DOCUMENT REVIEW
1. Policies and procedures on confidentiality of records
2. QA/CQI manual
3. Reports related to QI activities
INTERVIEW
Ask also
1. How the staff protect /ensure confidentiality of patient's data
especially in relation to audit or peer review and how they prevent staff
from leaking data or information.
2. How they present a picture of a patient like in IEC materials.
Note : The surveyor should look for any data that can be attributed to
specific individuals
Document review
Leadership
interview
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Page 74 of 76
THE BENCHBOOK ACCREDITATION PROCESS
(Self-Assessment)

The Benchbook lays out the new standards for quality of care that PhilHealth will use for accrediting
hospitals into the National Health Insurance Program. The Benchbook represents a shift from the old
standards that govern only inputs to health care into the new standards that also evaluate processes and
outcomes of care.

The new Benchbook accreditation process entails greater hospital involvement. The new process will be
as follows:

The Self-Assessment

The self-assessment is a venue for the hospital to assess its own strengths and weaknesses and
evaluate what it already has and what it still needs. It is an evaluation of the hospitals own performance
measured against the standards, criteria and indicators of the Benchbook. It is vital for improving
performance. Also, it will allow the hospitals to demonstrate to the PhilHealth surveyors their level of
achievement of the Benchbook indicators.

A. Expectations for the Self-Assessment

1. The hospital has attended the two-day orientation conducted by PhilHealth and has secured a
soft copy of the Self-Assessment and Survey Tool, Score Sheet and Benchbook Self-
Assessment Summary.
2. The hospital is responsible for printing the Self-Assessment and Survey Tool in 8 x 13
bond paper and shall complete and submit the Tool with the Score Sheet and Benchbook Self-
Assessment Summary in a folder to their respective PhilHealth Regional Office (PhRO) 40
working days after the orientation.
3. The hospital may follow the process for the self-assessment suggested here or they may devise
their own process/system. The important thing is, the Self-Assessment and Survey Tool,
Score Sheet and Benchbook Self-Assessment Summary are completed and submitted to the
PhRO on or before the deadline.

B. How to Conduct the Self-Assessment

1. Meet with hospital top management to echo proceedings of Orientation of Hospitals on
Benchbook Self-Assessment and Accreditation Process. The top management consists of the
hospital director, or chief of hospital or chief health officer together with the administrative officer
and/or service heads.

2. Create a committee or assign a person in charge of handling the conduct of the self-assessment.

3. Orient all hospital staff regarding the new accreditation standards of PhilHealth the Benchbook
and the conduct of the self-assessment.

4. Conduct initial survey using the Benchbook Self-Assessment and Survey Tool to measure the
baseline level of compliance of the hospital. This will identify gaps and deficiencies in the existing
structures, processes and outcomes of the hospital and determine which among the core
Self-assessment by the hospital
Application for accreditation +submission of self-assessment results
Actual PhilHealth Survey
Accreditation Decision
Page 75 of 76
indicators the hospital still needs to comply with. Core indicators are all or nothing indicators
that the hospital must comply with.

5. Plan and prioritize. After the initial survey, the hospital may conduct meetings to plan which
aspects of the Benchbook to prioritize. For the first round of accreditation, the hospitals are given
only eight weeks (40 working days) to accomplish and submit the Self-Assessment and Survey
Tool. During the planning and prioritization, the hospital may identify based on their strengths
and weaknesses which accreditation award to apply for Center of Safety, Center of Quality or
Center of Excellence.

6. Prepare all policies, memos, reports, procedures, processes, etc necessary for complying with
the indicators. The top management should ensure that all hospital staff are aware of all the
hospital policies, procedures and processes.

7. Conduct actual self-assessment. It is suggested that the hospital simulate the actual
accreditation survey during the conduct of the self-assessment. The process of accreditation
survey is found in the Guidelines for the Hospitals (Accomplishing the Benchbook Self-
Assessment and Survey Tool).

For the self-assessment survey, the hospital is encouraged to form a group of surveyors who
will assess the compliance of the hospital. Document reviews, chart reviews, leadership and
management interviews, patient and staff interviews and actual demonstration of some processes
should all be done as if in an actual accreditation survey.

8. Accomplish the Score Sheet and Benchbook Self-Assessment Summary (as instructed in the
Guidelines for Accomplishing the Benchbook Self-Assessment and Survey Tool) and determine if
they are able to meet the required compliance scores for the accreditation award they are
applying for.

9. Finalize the Self-Assessment and Survey Tool, Score Sheet and Benchbook Self-
Assessment Summary and submit it to the PhilHealth Regional Office.

Page 76 of 76

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Orientation of Hospitals on

(This form must be accomplished by the hospital.)

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