Form HOS-LTO-AT/L1-2007

Republic of the Philippines

Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila
Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179
URL: http://www.doh.gov.ph/

ASSESSMENT TOOL FOR LICENSING OF

LEVEL 1 HOSPITAL
Name of Hospital

Address of the Hospital

This tool serves as a guide for self-assessment of the health facility in preparation for
inspection/ monitoring visits.
1. GENERAL INFORMATION
Owner
Chief of Hospital/Medical Director

:
:

Classification

General
Special

[
[

Government

[
]
National
Local
Others, please
specify
[
]
Single
Proprietorship
Partnership
Corporation
Civic Organization
Religious
Foundation
Others, please
specify

Private

Chairman of the Board (If

Corporation)

Authorized Bed Capacity

Implementing Bed Capacity

:
:

]
]

[
[

]
]

[
[
[
[
[

]
]
]
]
]

Page 1 of 13

Form HOS-LTO-AT/L1-2007

2. SERVICE CAPABILITY
Service Capability of a Level 1 Hospital:
2.1.1.

(
if Available)

Manual of
Operations/
Written Policies
and Procedures

AVAILABILITY

Written Vision
and Mission

SERVICE

Duties and
Responsibilities

The hospital shall render quality health services appropriate to the level
of care being provided:
Master Staffing
Plan

2.2.

Provides emergency treatment and care to the sick and

injured, as well as clinical care and management to mothers
and newborn

Organizational
Chart

2.1.

REMARKS

Administrative Service
General Administrative
Service
Records
Bookkeeping
Clerical Work
Maintenance
Patient Transport Service
(May be contracted out;
available for 24 hours)
Clinical Service
General Medicine
General Pediatrics
General Obstetrics and NonSurgical Gynecology

Minor Surgery
Emergency and Outpatient
Service

Non-surgical Gynecology involves the diagnosis and treatment of gynecologic problems through
non-surgical or medical means.

Nursing Service
Minimal Care and
Management 
Health Education and
Counseling
 As defined in the Hospital Nursing Service Administration Manual (DOH, 1994), under the minimal or
self-care category, the patient is capable of carrying out daily activities as long as the nurse provides
the necessary materials and supplies.

Page 2 of 13

Form HOS-LTO-AT/L1-2007

AVAILABILITY

SERVICE

(
if Available)

LICENSE
NUMBER

DATE
ISSUED

VALIDITY

REMARKS

Ancillary Service
Clinical Laboratory 
Radiology 
Pharmacy 
 The health facility must be affiliated with a licensed clinical laboratory and radiology facility.
 A licensed pharmacy is optional.

2.3.

Hospital Operations
2.3.1.

Administrative Service
The performance of each personnel is monitored and
evaluated.
[
] Yes [
] No
New personnel receive an orientation program that covers the
essential components of the service being provided.
[
] Yes [
] No
An exit interview is conducted for personnel who resign or
retire from the service.
[
] Yes [
] No

2.3.2.

Emergency Room
Personnel to deliver emergency care are available for 24
hours.
[
] Yes [
] No
All equipment, medicines and supplies necessary to provide
emergency care are available.
[
] Yes [
] No

2.3.3.

Obstetrical Service
Proper identification of newborns is ensured before they leave
the delivery room and until discharge.
[
] Yes [
] No

2.3.4.

Nursing Service
Nursing care is provided at all times.

] Yes

] No

Written policies for all nursing service areas within the

hospital are available and reviewed annually.
[
] Yes [
] No
A Nursing Procedure Manual and a properly utilized Kardex
are available in all patient care units.
Nursing Procedure Manual
[
] Yes [
] No
Properly Utilized Kardex
[
] Yes [
] No

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Form HOS-LTO-AT/L1-2007

The delivery of nursing care utilizes the nursing process.

[
] Yes [
] No
2.3.5.

Medical Records
Medical records contain patient information that is uniquely
identifiable, accurately recorded, current, confidential and
accessible when required.
[
] Yes [
] No
Medical diagnoses, procedures and/or operations performed
on patients are recorded using ICD 10.
[
] Yes [
] No
ICD 10 reference books are available. [

] Yes

] No

The Medical Records Officer is trained in ICD 10.

[
] Yes [

] No

A Patient Logbook is properly filled up in the following areas:

Admitting Office
[
] Yes [
] No
Emergency and Outpatient
[
] Yes [
] No
Delivery Room
[
] Yes [
] No
Patient Charts are properly and completely filled up and
contain up-to-date information on the following:
In-Patient
Out-Patient
Contents of Medical Chart
(
if
(
if
available)

Available)

Identification Data
Chief Complaint
History of Present Illness
Physical Examination
Diagnosis/Admitting Diagnosis
Admitting/Attending Physician
Clinical Laboratory Report
X-ray Report
Consultation/Referral Notes
Medication/Treatment
Progress Notes
Final Diagnosis
Nursing Record
Discharge Summary
Obstetrical Record (if
applicable)
Consent
Doctors Order Sheet
Records of newborns are properly and completely filled up.
[
] Yes [
] No
Records of medico legal cases are properly and completely
filled up.
[
] Yes [
] No
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Form HOS-LTO-AT/L1-2007

Birth certificate forms are properly and completely filled up.

[
] Yes [
] No
Death certificate forms are properly and completely filled up.
[
] Yes [
] No
Confidentiality of patient information is maintained at all times.
[
] Yes [
] No
2.3.6.

Blood Services
The hospital ensures that its supply of blood and blood
products is safe.
[
] Yes [
] No
The hospital obtains blood and blood products only from
blood service facilities licensed/authorized by the Department
of Health (as required by R.A. 7719 National Blood Services
Act of 1994 and Its Implementing Rules and Regulations).
[
] Yes [
] No
The hospital obtains blood and blood products collected from
healthy voluntary blood donors only (as required by R.A. 7719
National Blood Services Act of 1994 and Its Implementing
Rules and Regulations).
[
] Yes [
] No

2.4.

Programs
2.4.1.

Health Promotion and Disease Prevention

The hospital has a health promotion and disease prevention
program that shall include the following:
Breastfeeding (as required by R.A. 7600 The Rooming-In and
Breastfeeding Act of 1992)
[
] Yes [
] No
Family Planning
[
] Yes [
] No
Immunization
[
] Yes [
] No
Newborn Screening (as required by R.A. 9288 Newborn
Screening Act of 2004 and Its Implementing Rules and
Regulations)
[
] Yes [
] No
Rooming-In (as required by R.A. 7600 The Rooming-In and
Breastfeeding Act of 1992)
[
] Yes [
] No

2.4.2.

Disaster Management
The hospital has a documented emergency and disaster
management plan.
[
] Yes [
] No

2.4.3.

Human Resource Development

The hospital implements a human resource development
program that identifies, plan, facilitate and record training and
education for all personnel.
[
] Yes [
] No

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Form HOS-LTO-AT/L1-2007

An appraisal system identifies and reviews the effectiveness

and appropriateness of the training provided.
[
] Yes [
] No
2.4.4.

Quality Management
The hospital has an established, documented and maintained
quality management program that reflects continuous quality
improvement principles.
[
] Yes [
] No
The program identifies the organizations quality goals,
objectives and scope; quality responsibility, authority and
resources; and quality activities and review processes.
[
] Yes [
] No
There is an exception reporting system that includes the
recording, reporting, investigation, analysis, corrective action
and review process for adverse, unplanned, or untoward
events such as:
Accidents, incidents, near misses, and adverse clinical events
[
] Yes [
] No
Complaints and suggestions
[
] Yes [
] No
Infectious / Notifiable diseases
[
] Yes [
] No
Service shortfalls
[
] Yes [
] No

3. PERSONNEL
3.1.

The health facility appoints and allocates personnel who are suitably
qualified, skilled and/or experienced to provide the service and meet
patient needs.
3.1.1.

Each personnel is qualified, skilled and/or experienced to

assume the responsibilities, authority, accountability and
functions of the position.
[
] Yes [
] No

3.1.2.

Professional qualifications are validated, including evidence

of professional registration/license, where applicable, prior to
employment.
[
] Yes [
] No

3.1.3.

An organized medical and nursing staff shall be responsible

for the quality of patient care and for the ethical conduct and
professional practices of its members. [
] Yes [
] No

POSITION
Administrative
Service
Administrator
Clerk (Accounting and
records)

REQUIREMENT

COMPLIANCE
(
if Compliant)

STATUS
(FT if Full Time)
(PT if Part Time)

REMARKS

1
1
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Form HOS-LTO-AT/L1-2007

POSITION

REQUIREMENT

Utility Worker
Driver (May be
contracted out)
Clinical Service

1
1

Physician

1 at any time plus

one (1) reliever

COMPLIANCE
(
if Compliant)

STATUS
(FT if Full Time)
(PT if Part Time)

REMARKS

The physician must not go on continuous duty for more than forty-eight (48) hours.
Nursing Service
Nurse 
Nursing Attendant/
Midwife 

1:12 beds at any

time
1:24 beds at any
time

 For every three (3) Nurses, there must be one (1) reliever.
 Nursing Attendant/Midwife is optional if the Authorized Bed Capacity (ABC) is less than twenty-four
(24) beds. If the ABC is 24 beds and above, the ratio will apply.
For every three (3) Nursing Attendants/Midwives, there must be one (1) reliever.

4. EQUIPMENT/INSTRUMENT
4.1.

All equipment and instruments necessary for the safe and effective
provision of services are available and are properly maintained.
4.1.1.

Records of equipment are maintained and updated regularly.

[
] Yes [
] No

4.1.2.

A preventive maintenance program ensures that all

equipment are maintained and/or calibrated to an appropriate
standard or specification.
[
] Yes [
] No

4.1.3.

There is a plan in place for essential equipment replacement.

[
] Yes [
] No

4.1.4.

Personnel are competent when using equipment in line with

manufacturers instruction/operational manual.
[
] Yes [
] No

4.1.5.

Operational manuals of all equipment and instruments are

available for reference and guidance.
[
] Yes [
] No

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Form HOS-LTO-AT/L1-2007

ITEM

REQUIREMENT

COMPLIANCE

CONDITION

(
if Compliant)

(
if Serviceable)

REMARKS

Administrative Service
Emergency Light
Fire Extinguisher
Standby Generator
Transport Vehicle
(Available for 24 hours)
Typewriter/Computer
Clinical Service
Ambu Bag
Adult
Pediatric
Clinical Weighing Scale
Delivery Set
Emergency Cart (or its
equivalent)
Examining Table with
Stirrup
Gooseneck Lamp /
Examining Light
EENT Diagnostic Set (or
its equivalent)
Instrument Table
Kelly Pad
Minor Surgery Instrument
Set
Neurological Hammer
Oxygen Unit
Sphygmomanometer
Adult Cuff
Pediatric Cuff Set
Sterilizer
Stethoscope
Suction Apparatus
Suturing Set
Vaginal Speculum Set
Wheelchair
Wheeled Stretcher

1
1
1
1
1

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Others, please specify

5. PHYSICAL PLANT
5.1.

All physical facilities and utility systems necessary for the safe and effective
provision of services are available and are properly maintained.
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Form HOS-LTO-AT/L1-2007

AREA

COMPLIANCE

LIGHTING

VENTILATION

(
if Compliant)

(
if Adequate)

(
if Adequate)

REMARKS

Administrative Service
Waiting Area
Admitting and Records
Area
Administrative and
Business Office
Staff Toilet
Parking Area for
Transport Vehicle
Clinical Service
Emergency and
Outpatient
Waiting Area
Toilet (adjacent or
within ER)
Nurse Station
Consultation Area
Examination and
Treatment Area with
Lavatory/Sink
Equipment and
Supply Storage Area
Wheeled Stretcher
Area
Delivery Room
Birthing Area
Scrub-up Area
Newborn Area with
lavatory/sink
Equipment and
Supply Storage Area
Nursing Unit
Patient Room
Toilet
Nurse Station
5.2.

Environment
The hospital is:
Readily accessible to the community.

] Yes

] No

Free from undue noise, smoke, dust, foul odor, flood.

[
] Yes

] No

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Form HOS-LTO-AT/L1-2007

Not located adjacent to railroads, freight yards, childrens playgrounds,

airports, industrial plants, and waste disposal plants.
[
] Yes [
] No
5.3.

Occupancy
The location of the hospital complies with all local zoning ordinances.
[
] Yes [
] No

5.4.

Safety
The hospital provides and maintains a safe environment for patients,
personnel and public.
[
] Yes [
] No
Buildings pose no hazards to the life and safety of patients, personnel
and public.
[
] Yes [
] No
Exits are restricted to the following types: door leading directly outside
the building, interior stair, ramp, and exterior stair.
[
] Yes [
] No
A minimum of two (2) exits, remote from each other, are provided for
each floor of the building.
[
] Yes [
] No
Exits terminate directly at an open space to the outside of the building.
[
] Yes [
] No

5.5.

Security
The hospital ensures the security of person and property within the
facility.
[
] Yes [
] No

5.6.

Lighting and Ventilation

Areas used by patients and personnel are adequately lighted and
ventilated.
[
] Yes [
] No

5.7.

Exposure to Environmental Tobacco Smoke

Patients and personnel are not put at risk by exposure to
environmental tobacco smoke.
[
] Yes [
] No
Smoking is absolutely prohibited throughout the hospital in accordance
with R.A. 9211 Tobacco Regulation Act of 2003. [
] Yes [
] No

5.8.

Patient Movement
Adequate space is provided to allow patients and personnel to move
safely around patient bed areas.
[
] Yes [
] No
Patients who use mobility aids are able to safely maneuver with the
assistance of their aid within their bed area.
[
] Yes [
] No
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Form HOS-LTO-AT/L1-2007

Doorways, corridors, elevators and turning areas readily accommodate

the bed, attached equipment and any escorts of patients who require to
be transported or transferred between rooms or services in their beds.
[
] Yes [
] No
Corridors in areas not commonly used for bed, stretcher and
equipment transport are at least 1.83 Meters in width.

[
] Yes [
] No
A ramp or elevator is provided for ancillary, clinical and nursing
services located on the upper floor.

[
] Yes [
] No


5.9.

DOH licensed facilities shall be given until end of 2010 to comply.

Auditory and Visual Privacy

Adequate privacy for patients is provided such that sensitive or private
discussion, examination, and/or procedure are conducted in a manner
or environment where these cannot be observed or the risk of being
overheard by others is minimized.
[
] Yes [
] No

5.10. Power Supply

The hospital has an approved power supply system.
[

] Yes

] No

] Yes

] No

5.11. Water Supply

The hospital has an approved water supply system.
[

The hospital has available water supply that is potable and safe for
drinking.
[
] Yes [
] No
Records of water analysis (bacteriological examination) are available
and updated regularly (at least annually).
[
] Yes [
] No
Frequency
.....................................................
5.12. Waste Management
5.12.1.

Liquid Waste
Liquid waste is discharged into a multi-chamber septic tank.
[
] Yes [
] No

5.12.2.

Solid Waste
Solid waste is collected, treated and disposed of in
accordance with the Health Care Waste Management Manual
of the Department of Health, 2004.
[
] Yes [
] No

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Form HOS-LTO-AT/L1-2007

The hospital observes segregation, coding and labeling of

waste.
Black Trash Bag
(General Non-Infectious Dry)
[
] Yes [
] No
Green Trash Bag
(General Non-Infectious Wet)
[
] Yes [
] No
Yellow Trash Bag
(Infectious Pathological)
[
] Yes [
] No
Sharp Container
(Sharps)
[
] Yes [
] No
Logbook Available and Updated
[
] Yes [
] No
Frequency
.....................................................
Protective equipment and clothing appropriate to the risks
associated with the handling, storage, and disposal of wastes
are provided to and used by personnel. [
] Yes [
] No
5.13. Sanitation
The hospital observes pest and vermin control:
In-House
[
] Yes [
] No
Contractor
[
] Yes [
] No
Company Name
.....................................................
Memorandum of Agreement is available and updated.
[
] Yes [
] No
Frequency
.....................................................
Records are available and updated.
[
] Yes [
] No
Frequency
.....................................................
There are screen wires on doors, windows, and other openings.
[
] Yes [

] No

5.14. Maintenance
A building maintenance program is in place to ensure that all
buildings/facilities are kept in a state of good repair.
[
] Yes [
] No
A building/facility inventory is maintained and updated regularly.
[
] Yes [
] No
Frequency
.....................................................
5.15. Material Specification
Floors, walls and ceiling are made of sturdy materials that allow
durability, ease of cleaning and fire resistance.
[
] Yes [
] No

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Form HOS-LTO-AT/L1-2007

5.16. Signage
There are visual aids and devices for:
Information and Orientation
Direction
Identification

[
[
[

] Yes
] Yes
] Yes

[
[
[

] No
] No
] No

5.17. Permits
A Permit to Construct is available for:
Construction of New Hospital (if applicable)
[
] Yes [
] No
Alteration/Expansion/Renovation of Existing Hospital (if applicable)
[
] Yes [
] No
Change in Classification (if applicable)
[
] Yes [
] No
Increase in Bed Capacity (if applicable)
[
] Yes [
] No

Page 13 of 13