DOH BENCHBOOK 2015.docx

7/25/2019 DOH BENCHBOOK 2015.docx

1/15

TA. RO A HO PITAL

AND MEDICAL CENTER

RSBS Blvd., San Lorenzo South, Balibago,City of Sta. Rosa, Laguna, Philippines, 402!04"# $%&'0"(( ) !02# *20'$42( ) +elefa-!04"# 420'04*

DOH Benchbook

Quality Manual

Table of ContentsDocumentNo.:

SRHMC-DOH-01-001

Page No.: 1 of 15

CODE /

DEPARTMENTPOLICY AND PROCEDURE EVIDENCE

Hosital A!"inist#ation

$%$%$

Human

Resources

Stang Plan

Record of scedule of dut!es

"##o!ntment$em#lo%ment

Contract& !f 'al!d

(#dated ealt cert!)cate

Or!entat!on #lan$#rogram of ne*

em#lo%ees !m#lemented

Recru!tment and Select!onH!r!ng$"##o!ntmentOr!entat!on and Sta+ De'elo#mentCont!nu!ng educat!on& and tra!n!ngPerformance ,'aluat!onRotat!on$ransferSuccess!on Plan

Mer!t& Promot!on& "*ards /ncent!'esRes!gnat!on& erm!nat!on

Ret!rement

P%s!cal ,am!nat!on

$%$%$%b%$

Accounting

S%stemat!c record!ng of all )nanc!al

transact!onsPre#arat!on of )nanc!al statementsand rele'ant re#ortsMa!ntenance and Safeee#!ng of

2oos of "ccounts

$%$%$%b%&

Accounting

Consol!dat!on and #re#arat!on of te

2udget Pro#osal& 3or and 4!nanc!al$

O#erat!onal Plans

/m#lementat!on and mon!tor!ng % te

os#!tal sta+ concerned

$%$%$%b%'

Billing

2!ll!ng of #at!ents and Process!ng of

cla!ms

$%$%$%(

Purchasing

Re6u!s!t!on& #urcase& !ssuance and

!n'entor%

"##ro'ed 3or and 4!nanc!al Plan and

!ts !m#lementat!on

D!s#osal of non-funct!onal

e6u!#ment& !nstruments& su##l!es&

e#!red drugs and med!c!nes and

reagents are !n #lace$%$%$%!

Property

Rece!#t& storage& !ssuance and

conduct of !n'entor%Proof of transact!ons

$%$%$%e

LinenClean!ng and *as!ng of so!led l!nens

$%$%$%f

Housekeepin

g

Houseee#!ng 7!st of Houseee#!ng Su##l!es

$%$%$%)

Security

Cec!ng for !nternal and eternal

customers !nclud!ng use of '!s!tor8s


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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 9 of 15

#ass

$%$%$%*

NSD (ER)

Pat!ent trans#ort to and from te

fac!l!t%

3!t a##ro#r!ate man#o*er&

e6u!#ment and su##l!es dur!ng #at!ent

trans#ort9 our a'a!la!l!t% of amulance for

read% use

/f contracted out; note s#ec!)cat!ons !n

contract or MO"Com#l!ance to ".O. 9010-000 "llocat!on of not

less tan 10B of !ts "utor!?ed ed

ca#ac!t% as car!t% eds.Counsel!ng of #at!ents$cl!ents and

te!r fam!l!es

Records of #re-adm!ss!on and #re-

d!scarge assessment& andd!scarge #lan

Com#l!ance to R"


3/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: < of 15

PND4 and DOH #ol!c!es& rules and

regulat!ons.


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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: of 15

CODE /


Patient-s Ri)*ts an! O#)ani.ational Et*i(s

&%$%$

NSD

Pat!ents8 R!gts

R!gt to Care

R!gt to Consent

4reedom of Co!ce

R!gt of /ncom#etent

/nd!'!duals

"ll #at!ent carts a'e s!gned consent.

Res#ons!!l!tes of #at!ents !n te!r care

are !n te cart.

&%$%&Aministratio

n

NSD

Determ!n!ng and Pr!or!t!?!ng Pat!ents8

cl!n!cal needsDeterm!n!ng and Pr!or!t!?!ng

"dm!ss!!l!t% of #at!ents7!st of ser'!ces a'a!lale

/dent!f%!ng cl!n!cal ser'!ces tat *!ll

est address #at!ents8 cl!n!cal needs.&%&%$%a

"acilities #

Maintenance

Presence of entrances and e!ts tat

are read!l% access!le and free from

ostruct!on.&%&%$%b

"acilities #

Maintenance

Safe and ,c!ent D!rect!on of

Pat!ents& te!r 4am!l!es and I!s!tors

and Sta+ rac

Presence of d!rect!onal s!gnages to

locate ser'!ce areas.

&%&%$%(

"acilities #

Maintenance

Presence of alternat!'e #assage*a%s=ram#s and ele'ators> tat are

#rom!nentl% mared and free from

ostruct!on for #at!ents *!t s#ec!al

needs.

&%&%&%a

NSD

Correctl% !dent!f%!ng #at!ents % te!r

cart

S#ec!)c #at!ent cart for eac #at!ent

tat !s read!l% access!le to autor!?ed

#ersonnel.

&%&%'%a

NSD

Conduct!ng !n!t!al assessment !n an

ec!ent and s%stemat!c manner

"ll #at!ents8 carts a'e

com#reens!'e !stor% and P, *!t!n

9 ours from adm!ss!on:

Present /llness

Re'!e* of S%stems

Past Med!cal H!stor%

4am!l% H!stor%

Personal H!stor%

&%&%'%b

NSD

"ll #at!ent carts a'e #rogress notes

% doctors.&%&%'%(

NSD

Pre-o#erat!'e assessment and$of

card!o#ulmonar% clearance

Pre-o#erat!'e anestet!c e'aluat!on !n

te #at!ent cart. Pre-o#erat!'e

assessment sould e done forPre-anestet!c assessment


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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 5 of 15

#at!ents re6u!r!ng more tan local

anestes!a.

&%'%$

BioMe

$ario%Pulmo

La&oratory

Raiology

Standard #erformance and 6ual!t%

control of d!agnost!c eam!nat!ons

Mon!tor!ng re#orts& e.g..ut!l!?at!on

re'!e* of d!agnost!cs eams done&

aud!t re#orts& manual of #rocedures&

or DOH mon!tor!ng re#orts e.g.. Jual!t%

control d!agnost!c re#orts =JC re#orts

on soft*ares& cal!rat!on of d!agnost!c

e6u!#ment& )lm reKect anal%s!s& etc.>

&%'%&%a &%'%&%e

NSD

Drug "dm!n!strat!on

"ll drugs are adm!n!stered !n a t!mel%&

safe& a##ro#r!ate and controlledmanner to te r!gt #at!ent"ll carts a'e #ro#er documentat!on

of drug adm!n!strat!on

&%'%&%b

HRD

ra!n!ng of Profess!onals *o

adm!n!ster drugs"ll doctors& dent!sts& nurses and

#armac!sts a'e u#dated l!censes

Su#er'!s!on of Profess!onals *o

adm!n!ster drugs,'aluat!on of Profess!onals *o

adm!n!ster drugs&%'%&%( 0

&%'%&%!NSD

Re'!e* of #rescr!#t!on orders Proof tat te #rescr!#t!ons or orders

are 'er!)ed efore med!cat!ons areadm!n!stered.

Ier!)cat!on of #rescr!#t!ons andorders

&%1%$

NSD"ll carts a'e d!scarge #lans

&%2%$%a

Aministratio

n

All

Departments

Strateg!call% Posted I!s!on and M!ss!on

of all te Ser'!ces

"##ro'ed Manual of O#erat!ons and$ or

3r!tten Pol!c!es& Au!del!nes and

Procedures on Cl!n!cal Ser'!ces O+ered

&%2%$%aMeical

Ser!ices

Strateg!call% Posted 4unct!onal and

Organ!?at!onal Cart *!t Potos

So*!ng Names andRelat!ons!# %Pos!t!ons

Proof of te creat!on of all comm!ttees

*!t!n te organ!?at!on *!c !ncludes

te terms of reference for memers!#&%2%$%(

Aministratio

n

Presence of e'aluat!on and mon!tor!ng

act!'!t!es to assess management and

organ!?at!onal #erformance


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TA. RO A HO PITAL

AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: L of 15


7/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: G of 15

CODE /


Hu"an Resou#(es Mana)e"ent/Plannin)

'%$%$%a

Human

Resources

H!r!ng of Sta+

'%$%$%a

Meical

Ser!ices

Credent!al!ng& and #r!'!leg!ng of te

med!cal sta+

'%$%$%b

HumanResources

NSD

Sta+ to ed rat!o for l!censed doctors&

reg!stered nurses andm!d*!'es$nurs!ng a!des follo* te DOH

#rescr!ed rat!o.


8/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: F of 15

CODE /


Data Colle(tion3 A))#e)ation an! Use

Re(o#!s Mana)e"ent

1%&%$%a

Meical

Recors

S%stemat!c record )l!ng& retr!e'al.

retent!on& storage& safeee#!ng and

ma!ntenance and d!s#osal.

Pat!ent8s cart contents !nclude te

follo*!ng:

Doctor8s Progress Notes

/nformed Consent

Prolem 7!st

Med!cat!on and reatment

Record 7aorator% and -ra% Re#orts

D!etar% "ssessment Cl!n!cal and

Ara#!c Record of I!tal S!gns

=PR seet>

Personal H!stor% and P%s!cal

,am!nat!on records

Ne*orn Record and P%s!cal

Matur!t% Rat!ng& !f *arranted

Doctor8s Progress Notes

Med!cat!on and reatment

Record 7aorator% and -ra% Re#orts

D!etar% "ssessment Nurses

Progress Notes

Records of ransfer$Referral to

anoter P%s!c!an or Healt

4ac!l!t%

/n#at!ent Referral$Consultat!on

Notes of Oter P%s!c!ans

4!nal D!agnos!s

"d'ance D!rect!'e& !f an%

Records management for te ent!re

os#!tal and ma!nta!n #r!'ac%&

accurac%& and #re'ent loss and

destruct!on of )les


9/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: of 15

CODE /


4afe P#a(ti(e an! En5i#on"ent

Patient an! 4ta6 4afety7%$%$%a

Aministratio

n

e organ!?at!onal en'!ronment

com#l!es *!t structural standards and

safet% codes as #rescr!ed % la*.

7%$%$%bBio Sa'ety

$ommittee

Hos#!tal 3!de Safet% PlanP%s!cal ,n'!ronment Safet%3aste Management ProgramHos#!tal ,mergenc% and D!saster

Pre#aredness,art6uae Management4!re Safet%Rad!at!on Safet%(t!l!t% S%stem Management4ac!l!t% Secur!t% Measures

7%$%$%(

Bio Sa'ety

$ommittee

Safe and ec!ent use of med!cal

e6u!#ment

/m#lementat!on of DOH "O900F-0091

on te gradual #ase-out of mercur%

7%$%$%!

n'ection

$ontrol

$ommittee

"acilities #

Maintenance

3ater safet% - *ater anal%s!s results for

te #ast L monts

,!t #lans& #lans for eart6uae andoter d!sastersMO"$Contract of outsourced ser'!ces

for *aste management3aste d!s#osal s%stem& segregat!on of

*aste& #ro#er lael!ng of *aste

rece#tacles

Storage and d!s#osal of reagentsJual!t% control #rograms and correct!'e

and #re'ent!'e ma!ntenance #rogramsRecord of d!s#osal of rad!olog!c *astes

Pre'ent!'e and correct!'e ma!ntenancelogoo4!lm reKect anal%s!s test results

7%$%$%e

8%$%'

BioMe

$ario%Pulmo

La&oratory

Raiology

ER$*+RDR

O#erat!ng manual

Pre'ent!'e and correct!'e ma!ntenance

logooJual!)cat!ons of sta+ andl!ng med!cal

e6u!#ment =Cert!)cate of ra!n!ng&

attendance seet& Cert!)cate of

"ttendance& d!#loma& c!tat!on>


10/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 10 of 15

N$*

Maintenance

MO"$Contract for outsourced ser'!ces

7%$%$%f

"acilities #

Maintenance

"de6uate s#ace"de6uate l!gt!ng =l!gts are *or!ng&

l!gt!ng !s ade6uate enoug for

conduct of

general act!'!t!es>"de6uate 'ent!lat!on

7%$%$%)

Risk

Management

$ommittee

R!s !dent!)cat!on& assessment and

control Presence of an a##o!nted #ersonnel !n

carge of secur!t%.Personal Protect!'e ,6u!#ment


11/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 11 of 15

CODE /


Maintenan(e of t*e En5i#on"ent of Ca#e

8%$%$

n'ection

$ontrol

$ommittee

Pharmacy

Meical

Ser!ices,-AP$

Pre'ent!on and control of nosocom!al

!nfect!ons

Presence of !nc!dent re#ort!ng

s%stem$sent!nel e'ent mon!tor!ng

s%stem =*!c ma% !nclude nosocom!al

!nfect!ons& une#ected deats& ad'erse

drug react!ons& ood transfus!on

react!ons& falls& etc>.

Re#ort!ng and mon!tor!ng of ad'ersee+ects

M!nutes of 7eaders!# meet!ng

/nc!dent$sent!nel e'ent re#orts or com-mun!cat!ons$memoranda$orders or

#roceed!ngs on sent!nel e'ents

8%$%&

"acilities #

Maintenance

Presence of generator$emergenc% l!gt&

*ater s%stem& ade6uate 'ent!lat!on or

a!r cond!t!on!ng.Pre'ent!'e and correct!'e ma!ntenance

logoos for generator$ emergenc%

l!gt$ *ater tans$ a!rcond!t!oners .8%$%1

"acilities #

MaintenanceProperty

O#erat!ng manual of generators& a!r

cond!t!oners and oter non-med!cal

e6u!#ment.


12/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 19 of 15

CODE /


Infe(tion Cont#ol

9%$%$%a

n'ection

$ontrol

$ommittee

Proof of Des!gnat!on/CC Montl% Re#orts =an - Se# 9015>/CC "ct!'!t!es 9015/CC M!nutes of Meet!ngs 9015Healtcare "ssoc!ated /nfect!on =H"/>

Stat!st!cs 9015

9%$%$%b

n'ection

$ontrol

$ommittee

Pre'ent!on and Control of Healtcare

"ssoc!ated /nfect!on

Cert!)cate of ra!n!ngsRat!onal "nt!m!cro!al (se 2ased on"nt!!ogramHand H%g!enePersonal Protect!'e ,6u!#ment/solat!on and Standard Precaut!on

9%$%&%a

9%$%&%b

n'ection

$ontrol

$ommittee

/solat!on and Case Conta!nment of

Healtcare "ssoc!ated /nfect!on/nfect!on Control Outrea /nc!dent

Re#ortPrograms for Protect!on of Hos#!tal

Personnel

9%$%&%(

n'ection

$ontrol

$ommittee

"se#s!s

9%$%'%a

n'ection

$ontrol

$ommittee

Pre'ent!on and reatment of Needle

st!c& Sar#s /nKur!es and ,#osure to

2lood and 2od% 4lu!dsPro#er Handl!ng and Safe D!s#osal of

Sar#s and Needles

9%$%'%b

n'ection

$ontrol

$ommittee

/solat!on and Standard Precaut!onPrograms for Protect!on of Hos#!tal

PersonnelPersonal Protect!'e ,6u!#ment

Pat!ent "dm!ss!on& Referral& /solat!on

and Case Re#ort!ng of H!gl%

ransm!ss!le and Not!)ale

D!aseases

Hand H%g!ene,n'!ronmental CareHealtcare 3aste ManagementRec%cl!ng and Reuse of ,6u!#ment

9%$%1 Clean!ng& D!s!nfect!ng and Ster!l!?!ng


13/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 1< of 15

n'ection

$ontrol

$ommittee

of ,6u!#ment& /nstruments and

Su##l!esDecontam!nat!on& D!s!nfect!on and

Ster!l!?at!on of S#ec!)c Med!cal

,6u!#ment and "reaHouseee#!ng Procedure !n S#ec!)c

Pat!ent "reas9%$%2

n'ection

$ontrol

$ommittee

Re#ort!ng of /nfect!ons to Personnel

and Pul!c Healt "genc!esP/DSR Re#orts

Hos#!tal D!sease Sur'e!llance and

Re#ort!ng S%stems

S/ Re#orts

SP,,D Re#orts


14/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 1 of 15

CODE /


Ene#)y an! :aste Mana)e"ent

;%$%$

Aministratio

n

Presence of l!censes$#erm!ts$

clearances from #ert!nent regulator%

agenc!es !m#lement!ng among oters

te follo*!ng: R" 00


15/15

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AND MEDICAL CENTER


DOH Benchbook

Quality Manual


SRHMC-DOH-01-001

Page No.: 15 of 15

CODE /


I"#o5in) Pe#fo#"an(e

$

DOH BENCHBOOK 2015.docx

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