Assessment

ASSESSMENT TOOL
Chapter 1: Access, Assessment and Continuity of Care (AAC)
Intent of the Standard
Target clientele is knowledgeable of the services that the HCO provides to ensure that there is matching of patients needs with the resources of the HCO. Only patients
that can be cared for by the HCO shall be admitted. Those that cannot be cared for shall be referred to other health organization. However, emergency cases that cannot
be admitted to the HCO shall be given necessary treatment before being transferred or referred to accredited facilities.
Standards/ Track Record Assessment

Indicators Evidences (in months) Findings
Measurable Elements Score
AAC1. The HCO informs the community of the health care services it provides.
Measurable Elements
a. Clearly defined clinical Availability of updated List of services identified in a  3 /Fully Met
services provided documentation/ "document"  2/Partially Met
materials/actual  1/Not Met
practices identified in  Not Applicable
the evidences
b. Days / hours of Availability of updated Days/hours of operations  3 /Fully Met
operation or availability documentation/ identified in a "document"  2/Partially Met
the evidences
c. List of health care Availability of updated Employee Masterlist with  3 /Fully Met
professionals and their documentation/ summary of qualifications  2/Partially Met
qualifications materials/actual  1/Not Met
the evidences
PTAHF Assessment Tool 1 Rev1Iss2 1-Nov-2018

d. Orientation of the HCO % Attendance to Training certificate/s in 201  3 /Fully Met
personnel about the required trainings file  2/Partially Met
services it provides. Formula:  1/Not Met
Numerator: Number of  Not Applicable
personnel oriented
Denominator: Number
of newly hired
personnel that needs to
be oriented
Then multiply by 100.

e. Presence of identifying
Availability of updated Signages - correct/updated  3 /Fully Met
signs and directional
documentation/ and installed in appropriate  2/Partially Met
signages materials/actual areas  1/Not Met
the evidences
AAC2. The HCO has established policies and procedures for consultation, admission and transfer process.
Measurable Elements
P a. Screening and triaging Availability of updated Policies and procedures in  3 /Fully Met
of patients, documentation/ screening and triaging of  2/Partially Met
materials/actual patients are identified in a  1/Not Met
practices identified in "document" and are carried  Not Applicable
the evidences out as evident in the patient
medical records. The HCO
should use an evidence-
based screening and triaging
process.
P b. Admission of patients Availability of updated Policies and procedures in  3 /Fully Met
documentation/ admission of patients are  2/Partially Met
materials/actual identified in a "document"  1/Not Met
practices identified in and are carried out as  Not Applicable
the evidences evident in the patient medical
records

P c. Transfer of patients if Availability of updated Policies and procedures of  3 /Fully Met
HCO cannot provide documentation/ patient transfers are identified  2/Partially Met
required services materials/actual in a "document” and are  1/Not Met
practices identified in carried out as evident in the  Not Applicable
the evidences patient medical records. List
of available services that the
organization offers and does
not offer (if any) as reference
of the personnel.
P d. Accessibility of patients Availability of updated Policies and procedures in  3 /Fully Met
with special needs documentation/ accessing hospital services  2/Partially Met
materials/actual by patients with special  1/Not Met
practices identified in needs are identified in a  Not Applicable
the evidences "document" and is carried out
as evident of hospital records
P e. Holding area for patient Availability of updated Policies and procedures  3 /Fully Met
on observation documentation/material regarding holding area for  2/Partially Met
s/actual practices patients on observation are  1/Not Met
identified in the identified in a "document"  Not Applicable
evidences
P f. Managing patients when Availability of updated Policies and procedures for  3 /Fully Met
bed space and or documentation/material managing patients when bed  2/Partially Met
facilities are not s/actual practices space or facilities are not  1/Not Met
available identified in the available are identified in a  Not Applicable
evidences "document" and are carried
out as evident in the patient
medical records. Identify
alternative areas within the
hospital where patients can
be transferred without
compromising quality of care.

AAC3. The HCO has established policies on scope, content and processes of patient’s assessment according to each professional clinical standards,
laws and regulations.
Measurable Elements
P a. There are well-defined Availability of updated Policies on scope, content  3 /Fully Met
policies on scope, documentation/material and processes of patient's  2/Partially Met
content and processes s/actual practices assessment according to  1/Not Met
of patient’s assessment identified in the each professional clinical  Not Applicable
according to each evidences standards, laws and
professional clinical regulations are identified in a
standards, laws and "document"
regulations.
b. Patient and family are % Availability of Policies and procedures  3 /Fully Met
involved in developing treatment plans regarding extent of patient  2/Partially Met
the patient’s treatment indicating participation and family's involvement in  1/Not Met
plan. of patient and family developing the patient's  Not Applicable
during its development treatment plan are identified
in a "document" and are
Formula: carried out as evident in the
patient medical records
Numerator: Number of
treatment plans
indicating patient and
family’s involvement
(i.e. presence of
signature)
Denominator: Number
of treatment plans
reviewed
Then multiply by 100

AAC4. All patients cared for by the HCO shall have regular assessment/re-assessment to determine response to treatment plan and to plan further
treatment or discharge.
Measurable Elements
a. There are qualified Availability of updated Personnel's qualifications in  3 /Fully Met
personnel for the documentation/ each care setting are  2/Partially Met
patient’s care in all materials/actual identified in a "document".  1/Not Met
setting practices identified in Different set of personnel  Not Applicable
the evidences qualifications should be
identified for each setting i.e.
a pediatric care nurse’s
qualifications should be
different from that of a
surgical care nurse’s
qualifications.
b. All patients are re- % Availability of Policies and procedures  3 /Fully Met
assessed at regular required patient re- regarding re-assessment and  2/Partially Met
intervals assessment in the re-assessment intervals are  1/Not Met
patient medical records identified in a "document"  Not Applicable
Formula: and are carried out as
Numerator: Number of evident in the patient medical
available documented records. Areas requiring re-
re-assessments/per assessment and re-
patient assessment intervals are also
Denominator: Number identified in the document.
of required re-
assessments/patient
To get the % availability
of all forms/records, get
the % availability of
each form then add all
results and divide by
the number of
forms/records reviewed

c. Assessment is properly a. % Availability of Patient assessment  3 /Fully Met
documented patient assessment in record/form is available in the  2/Partially Met
the patient medical patient chart and all required  1/Not Met
records information are completely  Not Applicable
Formula: filled-out. The person who
performed the assessment
Numerator: Number of should be identified in the
patient medical records document.
with available patient
assessment
Denominator: Number
of patient medical
records reviewed
b. % Completeness of
patient assessment in
the patient medical
records
Formula:
with complete patient
assessment
Denominator: Number
of patient medical
records reviewed

AAC5. Laboratory services are provided per scope of the HCO and adhere to best practices.
Measurable Elements
a. The scope of laboratory Availability of updated List and scope of laboratory  3 /Fully Met
procedures shall be documentation/ procedures depending on the  2/Partially Met
commensurate to materials/actual size and complexity of  1/Not Met
services provided practices identified in hospital services are  Not Applicable
the evidences identified in a "document"
b. Qualified personnel Zero percent (0%) Qualifications of laboratory  3 /Fully Met
perform laboratory incidence of laboratory personnel are identified in a  2/Partially Met
services, observe safe accidents/events "document". Policies and  1/Not Met
practices and use proper related to unsafe procedures regarding safe  Not Applicable
equipment. practices and improper laboratory practices and
use of equipment per proper use of equipment are
month and per year identified in a "document"
and are strictly
Formula: “implemented”.
laboratory
accidents/events
Denominator: Total
number of workdays
per month and per year
Then Multiply by 100

c. Standard practices for Zero percent (0%) Policies and procedures  3 /Fully Met
collection, identification, incidence of regarding collection,  2/Partially Met
handling, safe transport, accidents/events identification, safe transport,  1/Not Met
processing and disposal related to unsafe processing and disposal of  Not Applicable
of specimen are practices pertaining to specimen are identified in a
observed. collection, identification, "document" and are strictly
handling, transport, “implemented”.
processing and
disposal of specimen
Formula:
accidents/events
related to unsafe
practices per month
and per year
Denominator: Total
number of workdays
per month and per year
Then Multiply by 100
d. Laboratory tests not % Completion of List of outsourced laboratory  3 /Fully Met
available in the HCO are regular quality audits tests and organizations/  2/Partially Met
outsourced to other performed in facilities are identified in a  1/Not Met
organizations or facilities outsourced "document". Documents  Not Applicable
with comparable quality organizations/facilities pertaining to regular quality
standards. Formula: audits performed in
Numerator: Number of outsourced organizations/
quality audits facilities are available.
performed/completed
Denominator: Number
of required quality
audits that need to be
performed

e. Laboratory results are a. Turnaround time List of time frame on release  3 /Fully Met
available within (TAT) of release of of results per laboratory test  2/Partially Met
acceptable timeframe & results is identified in a "document".  1/Not Met
critical results are Formula: Policies and procedures  Not Applicable
immediately released to Numerator: Total length regarding communication of
concerned personnel. of time to release the critical results are identified in
results a "document".
Denominator: Number
of results released
b. %Compliance of
communicated
abnormal results to
the concerned
personnel
Formula:
communicated
abnormal results to the
concerned personnel
Denominator: Number
of total abnormal
results

f. Periodic inspection, % Compliance to Policies and procedures  3 /Fully Met
testing, calibration and scheduled calibration regarding calibration and  2/Partially Met
maintenance and and maintenance of maintenance of all equipment  1/Not Met
updating or replacement equipment are identified in a  Not Applicable
of all facilities and Formula: "document". Availability of
equipment in a planned Numerator: Number of records showing the
and systematic way. calibration and schedule of calibration and
maintenance completed maintenance and its
per schedule completion.
Denominator: Number
of scheduled calibration
and maintenance

AAC6. Imaging services are provided per the scope of HCO services and adhere to best practices.
Measurable Elements
P a. Imaging services comply Zero percent (0%) Policies and procedures  3 /Fully Met
with laws and other legal incidence of non- regarding imaging services  2/Partially Met
requirements. compliance with laws are identified in a  1/Not Met
and other legal "document". List of applicable  Not Applicable
requirements per year laws and other legal
requirements and the
Formula: corresponding policies and
Numerator: Number of procedures to comply with
incidence of non- such laws and requirements
compliance with laws are identified and are strictly
and other legal “implemented”.
requirements
Denominator: Number
of workdays per year
Then multiply by 100%

b. Scope of the imaging Availability of updated List of imaging services is  3 /Fully Met
services is aligned to the documentation/ identified in a "document"  2/Partially Met
services provided by the materials/actual  1/Not Met
organization practices identified in  Not Applicable
the evidences
c. Adequately qualified and a. % Completeness of Qualifications and required  3 /Fully Met
trained personnel personnel trainings trainings of imaging  2/Partially Met
perform safe practices Formula: personnel are identified in a  1/Not Met
and with appropriate Numerator: Number of "document". Policies and  Not Applicable
equipment. completed trainings procedures regarding safe
practices are identified in a
Denominator: Number "document" and are strictly
of required trainings “implemented”.
b. Zero Incidence of
accidents/events
related to unsafe
practice
d. Imaging results are a. Turnaround time List of time frame on release  3 /Fully Met
available within a (TAT) of release of of results per imaging  2/Partially Met
defined time frame and results procedure is identified in a  1/Not Met
emergency/abnormal "document". Policies and  Not Applicable
results are issued Formula: procedures regarding
immediately to the Numerator: Total length communication of
concerned personnel. of time to release the emergency/abnormal results
results are identified in a
"document".
Denominator: Number
of results released

b. %Compliance of
communicated
abnormal results to
the concerned
personnel
Formula:
communicated
abnormal results to the
concerned personnel
Denominator: Number
of total abnormal
results

e. Imaging services not % Completion of List of outsourced imaging  3 /Fully Met
available in the HCO are regular quality audits procedures and  2/Partially Met
outsourced to other performed in organizations/facilities are  1/Not Met
organizations or facilities outsourced identified in a "document".  Not Applicable
with comparable quality organizations/facilities Documents pertaining to
standards. Formula: regular quality audits
Numerator: Number of performed in outsourced
quality audits organizations/facilities are
performed/completed available.
Denominator: Number
of required quality
audits that need to be
performed

P f. Periodic inspection, % Compliance to Policies and procedures  3 /Fully Met
testing, calibration and scheduled calibration regarding calibration and  2/Partially Met
maintenance and and maintenance of maintenance of all equipment  1/Not Met
updating or replacement equipment are identified in a  Not Applicable
of all facilities and Formula: "document". Availability of
equipment in a planned Numerator: Number of records showing the
and systematic way. calibration and schedule of calibration and
maintenance completed maintenance and its
per schedule completion.
Denominator: Number
of scheduled calibration
and maintenance

AAC7. The HCO has an established discharge planning process.
Measurable Elements
P a. There are policies, Availability of updated Policies, procedures and  3 /Fully Met
processes and documentation/ guidelines regarding  2/Partially Met
guidelines to ensure materials/actual development, documentation  1/Not Met
understanding of the practices identified in and communication of  Not Applicable
patient’s discharge plan the evidences patient's discharge plan and
and access to other access to other relevant
relevant community community health services
health services for for continuity of care is
continuity of care. identified in a "document"
and carried out as evident in
the patient record.
P b. The discharge or Availability of updated Policies, procedures and  3 /Fully Met
transfer is based on the documentation/ criteria for patient discharge  2/Partially Met
patient’s needs for materials/actual and transfer is identified in a  1/Not Met
continuity care. practices identified in "document"  Not Applicable
the evidences

P c. There are policies and Availability of updated Policies, procedures and  3 /Fully Met
procedures on patients documentation/ criteria for allowing patients  2/Partially Met
“on pass” or “out on materials/actual on "on pass" or "out on pass"  1/Not Met
pass” for a defined practices identified in is identified in a "document"  Not Applicable
period of time. the evidences
d. The patient’s readiness Availability of updated Criteria for patient discharge  3 /Fully Met
for discharge is documentation/ is identified in a "document"  2/Partially Met
determined. materials/actual and is carried out as evident  1/Not Met
practices identified in in the patient record  Not Applicable
the evidences
e. The discharge plan is % Availability of Policies and procedures  3 /Fully Met
documented in the discharge plan within regarding documentation and  2/Partially Met
patient chart and shall the prescribed time contents of the discharge  1/Not Met
contain the following: frame plan containing elements i to  Not Applicable
i. May go home order Formula: iv is identified in a
ii. Home medications "document" "
(if applicable) Numerator: Number of
iii. Follow-up available discharge
visit/schedule plan on the prescribed
iv. Home care advise time frame
Denominator: Total
number of patient
medical records
reviewed

f. Patient’s chart shall % Availability of Policies and procedures  3 /Fully Met
contain a copy of the discharge summary in regarding availability of a  2/Partially Met
discharge summary. the patient medical copy of the discharge  1/Not Met
record summary is identified in a  Not Applicable
Formula: “document” and should be
carried out as evident in the
Numerator: Number of patient record
available discharge
summary
Denominator: Total
number of patient
medical records
reviewed

g. In case of death, the % Availability of cause Policies and procedures  3 /Fully Met
summary of the case of death documented in regarding documentation of  2/Partially Met
shall include the cause the discharge summary cause of death, in case of  1/Not Met
of death. death, should be identified in  Not Applicable
Formula: a “document”. The discharge
summary/ies selected for
Numerator: Number of review of the surveyors
available cause of should contain the cause of
death in discharge death, if applicable.
summary
Denominator: Total
number of patient
medical records (of
expired patients)
reviewed

Chapter 2: Care of Patients (COP)
The HCO develops and implements a responsive health care plan to deliver maximum outcome for the patient.

COP 1. Care of patients is standard and is guided by laws and regulations.
Measurable Elements
P a. Care delivery is uniform Availability of updated Policies and procedures in  3 /Fully Met
when similar care is documentation/ each care setting are  2/Partially Met
provided in more than materials/ actual identified in a "document"  1/Not Met
one area. practices identified in and are carried out as  Not Applicable
the evidences evident in the patient record.
Example, care delivery is
consistent for pediatric
patients admitted in the
private rooms and for those
admitted in the ward.
P b. Care delivery includes Availability of updated Policies and procedures  3 /Fully Met
patients with special documentation/ regarding care of patients  2/Partially Met
needs (elderly, pediatric, materials/actual with special needs are  1/Not Met
physically and/or practices identified in identified in a "document"  Not Applicable
mentally challenged) the evidences and are carried out as
evident in the patient record.
Patients with special needs
should be identified by the
HCO and interventions on
how their special needs can
be addressed are included in
the policies and are carried
out whenever applicable.

c. The care and treatment % Compliance with Policies and procedures  3 /Fully Met
orders are signed, policies and procedures regarding health  2/Partially Met
named, timed and dated regarding complete professionals’ documentation  1/Not Met
by the concerned doctor. documentation of care of care and treatment orders  Not Applicable
and treatment orders which should be signed,
named, timed and dated, are
Formula: identified in a "document"
and evident in the patient
Numerator: Number of record
with complete
signature, name , time
and date by the doctor
concerned in the care
and treatment plans
Denominator: Total
number of patient
medical records
reviewed

d. The care plan is % Compliance with Policies and procedures  3 /Fully Met
countersigned by the policies and procedures regarding countersigning of  2/Partially Met
personnel-in-charge of regarding availability of care plan by the personnel-  1/Not Met
the patient as per HCO personnel-in-charge's in-charge is identified in a  Not Applicable
policies. counter signature in the "document" and is evident in
care plan the patient record

Formula:
with available counter
signature of the
personnel-in-charge in
the care plan
Denominator: Total
number of patient
medical records
reviewed

P e. Evidence based % Completion of Policies and procedures  3 /Fully Met
medicine, clinical practice evidence based regarding regular review of  2/Partially Met
guidelines, and WHO medicine and clinical evidence based medicine,  1/Not Met
Patient Safety Initiatives practice guidelines clinical practice guidelines,  Not Applicable
are adopted to guide review based on plan and WHO Patient Safety
patient care whenever Formula: Initiatives are identified in a
possible. Numerator: Number of "document" and is carried out
evidence-based as evident in the
medicine and clinical organization's records.
practice guidelines The 9 WHO Patient Safety
reviewed Initiatives are as follows:
Denominator: Total 1. Look-Alike, Sound-Alike

number of evidence- Medication names
based medicine and 2. To use at least 2 Patient
clinical practice unique identification such as
guidelines that need to patient full name and date of
be reviewed birth.

3. Effective Communication
during patient hand-overs.
4. Performance of Correct
Procedure at Correct Body
Site.
5. Control of Concentrated
Electrolyte Solutions.
6. Assuring Medication
Accuracy at Transitions in
Care.
7. Avoiding Catheter and
Tubing Mis-Connections
8. Single Use of Injection
Devices.
9. Improved Hand-Hygiene to
Prevent Health Care
Associated-Infection
COP 2. Emergency services are guided by standard procedures and applicable laws.
Measurable Elements
P a. Written procedures Availability of updated Policies and procedures  3 /Fully Met
address care of patients’ documentation/ regarding patient admission,  2/Partially Met
admission, transfer and materials/ actual transfer and discharging  1/Not Met
discharge during practices identified in during emergency including  Not Applicable
emergency including the evidences handling of medico-legal
handling of medico-legal cases are identified in a
cases. "document" and are carried
record.

P b. Written procedures Availability of updated Policies and procedures  3 /Fully Met
guide the triage of documentation/material regarding triage of patients  2/Partially Met
patients for initiation of s/ actual practices for initiation of appropriate  1/Not Met
appropriate care. identified in the care is identified in a  Not Applicable
evidences "document" and are carried
record.
c. Personnel are trained on % Completion of List of required trainings for  3 /Fully Met
the procedure for care of required training staff assigned in emergency  2/Partially Met
emergency patients. department is identified in a  1/Not Met
Formula: "document". Proof of  Not Applicable
Numerator: Number of completion of training such
completed trainings as certificates is available in
the personnel’s 201 file.
Denominator: Number
of required trainings

d. Ambulance is % Completeness of List of equipment, drugs and  3 /Fully Met
appropriately equipped equipment and supplies supplies that should be  2/Partially Met
and manned by trained in the ambulance available in the ambulance is  1/Not Met
personnel. identified in a “document”.  Not Applicable
Formula: Qualifications and required
Numerator: Number of trainings of the ambulance
actual items/supplies in personnel should be
the ambulance identified in a “document”.
Proof of completion of
Denominator: Number training is available in the
of required personnel’s 201 file.
items/supplies in the
ambulance

e. In the ambulance, there % Availability and Policies and procedures  3 /Fully Met
is a checklist of all Completeness of regarding monitoring of all  2/Partially Met
equipment and information in the equipment, drugs and  1/Not Met
emergency drugs and checklist supplies in the ambulance  Not Applicable
supplies, which is and frequency/schedule of
monitored regularly. Formula: monitoring should be
Numerator: Number of identified in a “document” and
actual checklists is carried out as evident in
completely the ambulance records.
accomplished for a
specified period
Denominator: Number
of required checklists
that need to be
accomplished for a
specified period

COP 3. The HCO has established entry/ transfer criteria, policies and procedures for patients who need intensive and specialized services/care to meet
their concerns.
Measurable Elements
P a. There are policies and Availability of updated Policies and procedures for  3 /Fully Met
procedures for care of documentation/ care of patients with  2/Partially Met
patients with specialized materials/ actual specialized needs and critical  1/Not Met
needs and critical care. practices identified in care are identified in a  Not Applicable
the evidences "document". Measurable
criteria for entry/transfer
should be identified in a
“document”.

b. Qualified personnel % Qualified personnel List of qualifications of  3 /Fully Met
admit, transfers, and handling specialized personnel assigned into  2/Partially Met
cares for patients with services specialized and critical  1/Not Met
specialized and critical areas/patients are identified  Not Applicable
care needs. Formula: in a "document".
personnel with proper
qualifications as listed
in handling specialized
services
Denominator: Number
of total special services
personnel 201 files
reviewed

c. Care of patients is in % Compliance to HCO Policies and procedures for  3 /Fully Met
accordance with the policy in handling care of patients with  2/Partially Met
documented procedures. specialized service specialized needs and critical  1/Not Met
care are identified in a  Not Applicable
Formula: "document" and are carried
Numerator: Number out as evident in the patient
medical records who record. The patient record
comply with the HCO which was reviewed by the
policy in handling surveyor should satisfactorily
specialized services meet the policies set by the
HCO.
Denominator: Number
of total medical records
reviewed

d. Adequate supplies and % Availability of List of supplies and  3 /Fully Met
equipment are available. supplies/ equipment/ equipment in each  2/Partially Met
Inventory specialized and critical area  1/Not Met
are identified in a "document"  Not Applicable
Formula:
actual items/supplies
available
Denominator: Number
of required items/
supplies that need to
be available for a
specified period

COP 4. Care of patients take into account the psychological, social, cultural and spiritual , beliefs and customs of the patients and their families
Measurable Elements
P a. Respect for patient’s Availability of updated Policies and procedures on  3 /Fully Met
values, religion and documentation/ care with respect to patient's  2/Partially Met
cultural preferences and materials/ actual values, religion and cultural  1/Not Met
practices are evident. practices identified in preferences are identified in a  Not Applicable
the evidences "document" and are carried
record
P b. Respect for patient’s Availability of updated Guidelines on securing  3 /Fully Met
choices and preferences documentation/ consent for treatment and  2/Partially Met
are evident through materials/ actual procedures are identified in a  1/Not Met
continuum of care practices identified in “document” and are carried  Not Applicable
record

COP 5. The HCO has established procedures in the care of patients requiring cardio-pulmonary resuscitation.
Measurable Elements
P a. There are written Availability of updated Policies and procedures  3 /Fully Met
procedures in the documentation/ regarding resuscitation  2/Partially Met
performance of materials/actual services is identified in a  1/Not Met
resuscitation in all areas practices identified in "document"  Not Applicable
of the HCO. the evidences
b. Personnel is continually % Completion of A list of training is indicated in  3 /Fully Met
trained and updated in required training a document for cardio  2/Partially Met
cardio-pulmonary Formula: pulmonary resuscitation.  1/Not Met
resuscitation. Numerator: Number of Training certificates are  Not Applicable
trainings attended available in the personnel's
201 file
Denominator: Number

c. Events during cardio- % Number of cardio- Cardio-pulmonary events are  3 /Fully Met
pulmonary resuscitation pulmonary events recorded in a "document"  2/Partially Met
are documented. documented for a  1/Not Met
specified period and its  Not Applicable
outcome
Formula:
cardio-pulmonary
events documented for
a specified period
Denominator: Number
of total cardio
pulmonary events for a
specified period

COP 6. Documented procedures define the rational use of blood and blood products.
Measurable Elements
P a. The transfusion services Availability of updated Policies and procedures on  3 /Fully Met
are governed by the documentation/ transfusion services are  2/Partially Met
applicable laws and materials/ actual identified in a "document"  1/Not Met
regulations. practices identified in  Not Applicable
the evidences
b. Informed consent is % Availability of Policies and procedures  3 /Fully Met
secured for voluntary informed consent for all regarding securing informed  2/Partially Met
donation and voluntary donations consent for voluntary  1/Not Met
transfusion of blood and and transfusion of donation and transfusion of  Not Applicable
blood products blood and blood blood and blood products are
products identified in a "document"
and is carried out as evident
Formula: in the patient record
accomplished informed
consent form
Denominator: Number
of patient
records/hospital
records reviewed

P c. Procedure addressing Availability of updated Policies and procedures  3 /Fully Met
transfusion includes documentation/ regarding transfusion  2/Partially Met
documentation and materials/actual documentation and reporting  1/Not Met
reporting. practices identified in are identified in a "document'  Not Applicable
the evidences and is carried out as evident
in the patient record

COP 7. Documented procedures guide the care of obstetrical patients.
Measurable Elements
P a. The HCO identifies the Availability of updated List and scope of obstetrics  3 /Fully Met
scope of obstetric documentation/ services are identified in a  2/Partially Met
services. materials/actual "document"  1/Not Met
the evidences
b. Utilization of CPGs in Availability of updated List of CPGs adopted and  3 /Fully Met
the care of obstetrical documentation/ being used by the HCO in the  2/Partially Met
patients. materials/actual care of obstetrical patients  1/Not Met
practices identified in are identified in a "document"  Not Applicable
the evidences
c. The HCO provides Availability of updated List of services provided by  3 /Fully Met
services for the care of documentation/ the HCO for the care of the  2/Partially Met
the newborn. materials/actual newborn is identified in a  1/Not Met
practices identified in "document"  Not Applicable
the evidences
COP 8. Written procedures guide the care of pediatric patients.
Measurable Elements
P a. The HCO identifies the Availability of updated List and scope of pediatric  3 /Fully Met
scope of the pediatric documentation/ care offered by the HCO are  2/Partially Met
care. materials/actual identified in a "document"  1/Not Met
the evidences

b. Qualified and trained % Completion of List of qualifications and  3 /Fully Met
personnel provide required training required trainings of  2/Partially Met
special care of children. personnel providing care to  1/Not Met
Formula: children are identified in a  Not Applicable
Numerator: Number of "document" and supporting
trainings attended documents are available in
each personnel's 201 file
Denominator: Number

c. The HCO provides % Compliance for Policies and procedures  3 /Fully Met
comprehensive providing regarding assessment and  2/Partially Met
assessment and re- comprehensive re-assessment of pediatric  1/Not Met
assessment of pediatric assessment and re- patients are identified in a  Not Applicable
patients. assessment of pediatric "document" and are carried
patients out as evident in the patient
record
Formula:
pediatric patients with
comprehensive
assessment and re-
assessment
Denominator: Number
of total pediatric
patients medical
records reviewed

P d. Written procedures Availability of updated Policies and procedures  3 /Fully Met
address the prevention documentation/ regarding prevention and  2/Partially Met
and care for abandoned materials/actual care for abandoned,  1/Not Met
abducted and abused practices identified in abducted and abused  Not Applicable
pediatric patients and the evidences pediatric patients and
children with disabilities. children with disabilities are
identified in a "document
“and are carried out as
evident in the patient record
e. The HCO provides % Completion of family Policies and procedures  3 /Fully Met
education of family education on health, regarding conduct of family  2/Partially Met
members on health, nutrition, immunization, education on health, nutrition,  1/Not Met
nutrition, immunization, safe parenting and immunization, safe parenting  Not Applicable
safe parenting and early early detection of and early detection of
detection of diseases. diseases conducted diseases are identified in a
based on HCO's target "document" are carried out as
for a specified period evident in the patient record
or other records other than
Formula: the patient's
family education
conducted
Denominator: Number
of required patient
education to be done
for a specified period

COP 9. Written procedures guide the administration of anesthesia.
Measurable Elements
P a. There is standard Availability of updated Policies and procedures for  3 /Fully Met
procedure for the documentation/ the administration of  2/Partially Met
administration of materials/ actual anesthesia are identified in a  1/Not Met
anesthesia. practices identified in "document". The organization  Not Applicable
the evidences uses evidence-based
anesthesia administration
process or is based on
internationally accepted
standards.
b. All patients for % Compliance for Policies and procedures on  3 /Fully Met
anesthesia are provided providing pre- pre-anesthesia assessment  2/Partially Met
with pre-anesthesia anesthesia assessment by a qualified personnel and  1/Not Met
assessment by qualified by qualified personnel formulation of written  Not Applicable
personnel, which results and formulation of anesthesia plan is identified
in the formulation of anesthesia plan in a "document" and are
written anesthesia plan. carried out as evident in the
Formula: patient record
patients provided with
pre-anesthesia
assessment by
qualified personnel and
formulation of
anesthesia plan
Denominator: Number
of total patients medical
records reviewed that
requires anesthesia

c. A pre-operative re- a. % Availability of pre- Policies and procedures  3 /Fully Met
evaluation is done operative re- regarding pre-operative re-  2/Partially Met
according to protocol. evaluation in the evaluation is identified in a  1/Not Met
patient medical "document" and are carried  Not Applicable
records out as evident in the patient
Formula: record. A complete and
Numerator: Number of documented pre-operative
patient medical records evaluation is available in the
with available pre- patient record.
operative re-evaluation
Denominator: Number
of patient medical
records reviewed
b. % Completeness
pre-operative re-
evaluation in the
patient medical
records
Formula:
with complete pre-
operative re-evaluation
Denominator: Number
of patient medical
records reviewed

d. Anaesthesiologist a. % Availability of Policies and procedures on  3 /Fully Met
obtains informed written informed consent in securing consent for the  2/Partially Met
consent for the the patient medical administration of anesthesia  1/Not Met
administration of records is identified in a "document"  Not Applicable
anesthesia. and are carried out as
Formula: evident in the patient record.
Numerator: Number of A complete and documented
patient medical records consent is available in the
with available informed patient record.
consent
Denominator: Number
of patient medical
records reviewed
b. % Completeness
informed consent
Formula:
with complete informed
consent
Denominator: Number
of patient medical
records reviewed

e. Monitoring of % Compliance for Policies and procedures on  3 /Fully Met
anesthesia and monitoring of monitoring of anesthesia and  2/Partially Met
patient’s post- anesthesia and post-anesthesia status is  1/Not Met
anesthesia status is patient’s post- identified in a "document". A  Not Applicable
performed and anesthesia status is complete and documented
documented. performed and anesthesia monitoring and
documented patient's post-anesthesia
status is available in the
Formula: patient record.
patients monitored of
anesthesia and
patient’s post-
anesthesia status is
performed and
documented
Denominator: Number
of total patients medical
records reviewed that
requires anesthesia

P f. There are written policies Availability of updated Policies and procedures for  3 /Fully Met
and Procedures for documentation/ transfer of all post-operative  2/Partially Met
transfer of all post- materials/actual patients are identified in a  1/Not Met
operative patients. practices identified in "document" and are carried  Not Applicable
record. Criteria for transfer
should be identified in a
“document”.

g. All untoward anesthesia a. % Availability of Policies and procedures  3 /Fully Met
events are addressed, corrective actions to regarding reporting,  2/Partially Met
monitored and reported reported untoward addressing and monitoring  1/Not Met
according to HCO anesthesia events reported untoward  Not Applicable
protocol. anesthesia events are
Formula: identified in a "document"
reported untoward
events with corrective
actions
Denominator: Number
of reported untoward
events
b. % Implementation/
Completion of
corrective actions for
the reported untoward
anesthesia events
Formula:
implemented/completed
corrective actions
Denominator: Number
of planned corrective
actions

COP 10. The HCO has established policies and procedures to render surgical services that meet the applicable laws, regulations and standards.
Measurable Elements
P a. There are written Availability of updated Policies and procedures for  3 /Fully Met
policies and procedure documentation/ the provision of surgical  2/Partially Met
for the provision of materials/actual services are identified in a  1/Not Met
surgical services. practices identified in "document"  Not Applicable
the evidences
b. Only qualified and % Compliance for List of doctors' qualifications  3 /Fully Met
competent doctors monitoring privileged allowed to perform surgical  2/Partially Met
recognized by the HCO doctors to perform procedures are identified in a  1/Not Met
are allowed to perform surgical procedures "document". List of doctors  Not Applicable
surgical procedures. and a summary of their
Formula: qualifications recognized by
Numerator: Number of the HCO to perform surgical
patients monitored of procedures are identified in a
doctor’s privileged to "document".
perform the surgical
procedures
Denominator: Number
of total surgical patients
medical records
reviewed

c. All patients for surgery % Compliance surgical Policies and procedures on  3 /Fully Met
are provided with pre- patients provided with pre-surgery assessment,  2/Partially Met
surgery assessment by pre-surgery qualifications of personnel  1/Not Met
qualified personnel, assessment by and formulation of written  Not Applicable
which results in the qualified personnel and surgical plan are identified in
formulation of written with surgical plan a "document" and are carried
surgical plan. out as evident in the patient
record

Formula:
surgical patients
provided with pre-
surgery assessment by
qualified personnel and
with surgical plan
Denominator: Number
medical records
reviewed

d. The surgeon obtains a. % Availability of Policies and procedures  3 /Fully Met
informed written consent informed consent in regarding securing informed  2/Partially Met
for the performance of the patient medical consent for the performance  1/Not Met
surgery. records of surgery is identified in a  Not Applicable
Formula: "document" and are carried
Numerator: Number of out as evident in the patient
patient medical records record
with available informed
consent
Denominator: Number
of patient medical
records reviewed

b. % Completeness
informed consent
Formula:
with complete informed
consent
Denominator: Number
of patient medical
records reviewed

e. There is a written safety % Availability and Policies and procedures  3 /Fully Met
checklist to prevent Completeness of regarding use of written  2/Partially Met
adverse events (e.g. information in the safety checklist to prevent  1/Not Met
WHO Surgical checklist adverse events are identified  Not Applicable
Checklist). Formula: in a "document" and are
Numerator: Number of carried out as evident in the
actual checklists patient record
completely
accomplished for a
specified period
Denominator: Number
of required checklists
that need to be
accomplished for a
specified period

f. There is an adequately % Compliance of Adequately spaced and fully  3 /Fully Met
spaced, fully equipped operating room to equipped operating room is  2/Partially Met
operating room that is infection control available according to HCO's  1/Not Met
monitored for infection practices size and complexity. Policies  Not Applicable
control practices. and procedures on
Formula: monitoring infection control
Numerator: Number of practiced in the operating
areas where OR room is identified in a
complied with the "document" and is carried out
existing infection as evident in the HCO's
control policy records.
Denominator: Number
of areas observed in
the OR

g. Monitoring of patient’s % Compliance for Policies and procedures on  3 /Fully Met
surgical and post- monitoring patient’s monitoring of patient's  2/Partially Met
surgical status is surgical and post- surgical and post-surgical  1/Not Met
performed and surgical status is status are identified in a  Not Applicable
documented. performed and "document" and is carried out
documented as evident in the patient's
record. A completed record of
Formula: monitoring of surgical and
Numerator: Number of post-surgical status is
patients monitored available in the patient
patient’s surgical and record.
post-surgical status is
performed and
documented

Denominator: Number
medical records
reviewed

P h. There are written Availability of updated Policies and procedures for  3 /Fully Met
policies and procedures documentation/ transfer of all post-operative  2/Partially Met
for transfer of all post- materials/ actual patients are identified in a  1/Not Met
operative patients. practices identified in "document" and are carried  Not Applicable
record. Measurable criteria
for transfer of all post-
operative patients are
identified in a "document"
i. All untoward surgical a. % Availability of Policies and procedures  3 /Fully Met
events are addressed, corrective actions to regarding reporting,  2/Partially Met
monitored and reported reported untoward addressing and monitoring  1/Not Met
according to the HCO surgical events untoward surgical events are  Not Applicable
protocol. Formula: identified in a "document"
reported untoward
events with corrective
actions
Denominator: Number
of reported untoward
events

b. % Implementation/
Completion of
corrective actions for
the reported untoward
surgical events
Formula:
implemented/completed
corrective actions
Denominator: Number
of planned corrective
actions

COP 11. The HCO has established fair management policies and procedures to appropriately assess, monitor, evaluate and manage patients in pain.
Measurable Elements
P a. The HCO uses Availability of updated Policies and procedures on  3 /Fully Met
standardized clinical documentation/ standardized clinical  2/Partially Met
measures to determine materials/actual measures to determine pain  1/Not Met
pain and strategies to practices identified in and strategies to manage  Not Applicable
manage pain based on the evidences pain are based on research
research and evidence- and evidence-based practice
based practice. and are identified in a
"document"
P b. There are written Availability of updated Policies and procedures on  3 /Fully Met
policies and procedures documentation/ pain assessment and  2/Partially Met
on pain assessment and materials/actual management are identified in  1/Not Met
management practices identified in a "document"  Not Applicable
the evidences

c. Pain assessment tool is % Availability of Policies and procedures  3 /Fully Met
available in the patient completed pain regarding use and completion  2/Partially Met
chart. assessment tool in the of pain assessment tool is  1/Not Met
patient medical records identified in a "document"  Not Applicable
Formula:
with available pain
assessment tool
Denominator: Number
of patient medical
records reviewed

COP 12. The health personnel provide an end-of-life care to facilitate a dignified and peaceful closure of life of patients through physiological,
psychological, social and spiritual care, taking into consideration the cultural diversities in beliefs and customs and optimized caring
environment.
Measurable Elements
P a. Respect for patient’s Availability of updated Policies and procedures on  3 /Fully Met
values, religion and documentation/ end-of-life care with respect  2/Partially Met
cultural preferences and materials/actual to patient's values, religion  1/Not Met
practices are evident. practices identified in and cultural preferences are  Not Applicable
and are carried out as

b. Assessment of % Compliance for Policies and procedures on  3 /Fully Met
appropriate intervention assessment and re- assessment and re-  2/Partially Met
to alleviate the patient’s assessment of assessment of appropriate  1/Not Met
pain and discomfort appropriate intervention intervention to alleviate  Not Applicable
according to wishes of of dying patients patient's pain and discomfort
patient and family and Formula: are identified in a "document"
re-assessment are Numerator: Number of and are carried out as
evident. patients monitored for evident in the patient record
assessment and re-
assessment of
appropriate intervention
of dying patients
Denominator: Number
of total dying patients
medical records
reviewed

P c. The patient’s right to Availability of updated Policies and procedures on  3 /Fully Met
self-determination and documentation/ personnel's responsibilities  2/Partially Met
choice is respected and materials/ actual and accommodating patient's  1/Not Met
accommodated. practices identified in rights and preference are  Not Applicable
P d. Advance directives, Do Availability of updated Policies and procedures on  3 /Fully Met
Not Resuscitate Waiver, documentation/ personnel's responsibilities  2/Partially Met
Living will if any, are materials/ actual and handling advance  1/Not Met
respected. practices identified in directives, DNR Waiver ,  Not Applicable
the evidences Living Will, etc are identified
patient record

P e. Patient and family Availability of updated Policies and procedures on  3 /Fully Met
choices to donate documentation/ providing relevant information  2/Partially Met
organs and other tissues materials/actual to patient and family  1/Not Met
are supported through practices identified in regarding organ donation and  Not Applicable
provision of relevant the evidences other tissues are identified in
information in a "document"
accordance to statutory
laws, rules and
regulations.
P f. The policies and Availability of updated Policies and procedures on  3 /Fully Met
procedures in handling documentation/ handling end-of-life, including  2/Partially Met
end-of-life, including materials/actual death are based on existing  1/Not Met
death are based on practices identified in rules, regulations and  Not Applicable
existing rules, the evidences statutory laws and are
regulations and statutory identified in a "document".
laws. List of regulations and
statutory laws and the
corresponding policies to
comply with such laws are
identified in a "document".

Chapter 3: PATIENTS’ RIGHTS and EDUCATION (PRE)
The HCO has established policies and procedures that respect and support patient and family rights during care. It promotes the participation of patient and family in the
care process. It also educates all health care providers about their roles in protecting patients’ rights.

PRE 1. The HCO protects patient and family rights during care and informs them of their responsibility.
Measurable Elements
a. There is a written patient Availability of updated List of patient and family  3 /Fully Met
and family rights and documentation/ rights and responsibilities are  2/Partially Met
responsibilities. materials/actual identified in a "document"  1/Not Met
the evidences
P b. Patients and families are Availability of updated Policies and procedures on  3 /Fully Met
informed of their rights documentation/ communication of patient and  2/Partially Met
and responsibilities in a materials/actual family rights and  1/Not Met
format and language practices identified in responsibilities are identified  Not Applicable
they can understand. the evidences in a "document" and are
patient record or other
records
P c. Personnel is aware of Availability of updated Policies and procedures on  3 /Fully Met
their responsibility in documentation/ how patients and family rights  2/Partially Met
protecting patients and materials/actual and responsibilities can be  1/Not Met
family rights. practices identified in protected and acted on by  Not Applicable
the evidences the personnel are identified in
a "document" and is carried
record

d. Non-conformance to the % Corrective/ Policies and procedures on  3 /Fully Met
patient and family rights preventive measures reporting, reviewing,  2/Partially Met
is recorded, reviewed undertaken when non- correcting and monitoring  1/Not Met
and corrective/ conformance to patient non-conformance to patient  Not Applicable
preventive measures are and family rights was and family rights are
undertaken by the HCO. recorded identified in a "document"
Formula: evident in the patient record
or other hospital records
corrective/preventive
measures undertaken
when non-conformance
to patient and family
rights was recorded
Denominator: Number
of corrective/preventive
measures that need to
be undertaken when
non-conformance to
patient and family rights
was reported

PRE 2. The HCO has established policies, processes and guidelines that respect and support patient and family rights during care.
Measurable Elements
a. Patient has right to Availability of updated Availability of rooms,  3 /Fully Met
respect for dignity and documentation/ curtains, dividers and other  2/Partially Met
privacy during materials/actual means of ensuring privacy in  1/Not Met
examination procedures practices identified in all examination and treatment  Not Applicable
and treatment. the evidences areas

P b. Patient has right to Availability of updated Policies and procedures and  3 /Fully Met
protection from physical documentation/ personnel responsibilities on  2/Partially Met
abuse or neglect. materials/actual ensuring patient’s right to  1/Not Met
practices identified in protection from physical  Not Applicable
the evidences abuse or neglect and process
for handling such events, if it
occurred, are identified in a
"document"
P c. Patient has right to Availability of updated Policies and procedures in  3 /Fully Met
confidentiality of documentation/ ensuring confidentiality of  2/Partially Met
information. materials/actual patient information is  1/Not Met
practices identified in identified in a "document"  Not Applicable
the evidences and are carried out as
or other records
P d. Patient has right to Availability of updated Policies and procedures on  3 /Fully Met
refuse treatment. documentation/ handling patients who  2/Partially Met
materials/actual refused treatment are  1/Not Met
P e. Patient has right to Availability of updated Policies and procedures on  3 /Fully Met
informed consent before documentation/ securing informed consent  2/Partially Met
carrying out any materials/actual before carrying out any  1/Not Met
procedure. practices identified in procedure is identified in a  Not Applicable
record

P f. Patient has right to Availability of updated Policies and procedures on  3 /Fully Met
information and consent documentation/ communication/education of  2/Partially Met
before participation in materials/actual patients and securing  1/Not Met
any research. practices identified in patients consent before  Not Applicable
the evidences participation in any research
is identified in a "document"
g. There is a system for % Resolved complaints Policies and procedures on  3 /Fully Met
addressing, investigating for all reported how patients’ complaints are  2/Partially Met
and resolving patient’s complaints in a addressed, investigated and  1/Not Met
complaints in a timely specified period resolved identified in a  Not Applicable
manner. "document"
Formula:
resolved complaints in
a specified period
Denominator: Total
number of complaints
for a specified period

P h. Patient has right to be Availability of updated Policies and procedures on  3 /Fully Met
informed on the documentation/ how patients will be informed  2/Partially Met
expected cost of materials/actual on the expected cost of  1/Not Met
treatment and practices identified in treatment and information on  Not Applicable
addressed the evidences healthcare financing options
socioeconomic barriers and how to access them are
to access its services. communicated to the
patient/relatives is identified
patient record

P i. Patient has right to Availability of updated Policies and procedures on  3 /Fully Met
access his/her clinical documentation/ how to and who has access  2/Partially Met
records. materials/actual to the patient’s clinical  1/Not Met
practices identified in records are identified in a  Not Applicable
the evidences "document"
P j. HCO respects patients/ Availability of updated Policies and procedures on  3 /Fully Met
service users’ documentation/ communication/education for  2/Partially Met
preference and choices materials/actual respecting patients/service  1/Not Met
across the care practices identified in users’ preference and  Not Applicable
continuum. the evidences choices across the care
continuum is identified in a
"document" and are carried
out as evident in actual
practice.
PRE 3. There is a written policy for obtaining patient and/or family consent about their care.
Measurable Elements
P a. General consent for Availability of updated Policies and procedures on  3 /Fully Met
treatment is discussed documentation/ securing general consent for  2/Partially Met
and obtained from materials/actual treatment are identified in a  1/Not Met
patient and family practices identified in "document" and are carried  Not Applicable
members. the evidences out as evident in the patient
record.
The General Consent for

Treatment also includes
consent for experimental
procedures, invasive
procedures, sedation, and
risk of adverse events or
promotional photographs.

P b. The HCO has an Availability of updated Policies and procedures on  3 /Fully Met
established policy on documentation/ securing consent and who  2/Partially Met
who can give consent in materials/actual can give consent on behalf of  1/Not Met
behalf of patients who practices identified in patients who are incapable of  Not Applicable
are incapable of giving the evidences giving their own consent are
their own consent such identified in a "document"
as unconscious patient, and are carried out as
minor, mentally-ill, etc. evident in the patient record
P c. The HCO has a well- Availability of Policies, procedures, duly  3 /Fully Met
established policy in documents indicating signed informed consent,  2/Partially Met
obtaining consent from that consent is obtained interview and actual  1/Not Met
patient or families on the from patient or families observation to indicating that  Not Applicable
course of treatment to to on the course of consent is obtained from
be undertaken, taking treatment to be patient or families to on the
into account the cultural, undertaken, taking into course of treatment to be
social, and religious account the cultural, undertaken, taking into
values of patient/family social, and religious account the following
values of patient/family. aspects:
1. Provide access to spiritual
care or advice that meets
patient/service users’
needs.
2. Train staff on the cultural
beliefs, needs and
activities of different
patient groups, and
3. Where culturally
appropriate to provide
separate facilities and
services for women and
man.”

PRE 4. Patient and families have a right to information and education about their healthcare needs.
Measurable Elements
a. Patients and families are % Compliance in the Documents, materials and  3 /Fully Met
informed to make availability of observed actual practices  2/Partially Met
decisions pertaining to documents and/or indicating that patients and  1/Not Met
plan of care, preventive actual practice of the families or relatives are  Not Applicable
aspects, possible evidence. informed of the plan of care,
complications, expected Formula: preventive aspects, possible
results and cost at the complications, expected
time of admission. Numerator: Number of results and cost at the time of
documents and/or admission. Interview of
actual practice personnel, patients,
families/relatives may be
Denominator: Total undertaken.
number of documents
reviewed and/or
patient/family
interviewed

b. Patients and family are % Compliance in the Documents, materials and  3 /Fully Met
educated about the safe availability of observed actual practices  2/Partially Met
and effective use of documents and/or indicating that patients and  1/Not Met
medication and the actual practice of the families or relatives are  Not Applicable
potential side effects of evidence. educated about the safe and
medication in language effective use of medication.
they can understand. Formula: Actual interview of personnel,
patients, families/relatives
Numerator: Number of may be conducted.
documents and/or
actual practice

Denominator: Total
number of documents
reviewed and/or
patient/family
interviewed

c. Patients and family are % Compliance in the Documents, materials and  3 /Fully Met
informed about activities availability of observed actual practices  2/Partially Met
of daily living. documents and/or indicating that patients and  1/Not Met
actual practice of the families or relatives are  Not Applicable
evidence. informed about activities of
Formula: daily living. Actual interview
of personnel, patients,
Numerator: Number of families/relatives may be
documents and/or conducted.
actual practice
Denominator: Total
number of documents
reviewed and/or
patient/family
interviewed

d. Patients and family are % Compliance in the Documents, materials and  3 /Fully Met
educated about availability of observed actual practices  2/Partially Met
preventing infections. documents and/or indicating that patients and  1/Not Met
actual practice of the families or relatives are  Not Applicable
evidence. educated about infection
prevention. Actual interview
Formula: of personnel, patients,
families/relatives may be
Numerator: Number of conducted.
documents and/or
actual practice
Denominator: Total
number of documents
reviewed and/or
patient/family
interviewed

Chapter 4: MEDICATION MANAGEMENT and USE (MMU)
The HCO has a written process in medication management including medical gases to ensure patient and personnel safety. The documented procedures include
availability, order, purchasing, storing, prescribing, dispensing, inventory, disposal of expired drugs, changing, monitoring of adverse drug reaction and drugs interaction.
MMU 1. The HCO has established policies, procedures and guidelines on medication management from pharmacy to critical / clinical areas to ensure
standardized and systematic drug administration.
Measurable Elements
P a. The system of Presence/Availability of Policies and procedures on  3 /Fully Met
medication a document/s medication management  2/Partially Met
management, including establishing a system covering availability (request  1/Not Met
request for procurement, medication procurement, labeling,  Not Applicable
labelling, storage, management or storage, inventory, disposal
inventory, disposal of medication of expired drugs),
expired drugs, management plan. prescription, dispensation
prescription, (including preparation),
dispensation, is well charging and follow-ups of
established as evident in medication given to patients
a document. are identified in a "document"
or other hospital records
P b. The procedures are Availability of document Policies and procedures on  3 /Fully Met
based on existing rules, indicating the regular medication management are  2/Partially Met
regulations and statutory monitoring and based on existing rules,  1/Not Met
laws. updating of the regulations and statutory  Not Applicable
medication laws and are identified in a
management system "document". List of
according to the regulations and statutory
practice of the laws and the corresponding
regulating board. policies to comply with such
laws are identified in a
"document".

c. There is an available Availability of A hospital formulary is  3 /Fully Met
hospital formulary. document indicating available and updated  2/Partially Met
presence of an updated  1/Not Met
hospital formulary  Not Applicable
P d. There are policies, Availability of document Policies and procedures for  3 /Fully Met
procedures for training, indicating training, training, supervision and  2/Partially Met
supervision and supervision and evaluation of professionals  1/Not Met
evaluation of evaluation of involved in medication  Not Applicable
professionals involved in professionals involved management are identified in
medication in medication a "document"
management. management.
P e. There shall be policies Availability of updated Policies and procedures on  3 /Fully Met
and procedures that documentation/ selection and procurement of  2/Partially Met
determine selection and materials/ actual drugs consistent with  1/Not Met
procurement of drugs practices identified in scientific evidence and  Not Applicable
consistent with scientific the evidences government regulations are
evidence and identified in a "document"
government regulations.
MMU 2. There are well established policies and procedures in drug prescription and handling.
Measurable Elements
P a. Only licensed physicians a. Availability of Policies and procedures  3 /Fully Met
and dentists are allowed documents indicating only licensed  2/Partially Met
to prescribe medicines. indicating presence physicians & dentists are  1/Not Met
of established allowed to prescribe  Not Applicable
policies that only medicines are identified in a
licensed physicians "document" and are carried
& dentists are out as evident in the patient
allowed to prescribe record or other hospital
medicines. records

b. % Compliance on
Policy
Formula:
medical records
complied the policy
Denominator: Number
of open/closed medical
records reviewed

P b. Physician’s orders are a. Availability of Policies and Procedures  3 /Fully Met
written on the prescribed documents indicating that the physician’s  2/Partially Met
sheet of patient’s indicating presence orders are written on the  1/Not Met
medical record of established prescribed sheet on the  Not Applicable
policies that patients records and other
physician’s orders relevant hospital records and
are written on the are carried out as evident in
prescribed sheet of the patient record or other
patient’s record. hospital records
b. % Compliance on
Policy
Formula:
medical records
complied the policy
Denominator: Number
records reviewed

P c. Medication orders are a. Availability of Policies and Procedures  3 /Fully Met
written clearly, legibly, documents indicating that medication  2/Partially Met
dated, timed, named and indicating presence orders are written clearly,  1/Not Met
signed. of established legibly, dated, timed, named  Not Applicable
policies for and signed on the patient’s
medication orders records and other relevant
are written clearly, hospital records and are
legibly, dated, carried out as evident in the
timed, named and patient record or other
signed. hospital records.
b. % Compliance on
Policy
Formula:
medical records
complied the policy
Denominator: Number
records reviewed

P d. There are written a. Availability of Policies and procedures  3 /Fully Met
policies in prescribing documents indicating presence of  2/Partially Met
and handling high alert indicating presence established policies in  1/Not Met
medications such as but of established prescribing and handling high  Not Applicable
not limited to: policies in alert medications are
1. Anesthesia gases prescribing and identified in a "document"
2. Controlled/regulated handling high alert and are carried out as
drugs medications. evident in the patient record
3. Concentrated or other hospital records
electrolytes

4. Chemotherapeutic b. % Compliance on
Drugs Policy
5. Inotropic Drugs
6. Insulin Formula:
7. Anti-hemolytic Numerator: Number of
8. Toxic Drugs medical records
complied the policy
Denominator: Number
records reviewed

P e. There are written a. Availability of Policies and Procedures on  3 /Fully Met
policies on telephone documents telephone and verbal orders  2/Partially Met
and verbal orders indicating presence and are carried out as  1/Not Met
of established evident in the patient record  Not Applicable
policies on or other hospital records.
telephone and
verbal orders.
b. % Compliance on
Policy
Formula:
medical records
complied the policy
Denominator: Number
records reviewed

MMU 3. There are well written established procedures in the safe dispensing of medications.
Measurable Elements
P a. There are policies and Availability of document Policies and procedures on  3 /Fully Met
procedures on indicating presence of dispensing, retrieval and safe  2/Partially Met
dispensing, retrieval and policies and procedures disposal of drugs are  1/Not Met
safe disposal of drugs. on dispensing, retrieval identified in a "document"  Not Applicable
and safe disposal of such as hospital
drugs. memorandum.
MMU 4. There are written standardized and systematic procedures of drug administration
Measurable Elements
There are written policies, procedures and guidelines on medication management which include but are not limited on the following:
P a. Prescription Availability of Documents indicating  3 /Fully Met
documents indicating presence of established  2/Partially Met
presence of established policies that prescribing  1/Not Met
policies, procedures medications are according to  Not Applicable
and guidelines on Clinical Practice Guidelines
prescribing of recognized healthcare
medications. bodies, societies, and
associations.
P b. Transcribing a. Availability of Documents indicating  3 /Fully Met
documents presence of established  2/Partially Met
indicating presence policies that transcribing of  1/Not Met
of established medications is complete and  Not Applicable
policies in correct in line with duly
transcription. accepted nursing practice
or other hospital records.

b. % Compliance on
Policy
Formula:
medical records
complied the policy
Denominator: Number
records reviewed

P c. Preparation a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that preparation of  1/Not Met
of established medications is in line with  Not Applicable
policies in duly accepted nursing
medication practice and are carried out
preparation. as evident in actual practice.
b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number
of actual observations

P d. Administration a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that drug  1/Not Met
of established administration is according to  Not Applicable
policies in drug standard nursing practices
administration. and are carried out as
evident in actual practice.
b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number

P e. Documentation a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that drug  1/Not Met
of established documentation is according  Not Applicable
policies in drug to standard nursing practices
documentation. and are carried out as
b. % Compliance on
Policy
Formula:
actual observations
complied the policy

Denominator: Number

P f. Disposal a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that drug disposal is  1/Not Met
of established in line with duly approved  Not Applicable
policies on disposal practices by DOH and are
of medications. carried out as evident in
actual practice.
b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number

P g. Storage a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that storage of  1/Not Met
policies on storage practices duly approved by
of medications. DOH and are carried out as

b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number

P h. High Alert a. Availability of Documents indicating  3 /Fully Met
indicating presence policies that storage of  1/Not Met
policies on handling practices duly approved by
and administration DOH and are carried out as
of high alert drugs. evident in actual practice.
b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number

P i. Narcotics a. Availability of Documents indicating  3 /Fully Met
indicating presence policies on handling &  1/Not Met
of established administration of narcotics  Not Applicable
policies on handling are in line with practices duly
and administration approved by the DOH and
of narcotics. are carried out as evident in
actual practice.
b. % Compliance on
Policy
Formula:
actual observations
complied the policy
Denominator: Number

MMU 5. There are well-established policies for monitoring and resolving adverse drug reaction and drug interaction.
Measurable Elements
P a. There are policies and Availability of document Document indicating  3 /Fully Met
procedures for detecting, indicating presence of presence of policies and  2/Partially Met
documenting, reporting, policies and procedures procedures for detecting,  1/Not Met
monitoring and resolving for detecting, documenting, reporting,  Not Applicable
adverse drug reactions documenting, reporting, monitoring and resolving
and drug interaction. monitoring and adverse drug reactions and
resolving adverse drug drug interaction, including
reactions and drug presence of Adverse Drug
interaction. Could Reaction Committee or
include presence of similar body.
Adverse Drug Reaction
Committee or similar
body.

MMU 6. There are written procedures on the safe use of medical gases.
Measurable Elements
P a. There are well written Availability of Document/evidences  3 /Fully Met
established policies on documents indicating indicating presence of well-  2/Partially Met
the procurement, presence of well- established policies on the  1/Not Met
handling, storage, established policies on procurement, handling,  Not Applicable
distribution, usage, and the procurement, storage, distribution, usage
replacement of medical handling, storage, and replacement of medical
gases. (medical oxygen, distribution, usage and gases. Could include direct
compressed air, nitrous replacement of medical observation of actual
oxide, carbon dioxide) gases. practices in the HCO.
P b. Safety issues in the Availability of document Document/evidences  3 /Fully Met
handling of medical indicating presence of indicating presence of well-  2/Partially Met
gases well established. well-established safety established safety  1/Not Met
procedures in handling procedures in handling  Not Applicable
medical gases. medical gases. Could include
direct observation of actual
practices in the HCO.
P c. Appropriate recording Availability of evidences Document/evidences  3 /Fully Met
and documentation are indicated proper, indicating appropriate  2/Partially Met
maintained in complete and recording and documentation  1/Not Met
accordance with appropriate recording are maintained in accordance  Not Applicable
hospital policies. and documentation are with HCO policies.
maintained in
accordance with HCO
policies

Chapter 5: HEALTHCARE INFECTION PREVENTION AND CONTROL (HIP)
The Healthcare Organization (HCO) provides guidelines, proper facilities and resources in the effective infection control program of the organization to prevent and reduce
hospital associated infections in patients, personnel and visitors.

HIC 1. The HCO has an interdisciplinary, comprehensive, coordinated and hospital-wide disseminated infection control program directed at prevention
and controlling risk to patients, personnel and visitors.
Measurable Elements
P a. The HCO has a written a. Availability of Policies and procedures on  3 /Fully Met
hospital-wide infection documents hospital-wide infection control  2/Partially Met
control program aimed indicating presence program, addressing items  1/Not Met
at preventing risks to of established 1 to 3 are identified in a  Not Applicable
patients, personnel and policies that "document" and are carried
visitors which covers: addresses items out as evident in the hospital
1. Risk assessment 1-3. records
2. Surveillance
investigation b. Availability of risk
3. Prevention including assessment reports
developing policies, with corresponding
procedures, and surveillance
strategies for areas investigation and
such as hand corrective actions/
hygiene, equipment improvement plans
cleaning, disinfection
and sterilization, and
hazardous waste
collection and
management

P b. The HCO stays abreast Availability of updated Policies and procedures  3 /Fully Met
with national guidelines, documentation/ regarding the regular review  2/Partially Met
laws and regulations, materials/ actual of infection control program  1/Not Met
clinical pathways practices identified in based on latest/current  Not Applicable
including research data the evidences national guidelines, laws and
in addressing Infection regulations are identified in a
Prevention and Control "document". Documented
in the hospital. reviews of HCO’s Infection
control program are available
and done on a regular basis.
c. A hospital wide infection
Availability of updated Infection control monitoring  3 /Fully Met
control program is documentation/ reports are available and  2/Partially Met
implemented and materials/ actual updated  1/Not Met
monitored. practices identified in  Not Applicable
the evidences
HIC 2. The HCO has an infection control manual which is continuously updated and disseminated.
Measurable Elements
P a. There are written Availability of updated Policies and procedures on  3 /Fully Met
guidelines on prevention documentation/ prevention and control of  2/Partially Met
and control of infection. materials/actual infection, review of manual  1/Not Met
practices identified in and how its contents are  Not Applicable
the evidences disseminated to personnel
are identified in a "document"
evident in the hospital
records

P b. There are available Availability of updated
Policies and procedures on  3 /Fully Met
statistical reports on documentation/ how statistical reports are  2/Partially Met
hospital acquired materials/actual collected and disseminated to  1/Not Met
infection. practices identified in
personnel are identified in a  Not Applicable
out as evident in the hospital
records. Availability of
statistical report on hospital
acquired infection as
determined by the HCO.
HIC 3. The HCO takes actions to prevent the risks of Hospital Associated Infections (HAI).
Measurable Elements
a. Hand hygiene shall be % Compliance of Hand hygiene policies are  3 /Fully Met
observed by all personnel on proper identified in a "documented".  2/Partially Met
personnel. hand hygiene During the visit/survey/  1/Not Met
observation, personnel  Not Applicable
Formula: performed hand hygiene.
personnel who
complied with the
proper hand hygiene
Denominator: Number
of personnel observed

b. Use of personal % Compliance of Policies and procedures on  3 /Fully Met
protective equipment personnel on use of use of PPE are identified in a  2/Partially Met
(PPE) shall be observed PPE "document". During the  1/Not Met
in all patient care areas. visit/observation, personnel  Not Applicable
Formula: used PPE properly.
personnel who
complied with the
proper use of PPE
Denominator: Number
of personnel observed

P c. The HCO has a policy Availability of updated Policies and procedures on  3 /Fully Met
on the use of documentation/ the use of prophylactic  2/Partially Met
prophylactic antibiotic materials/ actual antibiotic before surgery are  1/Not Met
before surgery. practices identified in identified in a "document"  Not Applicable
P d. The HCO has a policy Availability of updated Policies and procedures on  3 /Fully Met
on monitoring documentation/ monitoring antimicrobial  2/Partially Met
antimicrobial resistance. materials/ actual resistance are identified in a  1/Not Met
practices identified in "document". Availability of  Not Applicable
the evidences reports on antimicrobial
resistance monitoring.

HIC 4. There are written procedures for disinfection and sterilization activities in the hospital.
Measurable Elements
P a. There are written a. Availability of Policies and procedures for  3 /Fully Met
procedures in cleaning, documents disinfection and sterilization  2/Partially Met
disinfection, sterilization, indicating presence activities in the hospital,  1/Not Met
storage and issuance of established addressing Measurable  Not Applicable
management for policies in cleaning, Elements a to b, are
supplies and equipment. disinfection, identified in a "document"
sterilization, storage and are carried out as
and issuance evident in the hospital
management for records
supplies and
equipment
b. % compliance to
policies and
procedures in
cleaning,
disinfection,
sterilization, storage
and issuance
management for
supplies and
equipment

Formula:
observations compliant
to policies and
procedures in cleaning,
disinfection,
sterilization, storage
and issuance
management for
supplies and equipment
Denominator: Total
number of observations

P b. There are written Availability of updated Policies and procedures for  3 /Fully Met
policies and procedures documentation/ disinfection and sterilization  2/Partially Met
in cleaning and materials/ actual activities in the hospital,  1/Not Met
disinfecting hospital practices identified in addressing Measurable  Not Applicable
facilities. the evidences Elements a to b, are
identified in a "document"
records

HIC 5. The rules and regulations on Bio-medical Waste Management (BMW) are strictly observed.
Measurable Elements
P a. There are written Availability of updated Policies and procedures in  3 /Fully Met
policies and procedures documentation/ handling biological hazardous  2/Partially Met
in handling biological materials/ actual healthcare waste collection  1/Not Met
hazardous healthcare practices identified in and management are  Not Applicable
waste collection and the evidences identified in a "document"
management. and are carried out as
records
b. There is continuous % Completeness of List of required trainings for  3 /Fully Met
training of personnel in required training personnel handling biological  2/Partially Met
handling biomedical hazardous healthcare waste  1/Not Met
waste. Formula: is identified in a "document".  Not Applicable
Numerator: Number of Training certificates are
trainings attended available in the personnel’s
201 file.
Denominator: Number
of required training

HIC 6. The HCO supports and prioritizes the infection control program.
Measurable Elements
a. The resources needed Availability of updated Budget and manpower  3 /Fully Met
for the infection control documentation/ allocation for the infection  2/Partially Met
program are prioritized materials/ actual control program are identified  1/Not Met
by the HCO. practices identified in in a "document"  Not Applicable
the evidences

b. Orientation and re- % Completeness of List of required infection  3 /Fully Met
orientation of the required orientation and control program trainings are  2/Partially Met
personnel on infection re-orientation identified in a "document".  1/Not Met
control program is Training certificates are  Not Applicable
mandatory. Formula: available in the personnel's
201 file.
orientation and re-
orientation attended
Denominator: Number
of required orientation
and re-orientation

Chapter 6: INFORMATION MANAGEMENT SYSTEM (IMS)
The HCO has an effective and efficient Information Management System to ensure accurate information, dissemination and feedback to patients and personnel. The
system shall support the goal of the HCO.

IMS1.The HCO shall have written policies on complete and accurate patient medical record.
Measurable Elements
P a. There is a standard Availability of updated Policies and procedures that  3 /Fully Met
patient medical record. documentation/ enumerate the standard  2/Partially Met
materials/ actual format required forms to be  1/Not Met
practices identified in included in medical records is  Not Applicable
the evidences identified in a “document” and
is carried out as evident in
hospital record.
(Note: Patient medical record

used by inpatient and
outpatient may differ in
contents and physical format.
But each type of patient shall
have a standard format of
patient record in circulation)
b. The medical record is % compliance on Policies and procedures that  3 /Fully Met
complete and accurate. completeness of enumerate required forms to  2/Partially Met
required forms in all be included in medical  1/Not Met
medical record records is identified in a  Not Applicable
“document” and is carried out
Formula: as evident in hospital record.
medical records
complied the required
medical records forms

Denominator: Total
number of medical
records reviewed

P c. There is a unique patient Availability of the Policies and procedures on  3 /Fully Met
medical record identifier. document that assigning unique patient  2/Partially Met
establishes the medical record identifier are  1/Not Met
presence of assigning identified in a “document” and  Not Applicable
the unique patient are carried out as evident in
medical record and is hospital record.
implemented.
P d. There is a medical Availability of the Policies and procedures that  3 /Fully Met
record committee that document that establish a medical record  2/Partially Met
regularly reviews the establishes the committee and its functions  1/Not Met
patient medical record. presence of and responsibilities are  Not Applicable
appointment of a identified in a “document” and
medical record are carried out as evident in
committee, regular hospital record.
minutes of the meeting,
and regular reports on
reviewed medical
records which includes
recommended action
plans.

IMS2.The HCO has written policies on confidentiality, integrity and security of patient information.
Measurable Elements
P a. Patient medical record is Availability of the Policies and procedures that  3 /Fully Met
secured from theft, fire, document that establish that the patient  2/Partially Met
loss, and other form of establishes the policy medical record is secured  1/Not Met
damage and destruction. and plan for patient from theft, fire, loss, and  Not Applicable
medical record to be other form of damage and
secured from theft, fire, destruction and is strictly
loss, and other form of carried out.
damage and
destruction and is
strictly carried out.
P b. There is a written Availability of updated Policies and procedures on  3 /Fully Met
procedure on access to documentation/ accessing patient medical  2/Partially Met
patient medical record. materials/actual record is identified in a  1/Not Met
practices identified in “document” and are carried  Not Applicable
the evidences out as evident in the hospital
records
Required: The document

should detail authorized
personnel with access to
medical records (Both for
inpatient and outpatient)
P c. There is a written Availability of updated Policies and procedures on  3 /Fully Met
procedure on filing documentation filing of medical records,  2/Partially Met
system, retrieval of materials/ actual access and retrieval of  1/Not Met
records, storage and practices identified in records and retention is  Not Applicable
safekeeping. the evidences identified in a “document” and
are carried out as evident in
the hospital records.
Note: Both for inpatient

and outpatient

d. There is an identified % Completeness of Policies and procedures  3 /Fully Met
person authorized to medical records with which identifies authorized  2/Partially Met
make entries in patient entries from person personnel who can make  1/Not Met
medical record. authorized entries to patient's medical  Not Applicable
records is identified in a
Formula: “document”
Numerator: Number
medical records with Note: Both for inpatient and
entries from person outpatient
authorized
Denominator: Total
number of medical
records observed

IMS3. Medical records reflect continuity of care
Measurable Elements
a. There is up to date % Completeness of Policies and procedures on  3 /Fully Met
chronological account of medical records with up how to chronologically  2/Partially Met
patient care. to date chronological of account the patient care is  1/Not Met
patient care, i.e., daily identified in a “document”  Not Applicable
progress report by all
healthcare team Note: Daily progress notes by
all healthcare team.
Formula:
Numerator: Number
medical records with
daily progress report by
all healthcare team

Denominator: Total
number of medical
records observed

b. Surgical and other % Availability of Availability of a surgical and  3 /Fully Met
procedures performed surgical and other other procedure documents  2/Partially Met
are incorporated in the procedures' document in the patient medical record.  1/Not Met
patient medical record. in the patient medical  Not Applicable
records
Formula:
available surgical
record and other
procedure record in
each medical record
Denominator: Total
number of medical
record reviewed

c. There is a copy of the a. % Availability of Availability of a  3 /Fully Met
discharge summary duly discharge summary signed/official discharged  2/Partially Met
signed by authorized on the established summary in the patient  1/Not Met
personnel. TAT medical record.  Not Applicable
Formula:
available discharged
summary on the
established TAT

Denominator: Total
number of medical
records reviewed
b. % availability of
signature per
discharge summary
Formula:
available signature per
discharged summary
Denominator: Total
number of medical
records reviewed

d. There is a copy of % Availability of Policies and procedures on  3 /Fully Met
transfer documents of transfer document on transferring patient is  2/Partially Met
patient. the established TAT identified in a “document”.  1/Not Met
Formula:  Not Applicable
Numerator: Number of Required: Copy of transfer
available transfer document in patient
document on the medical record
established TAT
Denominator: Total
number of medical
records reviewed

e. In case of death, there is % Availability of death Policies and procedures on  3 /Fully Met
a copy of death certificate and autopsy processing death certificate  2/Partially Met
certificate and a copy of report (if needed) on and autopsy report are  1/Not Met
autopsy report. the established TAT identified in a “document”.  Not Applicable
Formula: Required: Copy death

Numerator: Number of certificate and autopsy
available death report (if needed) in patient
certificate on the medical record
established TAT
Denominator: Total
number of medical
records reviewed
IMS4.There is a written policy for retention and disposal of patient medical record.
Measurable Elements
P a. There is an established Availability of updated Policies and procedures in  3 /Fully Met
procedure in retention documentation/ retention and disposal of  2/Partially Met
and disposal of patient materials/ actual patient’s records is identified  1/Not Met
medical record. practices identified in in a “document” and is  Not Applicable
the evidences carried out as evident in
hospital records.
P b. There is compliance to Availability of updated Policies and procedures on  3 /Fully Met
regulatory laws of local documentation/ how permits and certifications  2/Partially Met
and national materials/ actual from local and national  1/Not Met
government. practices identified in government processed is  Not Applicable
hospital records.

Required: Updated permits
and certifications from
local and national
government
IMS5.There shall be a regular medical records audit.
Measurable Elements
P a. The HCO observes Availability of updated Policies and procedures on  3 /Fully Met
regular medical records documentation/ how medical records are  2/Partially Met
audit through the materials/ actual audited are identified in a  1/Not Met
medical records practices identified in “document and is carried out  Not Applicable
management committee. the evidences as evident in hospital
records.
Required: Regular audit

report of medical records
committee
b. The Medical Record is Availability of updated Policies and procedures on  3 /Fully Met
reviewed and analyzed documentation/ how medical records is  2/Partially Met
using a statistically materials/ actual reviewed and analyzed using  1/Not Met
representative sample. practices identified in a statistically representative  Not Applicable
the evidences sample is identified in a
“document”
P c. The review addresses Availability of updated Policies and procedures on  3 /Fully Met
the timeliness, documentation/material the process of conducting  2/Partially Met
completeness and s/ actual practices patient medical record review  1/Not Met
deficiencies of the identified in the is identified in a  Not Applicable
medical records of both evidences “document” and is carried out
the active and as evident in hospital records
discharged patients.
Required: Audit report of
patient medical record

d. Relevant corrective and Availability of updated Policies and procedures on  3 /Fully Met
preventive measures audit report on medical how corrective measure and  2/Partially Met
taken are documented. records with the recommendation is  1/Not Met
corresponding implemented is identified in a  Not Applicable
recommendation on “document” and carried out
corrective measures as evident in hospital
records.

CHAPTER 7: Governance and Direction Management (GDM)
1. The Health Care Organization is governed, administered and managed according to its mission, goals and core values to assure better health outcomes of its patients.
2. Governance standard encourages professional and ethical behavior, decision making and directional goal setting. This ensures patient safety and quality of care.
GDM 1. The HCO has an organizational structure that delineates lines of authority, responsibility, accountability and communication mechanism.
Measurable Elements:
a. There is an approved Presence of approved Documents (such as  3 /Fully Met
organizational chart organizational chart approved organizational  2/Partially Met
(organogram) that that shows the lines of chart) that shows the lines of  1/Not Met
shows the lines of authority, responsibility authority, responsibility and  Not Applicable
authority, responsibility and accountability of its accountability of its members
and accountability of its members.
members.
P b. Well-defined lines of Presence of documents Document (such as policies  3 /Fully Met
authority and levels of that shows the levels of and procedures,  2/Partially Met
communication are in communication within memorandum, notifications)  1/Not Met
place. and outside the HCO indicating the levels of  Not Applicable
communication within and
outside of the HCO.
P c. There is a process Presence of documents Documents (such as policies  3 /Fully Met
through which relevant indicating the process and procedures, Quality  2/Partially Met
information including through which relevant Reports, Government  1/Not Met
risks are communicated information are Required Reports,  Not Applicable
to stakeholders – both communicated to Government Implementing
internal (within HCO) internal and external Guidelines) and other
and external (outside of stakeholders. evidences indicating on how
the HCO) relevant information
(including risks) is
communicated to
stakeholders – both internal
(within the HCO) and external
(outside HCO).

d. Relevant information is Presence of document Documents (such as policies  3 /Fully Met
communicated indicating the process and procedures) and other  2/Partially Met
throughout the HCO. how relevant evidences indicating on how  1/Not Met
information (including relevant information  Not Applicable
risks) is communicated (including risks) is
to stakeholders – both communicated to
internal (within the stakeholders – both internal
HCO) and external (within the HCO) and external
(outside HCO). (outside HCO”
e. The leaders of the HCO Presence of document/ Document (such as job  3 /Fully Met
should define the roles evidence indicating description of each  2/Partially Met
and functions at all every member of the personnel) and other  1/Not Met
levels of the organization HCO knows his/her evidence indicating that each  Not Applicable
respective function. member of the HCO is aware
of his/her role/ functions.
Observation/ Interview of
personnel may be conducted.
P f. The HCO should have Availability of Policies and procedures on  3 /Fully Met
policies, procedures and documents/ policies internal documentation which  2/Partially Met
processes for all key and procedures define all the internal  1/Not Met
functions in the manuals that identifies documentation in the  Not Applicable
organization that are: the requirements stated organization including
1. Documented under the evidence policies and procedure for all
2. Approved by key functions in the
Authorized Signatory organization that are:
3. Kept Current by being 1. Documented
reviewed and revised
against agreed 2. Approved by Authorized
timescale, and Signatory
4. Implemented 3. Kept Current by being
reviewed and revised against
agreed timescale, and
4. Implemented

GDM 2. The HCO has an established vision, mission, objectives and core values.
P a. The Vision, Mission, Availability of Policies and procedures on  3 /Fully Met
Objectives and core documents/evidence how the mission, vision and  2/Partially Met
values are written and indicating presence of core values is reviewed and  1/Not Met
widely disseminated and mission, vision, and the schedule;  Not Applicable
periodically objectives are widely Updated mission/vision
reviewed/updated. disseminated among statement
stakeholders and that
they are periodically
reviewed and updated.
b. Strategic and Availability of Documents such as policies  3 /Fully Met

operational plans are documents/evidence and procedures on how  2/Partially Met
documented and indicating strategic and strategic and operational  1/Not Met
reviewed periodically. operational plans are plans are reviewed is  Not Applicable
documented and identified in a “document” and
reviewed periodically is carried out as evident in
hospital record
Evidences such as updated
strategic and operational
plans are required.
c. There should be a System or policies on Availability of documents  3 /Fully Met
system to ensure stakeholders’ showing consultations with  2/Partially Met
participation of all participation in planning stakeholders and other  1/Not Met
internal and external processes. pertinent materials indicating  Not Applicable
stakeholders concerned that there is a procedure in
for the provision of consulting stakeholders in the
services. planning for provision of
services.

c.
d. There is Work and Availability of updated Documents and evidences  3 /Fully Met
Financial plan to meet Work and Financial such as current work and  2/Partially Met
its goals and operation. plan, aligned with the financial plan, projected  1/Not Met
HCO’s goals and income and expenditure  Not Applicable
operation. statements and similar
financial records and plans.
P e. All healthcare Availability of Documents (memorandum,  3 /Fully Met
personnel are aware of
documents indicating policies and procedures,  2/Partially Met
the operational plan and
presence of policies operational manuals) on how  1/Not Met
have access to these and procedures on how health care personnel are  Not Applicable
documents health care personnel informed and given access of
are informed and given operational plans of the HCO.
access of operational
plans.
GDM 3. Responsibilities of Management and Accountabilities are defined.
P a. The governance Availability of Updated documents (such as  3 /Fully Met
responsibilities and documents that clearly statement of management  2/Partially Met
accountabilities are identify the responsibility) that clearly  1/Not Met
described in written responsibilities of the identify the responsibilities of  Not Applicable
documents. management the management
b. The documents describe Availability of Document/evidences  3 /Fully Met
how the performance of document/evidences indicating how the  2/Partially Met
the governing leaders indicating how performance of the governing  1/Not Met
will be evaluated and management/ leaders is evaluated; i.e.  Not Applicable
any related criteria. governing leaders are Performance appraisal
appraised/evaluated managerial accountability
sheet

c. The governance Availability of Document/evidence that  3 /Fully Met
addresses social and document/evidences indicates that the HCO has  2/Partially Met
environmental indicating social andsocially and environmentally  1/Not Met
responsibility. environmental policies/
responsible programs i.e.,  Not Applicable
programs are present document on proper waste
or implemented disposal, interview of patient/
relatives, observation.
GDM 4. The management is guided by Ethical and Legal standards.
P a. There are policies, Presence of well- Policies, procedures,  3 /Fully Met
procedures and established policies, guidelines and similar  2/Partially Met
guidelines on ethical procedures, guidelines documents to ensure that  1/Not Met
dilemmas in patient care to serve as ethical ethical practice is observed in  Not Applicable
that should be resolved guide in patient care patient care. Other evidences
in a timely way.” could include interview of
patient/relative, review of
patient’s record/chart and
direct observation.
P b. There is compliance with Compliance to statutory Presence of compliance  3 /Fully Met

the applicable statutory laws as indicated by certificates, updated licenses  2/Partially Met
laws and regulations. presence of compliance and permits and certification  1/Not Met
certificates, required of no record of non-  Not Applicable
permits and licenses compliance to applicable
and no record of non- statutory laws and
compliance from regulations.
relevant government
body.

P c. There are written code of Availability of updated Policies and procedures on  3 /Fully Met
Ethical Behaviour, documentation/ how applicable laws and  2/Partially Met
Bioethics Manual, and materials/ actual regulations are widely  1/Not Met
Code of Discipline for practices identified in disseminated to the  Not Applicable
every HCW which are the evidences community is identified in a
consistent with “document” and is carried out
applicable laws and as evident in hospital records
regulations and widely such as in minutes of the
disseminated. meeting
d. The HCO clearly states Availability of updated Services of the HCO is  3 /Fully Met
the services it provides.
documentation/ identified in a “document” and  2/Partially Met
materials/ actual is carried out as evident in  1/Not Met
practices identified in hospital records  Not Applicable
the evidences
GDM 5. The leaders of HCO ensure that patient safety and quality issues are integral part of patient care and hospital management.
P a. There should be a team Availability of Policies and procedures that  3 /Fully Met
designated to oversee documents, materials identifies the team that will  2/Partially Met
patient safety and actual observation oversee the monitoring and  1/Not Met
throughout the care indicating presence of evaluation of the hospital  Not Applicable
continuum which patient safety initiatives safety program is identified in
includes monitoring and across continuum of a “document”; presence of
evaluation of the care records such as, but not
hospital-wide safety limited to monitoring or audit
program in line with report, checklists (e.g.
WHO Patient Safety surgical checklist), etc., hand
Initiatives (proper hygiene practices. Interview
patient identification, and observation may be
correct medication ID, conducted/
correct procedure at
correct body parts,
Control of Concentrated
Electrolyte Solutions,

Medication Accuracy at
Transitions in Care,
Avoiding Catheter and
Tubing Mis-Connections
Single Use of Injection
Devices, Improved Hand
Hygiene)
P b. The management Availability of updated Policies and procedures on  3 /Fully Met
ensures internal and documentation/ how system deviation from  2/Partially Met
external reporting materials/ actual standards, process failures  1/Not Met
system on deviation practices identified in and concerns related to  Not Applicable
from standards, process the evidences patient safety and quality is
failures, and issues and reported internally and
concerns related to externally is identified in a
patient safety and “document” and is carried out
quality. as evident in hospital
records.
Required: Incident Reports
P c. There is a mechanism Availability of updated Policies and procedures that  3 /Fully Met
for reviewing, analyzing, documentation/ establishes mechanism for  2/Partially Met
processing and resolving materials/ actual reviewing, analyzing and  1/Not Met
issues related to quality practices identified in resolving issues related to  Not Applicable
and patient safety. the evidences quality and patient safety is
identified in a “document” and
hospital records such as, but
not limited to patient
identification, communication
during hand overs,
prevention of infection,
analysis report, summary of
corrective actions done and
its status, etc.

GDM 6. There shall be inter and intra departmental communication and coordination system
Measurable Elements
P a. There shall procedure Availability of flow Availability of flow chart,  3 /Fully Met
and guidelines for chart, forms and other forms, standards for  2/Partially Met
communication and documents that shows communication during hand  1/Not Met
coordination between coordination and overs, and other documents  Not Applicable
and among sections communication among that shows coordination and
within the department to the health care team communication among the
ensure delivery of safe health care team
and quality care
b. There shall well- Availability of Documents/materials such as  3 /Fully Met
established procedure documents/materials but not limited to policies,  2/Partially Met
and guidelines for indicating the presence guidelines indicating the  1/Not Met
communication and of well-established presence of well-established  Not Applicable
coordination between procedure and procedure and guideline for
and among different guideline for communication and
departments to ensure communication and coordination between and
delivery of safe and coordination between among different departments
quality care and among different to ensure delivery of safe and
departments to ensure quality care. Actual
delivery of safe and observation and interviews
quality care. may be conducted.

GDM 7. The HCO has Risk Management Plan
Measurable Elements
P a. There shall be risk Availability of updated Risk management plan (or  3 /Fully Met
management plan that documentation/ similar documents) that  2/Partially Met
includes risk materials/ actual include risk identification, risk  1/Not Met
identification, risk practices indicating responsibility, risk  Not Applicable
responsibility, risk presence of a risk assessment and risk
assessment and risk management plan (or response both for clinical and
response, staff training similar documents) that non-clinical risk. There
and communication to includes risk should also be
stakeholders. identification, risk documents/materials
responsibility, risk indicating that this plan is
assessment and risk regularly reviewed and
response both for updated such as but not
clinical and non-clinical limited to policy, minutes of
risk. the meeting,
P b. There should be a Availability of updated Policies and procedures that  3 /Fully Met
contingency plan documentation/ identifies contingency plan in  2/Partially Met
including risk mitigation materials/ actual case of plan failure including  1/Not Met
both for clinical and non- practices identified in risk mitigation is identified in  Not Applicable
clinical risks the evidences a document and is carried out
as evident in hospital
records. The plan should be
reviewed and updated on a
regular basis.
P c. There shall be a system Availability of updated Policies and procedures that  3 /Fully Met
for tracking and documentation/ tracks and reports risk in  2/Partially Met
reporting of risk. A risk materials/ actual HCO is identified in a  1/Not Met
register should be kept practices identified in document and is carried out  Not Applicable
and updated regularly. the evidences as evident in hospital records
such as, but not limited to
Risk Management Database
that is being reviewed and
updated on a regular basis.

CHAPTER 8: Facility Management and Environmental Safety (FME)
This standard ensures the provision of a safe and secure environment and facilities for patients, visitors and health workers and compliance to relevant statutory laws and
regulations required by government and other regulatory bodies.

FME 1. The HCO complies with relevant statutory laws and regulations.
Measurable Elements
a. The management Compliance to statutory Updated permits and  3 /Fully Met
complies with statutory laws as evident in the licenses, certificate of  2/Partially Met
laws and regulation and HCO’s ability to secure compliance  1/Not Met
ensures implementation. the required licenses,  Not Applicable
permit, certificate of
compliance and no
record of non-
compliance e.g. fire
safety compliance
certificate
P b. There is a process to Presence of a system Policies and procedures that  3 /Fully Met
regularly update licenses to ensure licenses, specify the process to  2/Partially Met
and registration and permits and certification regularly update statutory  1/Not Met
certification. are updated laws and regulations  Not Applicable
licenses, registration and
certification.

FME 2. The HCO provides and maintains a safe environment and facilities which ensures that buildings, space, equipment and supplies are provided in
line with the scope of services.
Measurable Elements
P a. The HCO provides and Availability of well- Documents indicating well-  3 /Fully Met
maintains a safe established policies and established policies and  2/Partially Met
environment and procedures regarding procedures on providing and  1/Not Met
facilities safe environment and maintaining safe environment  Not Applicable
facilities and facilities including but not
limited to hospital order,
maintenance schedule,
safety or monitoring reports,
etc. Interview of personnel
and patients, direct
observation maybe included
as evidence.
b. There is a documented Availability of well- Documents indicating that  3 /Fully Met
operational and established system for there is an operational and  2/Partially Met
maintenance plan for operation and maintenance plan for facilities  1/Not Met
facilities and equipment. maintenance of and equipment such as but  Not Applicable
facilities and not limited to operational and
equipment. maintenance plan, preventive
maintenance schedule,
facility safety inspection
report, and similar
documents.

c. Conducts regular safety Presence of documents Documents/ evidences  3 /Fully Met
training among indicating regular indicating regular conduct  2/Partially Met
personnel and clients. conduct of safety of safety training (e.g.,  1/Not Met
training as stated in the general safety training,  Not Applicable
evidence and similar hazardous training, radiation
activities as well as safety, equipment safety, etc)
record of personnel and records of personnel
participation to such participation such as
activities. certificate of attendance.
Photo/video documentation
may be included as well as
interview of personnel/
patients/relatives.
d. The organization has a Presence of a well- Presence of documents/  3 /Fully Met
process to identify the established system of evidences indicating a  2/Partially Met
potential safety and identifying potential system of identifying potential  1/Not Met
security risk including safety and security list safety and security risk such  Not Applicable
hazardous material. those involving as memorandum, risk
hazardous materials. register, among others.
e. The organization has a Availability of updated Policies and procedures and  3 /Fully Met
program for Building documents on building tools on building  2/Partially Met
Management System management system management safety  1/Not Met
 Not Applicable

FME 3. The organization has a well-established emergency and disaster management plan.
Measurable Elements
P a. There is a written widely Availability of updated Policies and procedures  3 /Fully Met
disseminated plan. documentation and indicating presence of an  2/Partially Met
evidences indicating emergency management or  1/Not Met
presence of a well- preparedness (such as  Not Applicable
established emergency patient influx, code 99/blue,
and disaster medical equipment
management/prepared breakdown) and disaster plan
ness plan (or similar (such as fire, earthquake,
document) and flood, hostage taking, bomb
evidences that it is threat) or similar documents
widely disseminated. and evidences that it is
widely disseminated.
b. This plan is periodically Availability of updated Updated disaster  3 /Fully Met
reviewed. documentation and management plan, minutes of  2/Partially Met
evidences indicating meeting (of the body  1/Not Met
that the disaster responsible for the updating  Not Applicable
management plan (or of the plan), hospital order
similar document) is and similar documents
periodically reviewed. indicating that the plan is
periodically reviewed and
updated.
c. Conducts a plan for Presence of documents Documents/ evidences  3 /Fully Met

training and mock drills indicating regular indicating regular conduct of  2/Partially Met
for all employees on a conduct of training and training and mock drills and  1/Not Met
regular basis. mock drills and well as records of personnel  Not Applicable
record of personnel participation such as
participation to such certificate of attendance.
activities. Photo/video documentation
may be included as well as
interview of personnel/
patients/relatives

d. There is a safe exit plan Availability of updated Safe exit plan posted in  3 /Fully Met
for fire and non-fire documentation and strategic locations, interview  2/Partially Met
emergencies. evidences indicating of personnel and patients/  1/Not Met
that presence of safe relatives  Not Applicable
exit plan.
FME 4. The HCO provides safe water, continuous electricity and medical gas.
Measurable Elements
a. Potable water and Availability of updated Documents/evidences to  3 /Fully Met
electricity are available documentation/ indicate steady or continuous  2/Partially Met
round the clock and evidences indicating supply of potable water,  1/Not Met
alternative sources of continuous supply of electricity and medical gases  Not Applicable
water, electricity and potable water, such as but not limited to
medical gases electricity and medical MOA with water supplier or
gases and alternative fire department, supplier of
sources of the same in medical gases, presence of
case of emergencies/ deep well or other alternative
disasters water source, generators,
reasonable stocks of medical
gases.
b. There is a maintenance Availability of updated Current/updated  3 /Fully Met
plan for medical gases documentation and maintenance plan for medical  2/Partially Met
and vacuum systems. evidences indicating gases and vacuum  1/Not Met
that the maintenance systems that is reviewed and  Not Applicable
plan (or similar evaluated on a regular basis.
document) for medical Could also include minutes of
gases and vacuum meeting of body responsible
systems are for the task.
periodically reviewed

FME 5. The organization has a program for Equipment Management System
Measurable Elements
a. There is an Annual Availability of document Document/evidences to  3 /Fully Met
Procurement Plan of indicating plan/program indicating presence of  2/Partially Met
equipment in to acquire equipment in current/updated procurement  1/Not Met
accordance with its accordance to the plan to acquire equipment is  Not Applicable
services. service it provides reviewed and evaluated on a
regular basis. Could also
include minutes of meeting of
body responsible for the task
b. There is a regular Document/evidences Documents/ evidences  3 /Fully Met
inventory of equipment. indicating that there is indicating regular inventory of  2/Partially Met
regular inventory of equipment such as schedule  1/Not Met
equipment of inventory, updated  Not Applicable
inventory record and other
similar documents, updated
inventory of equipment.
Observation and interview
may also be conducted.
P c. There is a schedule and Availability of updated Documents/evidences  3 /Fully Met
guidelines on updating documentation indicating presence of well-  2/Partially Met
and replacement of indicating procedures established procedures on  1/Not Met
equipment. on updating and updating and replacement of  Not Applicable
replacement of equipment i.e. policies,
equipment maintenance report,
equipment appraisal report
and similar documents

d. All personnel operating % personnel who Documents/evidences  3 /Fully Met
the equipment (including operate equipment has indicating that the personnel  2/Partially Met
specialized and new undergone required operating the machine/  1/Not Met
equipment) and training relevant to the equipment are trained  Not Applicable
machines are competent job accordingly i.e. training
and trained. certificate, updated licenses,
Formula: etc.
personnel trained to
operate equipment and
machines
Denominator: Total
number of personnel
who are operating
equipment and
machine

e. There are qualified % personnel who Documents/evidences  3 /Fully Met
personnel trained to maintain equipment has indicating that the personnel  2/Partially Met
maintain the equipment. undergone required maintaining the machine/  1/Not Met
training relevant to the equipment are trained  Not Applicable
job accordingly i.e. training
certificate, updated licenses,
Formula: etc., or MOA, contracts, and
similar documents/evidences
Numerator: Number of indicating arrangement for an
personnel trained to outsource maintenance
maintain equipment service with a duly authorized
and machines body

Denominator: Total
number of personnel
who maintain
equipment and
machine. Alternatively,
presence of
documents/evidences
indicating arrangement
for an outsource
maintenance service
with a duly authorized
body

f. All of the equipment is % compliance to Policies and procedures on  3 /Fully Met
periodically inspected, scheduled calibration how equipment are calibrated  2/Partially Met
tested, calibrated and as part of the as part of preventive and  1/Not Met
maintained as part of the preventive and corrective maintenance  Not Applicable
preventive and corrective maintenance program is identified in a
corrective maintenance program “document” and is carried out
program in a planned as evident in hospital
and systematic way Formula: records.
Numerator: Number of Required: Current/updated

calibrated equipment preventive maintenance
on schedule checklist and corrective
maintenance program
Denominator: Total
number of equipment to
be calibrated on
schedule

g. There is proper Availability of Maintenance record  3 /Fully Met
documentation/ record of document/evidence indicating there is proper  2/Partially Met
equipment maintenance. indicating system of documentation/ record of  1/Not Met
proper recording of equipment maintenance such  Not Applicable
equipment as but not limited to
maintenance. accomplished maintenance
report, job order request, and
other relevant
documents/evidences.
Interview may also be
conducted.

CHAPTER 9: Human Resource Management (HRM)
The goal of HRM standards is to ensure the right number and mix of health workers with the right appropriate qualification to meet the needs of patients and the
community.

HRM 1. The organization has a documented system of human resource planning.
Measurable Elements
P a. The organization has Availability of policies Documents indicating policies  3 /Fully Met
established policies on and procedures and procedures on the  2/Partially Met
recruitment, selection, regarding recruitment, recruitment, selection and  1/Not Met
appointment and selection, appointment promotion of personnel  Not Applicable
promotion including and promotion including credentialing of
credentialing of medical medical personnel are
personnel. identified.
b. The HCO maintains Availability of updated Current/updated manpower  3 /Fully Met
adequate number and documentation plantilla or personnel  2/Partially Met
mix of personnel to meet indicating the required requirement to complement  1/Not Met
the care, treatment and personnel complement the services provided by the  Not Applicable
services needed to the services provided HCO
by the HCO.
c. There is presence of HR Availability of HR plan Current/updated HR  3 /Fully Met
development plan and regarding recruitment development plan and list of  2/Partially Met
manual of job and maintaining job description per category  1/Not Met
description. adequate number of that is reviewed and  Not Applicable
personnel base on the evaluated on a regular basis
needs of the HCO

d. The healthcare Availability of updated Policies and procedures on  3 /Fully Met
organization has human documentation/ personnel deployment is  2/Partially Met
resource management materials/actual identified in a “document” and  1/Not Met
(HR) plan and records of practices identified in carried out as evident in  Not Applicable
personnel deployment the evidences hospital records
(Assignments should be
commensurate to his
qualification and
training).
e. There is a list of job Availability of updated Current/updated HR  3 /Fully Met
positions with job documentation/ development plan and  2/Partially Met
descriptions for all staff, materials/actual manual of job description &  1/Not Met
independent practices identified in specification and desired  Not Applicable
practitioners and the evidences qualification that is reviewed
volunteers and the job and evaluated on a regular
description shall indicate basis
the following:
1. Orientation and
trainings
2. Education
3. Knowledge
4. Skills
5. Experience

f. The HCO has Availability of updated Current/updated list of job  3 /Fully Met
information on: documentation/ vacancy that is reviewed and  2/Partially Met
1. Job Vacancy materials/actual evaluated on a regular basis  1/Not Met
the evidences
2. Availability of funds Availability of updated Current/updated budget plan  3 /Fully Met
for vacant positions documentation/  2/Partially Met
the evidences
3. Appointments of Availability of updated Current/updated appointment  3 /Fully Met
personnel documentation/ of personnel that is identified  2/Partially Met
materials/actual in a “document” and carried  1/Not Met
practices identified in out as evident in hospital  Not Applicable
the evidences record
4. Minutes of meetings Availability of updated “Document” on selection and  3 /Fully Met
in selection and documentation/ promotion deliberation  2/Partially Met
promotion materials/actual  1/Not Met
deliberation practices identified in  Not Applicable
the evidences
5. Existing labor Availability of updated List of existing labor laws and  3 /Fully Met
laws/civil service documentation/ civil service rules is identified  2/Partially Met
rules materials/actual in a “document”  1/Not Met
the evidences

HRM 2. The HCO has an orientation and re-orientation program for all personnel.
Measurable Elements
a. All personnel are % of employees who Capability of personnel to  3 /Fully Met
appropriately oriented to can explain the vision, explain the vision, mission,  2/Partially Met
the organization’s vision, mission, objectives and objectives and specific  1/Not Met
mission, objectives, specific policies and policies and procedures of  Not Applicable
values, policies and procedures of the the organization and
procedures. organization documents showing the
actual conduct of training
Formula: such as attendance report or
attendance certificate.
employees who can
explain the vision,
mission, objectives and
specific policies and
procedures of the
organization
Denominator: Total
Number of employees
interviewed
Then multiplied by 100

b. All personnel know their % of employees who Capability of personnel to  3 /Fully Met
rights and can explain their job explain their job description,  2/Partially Met
responsibilities and job description, responsibilities and functions.  1/Not Met
functions. responsibilities and  Not Applicable
functions.
Formula:
employees who can
explain their job
description,
responsibilities and
functions.
Denominator: Total
Number of employees
interviewed

c. All personnel are % Completed/ Policies and procedures on  3 /Fully Met
educated on patient’s accomplished training how training programs are  2/Partially Met
rights and feedback form conducted is identified in a  1/Not Met
responsibilities. Formula: “document” and is carried out  Not Applicable
Numerator: Number of as evident in hospital records
completed/
accomplished training
feedback form
Denominator: Total
Number of training
programs conducted in
a year

HRM 3. The HCO has ongoing professional training and development program for employees.
Measurable Elements
a. There is a training needs Availability of updated Policies and procedures on  3 /Fully Met
assessment for documentation/ how the training needs of  2/Partially Met
personnel development. materials/actual personnel are assessed is  1/Not Met
practices identified in identified in a “document” and  Not Applicable
the evidences is carried out as evident in
hospital records
b. There is presence of Availability of updated Current/updated training  3 /Fully Met
documented trainings documentation/ plans and modules and is  2/Partially Met
plans and modules. materials/actual reviewed and evaluated on a  1/Not Met
practices identified in regular basis  Not Applicable
the evidences
c. There are documented Availability of updated Policies and procedures on  3 /Fully Met
training programs with documentation/ how training programs are  2/Partially Met
participants to include materials/actual conducted and evaluated is  1/Not Met
feedback from practices identified in identified in a “document” and  Not Applicable
participants regarding the evidences is carried out as evident in
the training. hospital records
d. There is presence of % Certificates of Copies of certificates of  3 /Fully Met

monitoring system to continuing training, degrees of each  2/Partially Met
ensure that personnel education/training personnel as found in their  1/Not Met
undergone continuing relevant to their respective 201 files  Not Applicable
education/training functions/assignment in
relevant to their their respective 201
functions/assignment files

Formula:
201 files with
certificates of
continuing
education/training
relevant to their
functions /assignment
Denominator: Total
Number of continuing
education/training
programs based on the
training plan

HRM 4. The HCO has a standard appraisal system in place for evaluating the performance of employees.
Measurable Elements
a. All employees are aware % of employees who Policies and procedures on  3 /Fully Met
of the system. are aware of the how the appraisal system is  2/Partially Met
standard appraisal conducted and disseminated  1/Not Met
system to personnel is identified in a  Not Applicable
Formula: as evident in the hospital
records
employees who can
explain the
performance appraisal
system

Denominator: Total
Number of employees
interviewed

P b. There is a documented Availability of updated Policies and procedures  3 /Fully Met
procedure of appraisal documentation/ pertaining to the appraisal  2/Partially Met
system. materials/actual system of the organization is  1/Not Met
practices identified in identified in a “document” and  Not Applicable
the evidences is carried out as evident in
hospital records
P c. The HCO has an Availability of updated The Performance Review  3 /Fully Met
established Performance documentation/ Committee and its  2/Partially Met
Review Committee. materials/actual responsibilities is identified in  1/Not Met
practices identified in a “document” that is carried  Not Applicable
the evidences out as evident in hospital
records
d. Performance appraisal % compliance in Policies and procedures on  3 /Fully Met
is carried out at carrying out conduct of performance  2/Partially Met
predefined intervals and performance appraisal appraisal is identified in a  1/Not Met
is documented. as scheduled “document” and is carried out  Not Applicable
as evident in hospital
Formula: records.
performance appraisal
carried out within
specified schedule
Denominator: Total
number of performance
appraisal to be carried
out within the specified
schedule.

HRM 5. The organization has an existing process of addressing of disciplinary and grievance issues.
Measurable Elements
P a. There is a documented Availability of updated Policies and procedures in  3 /Fully Met
process of handling documentation/ handling employee’s  2/Partially Met
grievance. materials/actual grievance is identified in a  1/Not Met
practices identified in “document” and carried out  Not Applicable
the evidences as evident in hospital records
P b. Disciplinary actions are Availability of updated Policies and procedures that  3 /Fully Met
in accordance with documentation/ addresses violations and  2/Partially Met
existing laws. materials/actual disciplinary actions of the  1/Not Met
practices identified in organization is subject to  Not Applicable
the evidences applicable statutory laws and
regulations is identified in a
as evident in hospital records
P c. There is a progressive Availability of updated Policies and procedures on  3 /Fully Met
discipline system. documentation/ progressive discipline system  2/Partially Met
materials/actual are identified in a “document”  1/Not Met
practices identified in and is carried out as evident  Not Applicable
the evidences of hospital record.
Required: Employee’s
Code of discipline/
standards
d. Due process is % compliance to due Policies and procedures on  3 /Fully Met
observed at all times. process in addressing conduct of due process in  2/Partially Met
grievance issues addressing disciplinary and  1/Not Met
grievance issues is identified  Not Applicable
Formula: in a “document”
addressed grievance
issues that undergoes
due process

Denominator: Total
number of grievance
issues

HRM 6. The organization addresses the health needs and other benefits of its personnel.
Measurable Elements
P a. The HCO has policies Availability of updated Policies and procedures on  3 /Fully Met
and procedures on work documentation/ how the organization  2/Partially Met
life balance and safety of materials/actual addresses work life balance  1/Not Met
all personnel. practices identified in and safety of all personnel is  Not Applicable
hospital records
b. Occupational health % Completion of Policies and procedures in  3 /Fully Met
hazards are corrective actions for addressing occupational  2/Partially Met
appropriately addressed. reported/identified health hazards are identified  1/Not Met
occupational health in a “document” and are  Not Applicable
hazards carried out as evident in
hospital records.
Formula:
implemented corrective
actions
Denominator: Number
of reports/identified
occupational health
hazards

P c. The HCO provides Availability of updated List of monetary and non-  3 /Fully Met
monetary and non- documentation/ monetary benefits provided to  2/Partially Met
monetary benefits to the materials/actual the employees as identified in  1/Not Met
employees. practices identified in a “document”  Not Applicable
the evidences
d. The HCO complies with % compliance to List of mandatory benefits  3 /Fully Met
mandatory benefits as mandatory benefits and availability of policies  2/Partially Met
prescribed by law. prescribed by law. and procedures identified in a  1/Not Met
“document” that addresses  Not Applicable
the compliance of HCO and
Formula: proof of transmittal.
provided mandatory
benefits prescribed by
law
Denominator: Total
number of mandatory
benefits prescribed by
law

HRM 7. The organization maintains a personal file (including relevant updated licenses and certifications) of all its employees.
Measurable Elements
P a. Confidential personnel Availability of updated Policies and procedures on  3 /Fully Met
files are maintained and documentation/ how confidential personnel  2/Partially Met
updated. materials/actual files are maintained and  1/Not Met
practices identified in updated is identified in a  Not Applicable
the evidences “document” and is carried out
as evident in hospital records

b. Personnel files contain % Completeness of List of relevant personal  3 /Fully Met
relevant personal personal information information is identified in a  2/Partially Met
information regarding regarding employees’ “document”  1/Not Met
employee’s which qualification as  Not Applicable
includes the following: prescribed by the
1. Orientation and organization
trainings
2. Education Formula:
3. Knowledge Numerator: Number of
4. Skills present training and
5. Experience education records in
201 file
Denominator: Number
of prescribed trainings
and education records

c. All records of training % Completeness of Records/certifications of  3 /Fully Met
and education are required training and training and education in 201  2/Partially Met
contained in the education records file  1/Not Met
personnel file. prescribed by the  Not Applicable
organization in 201 file
Formula:
present training and
education records in
201 file
Denominator: Number
of prescribed trainings
and education records

d. Personnel file contains % availability of Current and previous  3 /Fully Met
result of performance personnel file with performance appraisal result  2/Partially Met
appraisal. updated Performance in 201/personnel file  1/Not Met
Appraisal Form (PAF)  Not Applicable
Formula:
personnel file with
updated PAF
Denominator: Total
number of personnel
file

HRM 8. There is a process for authorizing medical professionals to admit and treat patients and provide other clinical services commensurate with their
qualification. (Credentialing)
Measurable Elements
P a. HCO should have an Availability of updated Policies and procedures that  3 /Fully Met
established Medical documentation/ establishes the Medical  2/Partially Met
Credentials Committee. materials/actual Credentials Committee, its  1/Not Met
practices identified in functions and responsibilities  Not Applicable
the evidences is identified in a “document”
and is carried out as evident
in hospital records
b. All medical professionals % compliance of List of applicable laws and  3 /Fully Met
should comply with all medical practitioners to regulations that medical  2/Partially Met
applicable laws and applicable laws and professionals should comply  1/Not Met
regulations. regulations and availability of policies  Not Applicable
and procedures identified in a
“document” that addresses
the compliance of HCO

Formula:
medical professionals
who comply with
applicable laws and
regulations
Denominator: Total
number of medical
practitioners reviewed

c. All medical professionals % compliance of Policies and procedures on  3 /Fully Met
should comply or medical professional to how compliance of medical  2/Partially Met
behave according to hospital policies and professionals to hospital  1/Not Met
hospital policies and procedures policies and procedures are  Not Applicable
procedures. measured and monitored is
Formula: identified in a “document” and
Numerator: Number of is carried out as evident in
medical professional hospital records
who comply with the
required hospital Required: Compliance to
procedures hospital policies and
procedures is part of the
Denominator: Total PAF of medical
number of medical professionals
practitioners reviewed

d. All medical practitioners % of credentialed Policies and procedures on  3 /Fully Met
should pass through medical practitioner how medical practitioners are  2/Partially Met
credentialing. credentialed is identified in a  1/Not Met
Formula: “document” and is carried out  Not Applicable
Numerator: Number of as evident in hospital records
credentialed medical
practitioner Required: Credentialing
record of medical
Denominator: Total practitioners
number of medical
practitioner that should
be credentialed

HRM 9. There is a process for authorizing all clinical professionals to practice in the HCO in line their competencies and credentialing requirement
Measurable Elements
a. All practitioners – para- % of credentialed Policies and procedures on  3 /Fully Met
medical and non- practitioner how practitioners are  2/Partially Met
medical should be credentialed is identified in a  1/Not Met
properly credentialed by Formula: “document” and is carried out  Not Applicable
duly authorized body of Numerator: Number of as evident in hospital records
the HCO credentialed
practitioner
Denominator: Total
number of practitioner
that should be
credentialed

b. HCO must have a % Practicing Updated licenses, valid  3 /Fully Met
system to ensure that professionals with credentials as well as  2/Partially Met
practicing professionals updated licenses and document indicating  1/Not Met
have updated licenses credentialed presence of policy/procedure  Not Applicable
and credentialed to ensure that all practicing
Formula: professionals have updated
Numerator: Number of and valid licenses
practicing professionals
with updated licenses
and credentialed
Denominator: Total
number of practicing
professionals 201 files
reviewed.

CHAPTER 10: Continuous Quality Improvement
Continuing quality improvement shall be the core business of all involved in health care.

CQI 1. The HCO has an established CQI program in line with its vision, mission, objectives and core values.
Measurable Elements
P a. The organization Availability of updated There is a written document  3 /Fully Met
develops, implements, documentation/ that shows the development  2/Partially Met
periodically reviews, materials/actual and periodic review of the  1/Not Met
maintains and practices identified in HCO’s vision, mission,  Not Applicable
documents its vision, the evidences objectives and core values.
mission, objectives and
core values.
b. There is wide Availability of updated HCO's mission, vision, core  3 /Fully Met
dissemination of documentation/ values and objectives of the  2/Partially Met
mission, vision, core materials/actual institution is visible (through  1/Not Met
values and objectives of practices identified in poster, and other materials)  Not Applicable
the institution. the evidences to the personnel, patients and
visitors. During visit/interview,
personnel are aware of the
HCO's mission, vision, core
values and objectives.
P c. All CQI activities are in Availability of updated There is a written document  3 /Fully Met
line with the hospital’s documentation/ that defines the HCO CQI  2/Partially Met
mission, vision and materials/actual activities that are in line with  1/Not Met
objectives. practices identified in the hospital’s vision, mission,  Not Applicable
the evidences and objectives.

CQI 2. The HCO shall implement an organization-wide quality improvement program.
Measurable Elements
P a. The health care Availability of updated Written quality improvement  3 /Fully Met
organization adopts documentation/ program which includes  2/Partially Met
quality management materials/actual adopted quality management  1/Not Met
principles. practices identified in principles is available  Not Applicable
the evidences
b. All employees in the % Attendance/ List or scope of CQI  3 /Fully Met
HCO participate in the Participation of programs is available  2/Partially Met
CQI program. personnel to HCO's  1/Not Met
CQI program  Not Applicable
Formula:
personnel who
participated
Denominator: Number
of personnel

P c. There is a body that Availability of documents Policies and procedures on  3 /Fully Met
ensures clinical indicating that the clinical effectiveness & audit,  2/Partially Met
governance is observed various elements of transparency, risk  1/Not Met
across different sections clinical governance are management as well as  Not Applicable
to ensure maximum observed across the documents indicating
outcome for patients different sections of the continuing education and
HCO: training of personnel (e.g.
1. Continuing certificate of training). Also
education/training on documents/materials
personnel
indicating a regularly review
2. Clinical audit
information system. Actual
3. Clinical effectiveness
4. Research and observation and interview
Development maybe conducted.
5. Transparency
(Openness)
6. Risk Management
7. Information
Management
P d. There is a designated Availability of updated List of individual/team  3 /Fully Met
individual/team for documentation/ responsible for coordinating  2/Partially Met
coordinating and materials/actual and implementing the CQI  1/Not Met
implementing the CQI. practices identified in program is identified in a  Not Applicable
the evidences "document"
P e. There is a team that Availability of updated The team responsible for  3 /Fully Met
collects and analyze documentation/ collecting and analyzing  2/Partially Met
significant performance materials/actual significant performance  1/Not Met
issues within the practices identified in issues is identified in a  Not Applicable
appropriate level, the evidences "document"
whether clinical or
administrative.

f. There is a reliable % Availability of Policies and procedures/  3 /Fully Met
system to manage risk documented review of system to manage risk and  2/Partially Met
and escalate information risk management escalate information to the  1/Not Met
on significant system and appropriate level within the  Not Applicable
performance issues to corresponding organization are identified in
the appropriate level corrective actions, if a "document"
within the organization. any
Formula:
documented risk
management system
review with
corresponding
corrective actions
Denominator: Number
of required risk
management system
review

g. The CQI program is % Compliance to the Policies and procedures on  3 /Fully Met
reviewed at predefined CQI program review the review of CQI program  2/Partially Met
intervals and schedule and are identified and are carried  1/Not Met
opportunities for availability of out as evident in the hospital  Not Applicable
improvement are documented corrective records
identified. actions/ improvement
plans

Formula:
CQI program reviews
conducted with
corresponding
corrective actions
Denominator: Number
of required CQI
program reviews

h. The management makes Availability of updated Budget and manpower  3 /Fully Met
available adequate documentation/ allocation for the CQI  2/Partially Met
resources required for materials/actual program are identified in a  1/Not Met
CQI. practices identified in "document"  Not Applicable
the evidences
P i. There is an established Availability of updated Policies and procedures on  3 /Fully Met
process for clinical audit. documentation/materials clinical audit are identified in  2/Partially Met
/actual practices a "document" and are carried  1/Not Met
identified in the out as evident in the hospital  Not Applicable
evidences. records

CQI 3. The organization identifies key indicators to monitor the structures, processes and outcomes which are used as tools for continuous
improvement.
Measurable Elements
P a. The HCO has a process Availability of updated Policies and procedures/  3 /Fully Met
for identifying documentation/ process for identifying  2/Partially Met
appropriate key materials/ actual appropriate key performance  1/Not Met
performance indicators practices identified in indicators are identified in a  Not Applicable
in both clinical and the evidences "document" and are carried
administrative areas. out as evident in the hospital
records
P b. Indicators shall be Availability of updated Policies and procedures/  3 /Fully Met
monitored regularly and documentation/ process for monitoring and  2/Partially Met
periodically to include materials/actual list of indicators are identified  1/Not Met
patient satisfaction, practices identified in in a "document" and are  Not Applicable
employee’s satisfaction, the evidences carried out as evident in the
adverse events, clinical hospital records. Availability
audits and administrative of key performance indicators
processes in both clinical and
administrative areas including
patient satisfaction,
employees’ satisfaction,
adverse events, clinical
audits and administrative
processes and appropriate
corrective actions as
indicated by the results
c. Data are documented, Availability of updated Policies and procedures for  3 /Fully Met
collected, analyzed and documentation/ documenting, collecting and  2/Partially Met
used for improvement. materials/ actual analyzing data are identified  1/Not Met
practices identified in in a "document”. Written  Not Applicable
the evidences improvement plans are
available

P d. Medical personnel % Participation of Policies and procedures  3 /Fully Met
including relevant medical personnel to the regarding personnel  2/Partially Met
personnel participate in CQI program participation in HCO's CQI  1/Not Met
this system. program are identified in a  Not Applicable
Numerator: Number of "document". Other
medical personnel who documents indicating
participated personnel's participation are
available i.e. Minutes of the
Denominator: Number of meeting, Attendance Sheet,
medical personnel
etc.
required to participate

CQI 4. There shall be a system of assessment of clinical risk for patients and service users
Measurable Elements
P a. There should be a Availability of updated Policies and procedures on  3 /Fully Met
system of identification, documents and identification, collating,  2/Partially Met
collating, analyzing and relevant materials analyzing and addressing  1/Not Met
addressing safety indicating a system of sentinel events are identified  Not Applicable
incidents, sentinel identifying, collating, in a "document". Presence of
events, adverse events analyzing safety a body responsible for the
and near misses incidents, sentinel above, minutes of their
events, adverse events meeting, reports, evaluation,
and near misses incident reports, medical
audits, and similar
documentation maybe
considered. Interview may
also be conducted.

b. The HCO must have a Availability of Policies, procedures and  3 /Fully Met
well-established documents/materials other materials/document  2/Partially Met
implemented clinical risk indicating a system of indicating the presence of a  1/Not Met
management system for clinical risk clinical risk management  Not Applicable
patients and service management that is system that is operational.
users. The clinical risk fully operational and Additional documents are
management includes, updated incident reports, minutes of
risk identification, risk the meeting of active
responsibility, risk committees (or similar body)
assessment and risk
in the HCO, such as medical
response.
audit, CQI, infection control
committee and other related
personnel
c. There shall be Presence of documents Records of safety incidents,  3 /Fully Met
processes for reporting, indicating a system of sentinel events, adverse  2/Partially Met
investigating, and reporting, investigating, events and near misses,  1/Not Met
resolving safety and resolving safety incident reports,  Not Applicable
incidents, sentinel incidents, sentinel recommendation of therapeutic
events, adverse events events, adverse events committee or similar body. The
and near misses and near misses process should include the
following: (1) Training for staff
in the reporting and
investigation methods, (2)
Means for documenting and
reporting incidents/events, (3)
Conduct of root cause analysis
(RCA), and (4) Processes for
informing patients/service
users of adverse events they
are effected by.

d. Corrective and Documents & materials Records of corrective and  3 /Fully Met
preventive actions are indicating corrective preventive actions and  2/Partially Met
taken based on analysis action are taken. analysis are available; action  1/Not Met
on clinical risk such as risks  Not Applicable
resulting from falls, nutrition,
equipment use or from long
term conditions, medical audit
report, report of therapeutic
committee or issuances of
relevant policies/ revised
procedures and guidelines
e. Results are evaluated Availability of updated Policies and procedures on  3 /Fully Met
for improvement. documentation/ the evaluation of sentinel  2/Partially Met
materials/actual event analysis results are  1/Not Met
records
CQI 5. The Healthcare organization shall implement an organization-wide training program to support quality improvement plan.
Measurable Elements
a. The Healthcare Availability of updated Training programs on quality  3 /Fully Met
organization shall documentation/ improvement are identified in  2/Partially Met
develop and implement materials/ actual a "document" and are carried  1/Not Met
training programs on practices identified in out as evident in the hospital  Not Applicable
quality improvement. the evidences records. Availability of record
on HCO's review of existing
training program on quality
improvement
b. There is a manual/ Availability of updated Manual/module for CQI  3 /Fully Met
module for CQI training. documentation/ training is available and  2/Partially Met
materials/ actual carried out as evident in the  1/Not Met
practices identified in hospital records  Not Applicable
the evidences

c. All employees are % Attendance of List of trainings are identified  3 /Fully Met
trained in the CQI employees in CQI in a "document". Training  2/Partially Met
activities. activities certificates are available in  1/Not Met
the personnel's 201 file.  Not Applicable
Formula:
employees who are
trained in the CQI
activities
Denominator: Number
of all employees

P d. There is a system for Availability of updated Policies and procedures/  3 /Fully Met
evaluation, monitoring documentation/ system on the evaluation,  2/Partially Met
and feedback based on materials/actual monitoring and feedback on  1/Not Met
the programs conducted. practices identified in the CQI training programs  Not Applicable
the evidences are identified in a "document"
records. Availability of
corrective
actions/improvement plans
based on the regular system
review/evaluation

Assessment

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Assessment

Uploaded by

Copyright:

Available Formats

ASSESSMENT TOOL

Chapter 1: Access, Assessment and Continuity of Care (AAC)

Intent of the Standard

Standards/ Track Record Assessment

PTAHF Assessment Tool 1 Rev1Iss2 1-Nov-2018

Then multiply by 100.

PTAHF Assessment Tool 2 Rev1Iss2 1-Nov-2018

PTAHF Assessment Tool 3 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 4 Rev1Iss2 1-Nov-2018

PTAHF Assessment Tool 5 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 6 Rev1Iss2 1-Nov-2018

Then Multiply by 100

PTAHF Assessment Tool 7 Rev1Iss2 1-Nov-2018

PTAHF Assessment Tool 8 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 9 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100%

PTAHF Assessment Tool 10 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 11 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 12 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 13 Rev1Iss2 1-Nov-2018

Then multiply by 100.

PTAHF Assessment Tool 14 Rev1Iss2 1-Nov-2018

Then multiply by 100.

Then multiply by 100

PTAHF Assessment Tool 15 Rev1Iss2 1-Nov-2018

Intent of the Standard

Standards/ Track Record Assessment

PTAHF Assessment Tool 16 Rev1Iss2 1-Nov-2018

Then multiply by 100.

PTAHF Assessment Tool 17 Rev1Iss2 1-Nov-2018

Then multiply by 100.

Denominator: Total 1. Look-Alike, Sound-Alike

Then multiply by 100.

PTAHF Assessment Tool 18 Rev1Iss2 1-Nov-2018

PTAHF Assessment Tool 19 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 20 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 21 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 22 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 23 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100

PTAHF Assessment Tool 24 Rev1Iss2 1-Nov-2018

Then multiply by 100

PTAHF Assessment Tool 25 Rev1Iss2 1-Nov-2018

PTAHF Assessment Tool 26 Rev1Iss2 1-Nov-2018

Then multiply by 100

Then multiply by 100