Self Assessment Tool

The PhilCAT/ DOH Certification Self-assessment and Survey Tool
PhilCAT CERTIFICATION STANDARDS

Survey Criterion Evidence of Progress and Achievements DOTS Surveyors' Comments Survey
Item (Completed by TB DOTS Center) Center Team
Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
1. The TB DOTS center is TB Dots facility is within the Rural Health 4
easily located and Unit area.
patients have convenient
and safe access to the
center.
This standard will be achieved when:
1.1. There is appropriate Inplaced signages on the road leading to the 4
signage bearing the name TB Dots facility.
of the TB DOTS center to
assist patients accessing
the center.
1.2. Physical access is Adequate space and easy to locate the area. 4
appropriate for the needs
of patients.
1.3. Entrances and exits are Separate entry and exit from the RHU. 2
clearly marked and free of
obstruction and other
hazardous conditions.
1.4. There are resources to Inplaced signages and information at the 4
inform patients of the facility.
daily and hourly schedule
of TB DOTS services,
ensure the quality of
patient waiting.
*Rating scale: 1
1. Non Achievement - The requirements of standard / criterion are not met.
2. Low Achievement - The requirements of standard / criterion are scarcely met
3. Moderate Achievement - The requirements of the standard / criterion are generally met in most circumstances.
4. Extensive Achievement - The requirements of the standard / criterion are fully met in the majority of circumstances and have been for some time.
OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

(To be completed by survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with
information provided by the TB DOTS center.)
Goal: The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
Standard 1: The TB DOTS center is easily located and patients have convenient and safe access to the center.
Rating (please tick appropriate overall rating for this standard)
Non- Low Moderate Extensive

Achievement Achievement Achievement Achievement
*Rating scale: 2

Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients
2. The TB DOTS Center 4
provides facilities for the A consultation and waiting area is provided.
comfort and privacy of
its patients and staff.
2.1. The TB DOTS center A personnel in charge of the center 4
maintains a clean and maintaining it’s cleanliness and orderliness.
wholesome environment
within and immediately
outside its premises.
2.2 There are resources and Patients are on scheduled visit. Walk-ins are 4
processes to ensure the also entertained promptly.
quality of patient waiting.
2.3 The lighting in each area The center is an open area at the back of 4
of the center is the RHU.
appropriate for the
assigned purpose of the
area.
2.4 The privacy of the staff- Privacy of the patient’s records are assured. 4
patient encounter is
assured.
*Rating scale: 3

Standard 2: The TB DOTS center provides for the privacy and comfort of its patients and staff.

*Rating scale: 4

Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
3. The TB DOTS center It is safe from any sharps and falling debris, 4
provides for the safety of contaminations.
its patients and staff.
3.1 There is adequate clean A wash area and a comfort room is provided. 4
water for personal hygiene
and sanitation purposes.
3.2 The TB DOTS center Maintained cleanliness. Decontaminations 4
maintains appropriate and harmful objects through personnel
levels of cleanliness and assigned.
antisepsis of all physical
areas, equipment and
instruments.
3.3 General waste, sharps, Appropriate segregations of wastes and 4
pathological and sharps are ensured.
infectious waste,
pharmaceutical and
chemical wastes are
appropriately segregated,
safely handled and
disposed of according to
accepted safe disposal
practices.
3.4 TB drugs are securely A cabinet for TB drugs is provided. 4
stored under appropriate
storage conditions.
3.5 Sputum and other body Sputum collection area is provided. 4
fluids are collected in a
*Rating scale: 5

Rating* Rating*
safe and hygienic way.
3.6 There are documented, Health staff assigned at TB Dots are well- 4
disseminated and trained through NTP
implemented procedures
to identify and address the
risks of contamination of
staff and patients from
sources of infectious
diseases.
Standard 3: The TB DOTS center provides for the safety of its patients and staff.

*Rating scale: 6

Rating* Rating*
Goal Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB to
rehabilitation.
4. All patients undergo a Complete physical evaluation and clinical 4
comprehensive assessment is done on every patient.
assessment to facilitate
the planning and
delivery of treatment.
4.1 Appropriate professionals TB coordinator, medical technologist and 4
obtain and document the physician evaluates the patient and dig out
relevant history for each history.
patient.
4.2 A physician completes Physician diagnosed each patient through 4
and documents the history, clinical evaluation and sputum
relevant physical analysis. (gen X / X-ray)
examination for each
patient.
*Rating scale: 7

Goal: Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB to
rehabilitation.
Standard 4: Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB
to rehabilitation.

*Rating scale: 8

Rating* Rating*
rehabilitation.
5. All patients have Medical technologist is a regular personnel 4
continuous access to and on a daily duty.
accurate and reliable TB
diagnostic tests.
5.1 All patients undergo Regular medical technologist 4
sputum microscopy by a
qualified and trained
microscopist.
5.1.1 The TB DOTS With policies and procedures implemented 4

center plans and with a regular medical technologist
implements policies and personnel/staff.
procedures for assuring
the quality of sputum
microscopy results.
*Rating scale: 9

Rating* Rating*
5.1.2 If sputum Referred to TB Dots Caraga for GenX.
microscopy facilities are
not available in the TB
DOTS center, policies
and procedures for
referring patients to
accessible centers are
implemented and
monitored for
effectiveness.
5.1.3 External providers Referring unit is at TB Dots Caraga. 4
of sputum microscopy are
contracted based on
policies and procedures
that include accreditation
status and the presence of
quality control systems.
5.2 Policies and procedures Referred patients are followed up and 4
for referring patients to monitored of their results x-rays are done at
accredited and accessible any accredited facilities.
X-ray facilities are
implemented and
monitored for
effectiveness.
5.3 Policies and procedures Patients are referred to TB Dots Caraga for 4
for referring patients to an easy tracing and follow up of results
appropriately constituted
and accessible TB
*Rating scale: 10

Rating* Rating*
Diagnostic Committee are
implemented and
monitored for
effectiveness.

rehabilitation.
Standard 5: All patients have continuous access to accurate and reliable TB diagnostic tests.

*Rating scale: 11

Rating* Rating*
rehabilitation.
6. A care plan is developed Individual record for every patient provided. 4
and followed for all
patients.
6.1 All treatment is consistent Treatment is in line with NTP guidelines 4
with the National
Tuberculosis Program
guidelines.
6.2 Flow charts of patient Every diagnostics and treatment procedures 4
management from entry to are in line with the NTP guidelines.
separation are used to
facilitate quality care and
are accessible to patients
and staff.
*Rating scale: 12

Rating* Rating*
6.3 DOTS partners are Every criteria, procedures and diagnostics are 4
selected and assigned consistent with NTP guidelines.
based on predetermined
criteria and procedures
and these are accessible to
patients and staff.

Rating* Rating*
6.4 Education is provided to Proper IEC and health promotions are given 4
all patients to help them to every patients diagnosed and treated.
understand their medical
condition and prognosis
and to encourage their
adherence to the treatment
regimen and health
promotion / illness
prevention activities.
6.5 An appropriately An individual record of each patient is 4
comprehensive evaluation provided.
of the patient's clinical
*Rating scale: 13
progress is made
and documented at each
visit.
6.6 Policies and procedures Health partners, (BHWs, immediate families) 4
for detecting treatment are included in every treatment.
defaulters and getting
them back into treatment
are implemented and
monitored for
effectiveness.
rehabilitation.
Standard 6: A care plan is developed and followed for all patients.
*Rating scale: 14


Rating* Rating*
rehabilitation.
7 Patients have continuous Every TB medications are assured of 4
access to safe and availability of stocks and efficacy.
effective anti-TB
medications throughout
the duration of their
treatment.
7.1 The TB DOTS Center has A health budget of municipality is provided 4
developed and (P 100,000.00)
implemented policies and
procedures for assuring a
continuous supply of TB
drugs to all its patients for
the entire six months
*Rating scale: 15
duration of
therapy.
7.2 The TB DOTS center Maintained buffer stocks of anti-TB drugs. 3
maintains an appropriate
buffer stock of anti-TB
medications.
7.3 The TB DOTS Center has Anti TB drugs are placed in a safety cabinet, 4
developed and on a TB room.
implemented policies and
procedures for assuring the
quality and safety of its
TB drugs.
rehabilitation.
Standard 7: Patients have continuous access to safe and effective anti-TB medications throughout the duration of their treatment.
*Rating scale: 16


Rating* Rating*
Goal The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB
DOTS center.
8. Policies and procedures Every patients are followed up and 4
for providing care to monitored by a HCW and BHWs in every
patients are developed, barangay.
disseminated,
implemented and
monitored for
effectiveness.
8.1 The TB DOTS center's TB Dots center are consistent with the NTP 4
policies and procedures guidelines and standards.
are consistent with the
organization's goals,
*Rating scale: 17

Rating* Rating*
statutory requirements,
accepted standards, and
the TB DOTS center's
community
responsibilities.
8.2 Policies and procedures Sole referral facility is TB Dots Caraga. For 4
for patient referral to other quality assurance and easy follow-up.
services are implemented
and monitored for
effectiveness.

Survey Survey Item Survey Item Survey Survey Item Survey
Item Item Item
8.3 Patient default rates are Every defaulters are followed up and 4
monitored and policies and encouraged to continue treatment and
procedures are developed assured of efficacy and safety of treatment.
and implemented to
improve default rates. The
policies and procedures
are monitored for
effectiveness.
8.4 Policies and procedures TB Dots center is in partnership within ILHZ 4
*Rating scale: 18
for identifying and municipality and TB Dots Caraga.

working with external
groups in providing DOTS
services are developed,
implemented and
monitored for
effectiveness.
Goal: The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB DOTS
center.
Standard 8: Policies and procedures for providing care to patients are developed, disseminated, implemented and monitored for effectiveness.

*Rating scale: 19

Rating* Rating*
Goal The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB
DOTS center.
9. Policies and procedures Every patient is of individual record and 4
for managing patient history with appropriate treatment category.
information are
developed, disseminated,
implemented and
monitored for
effectiveness.
9.1 Each patient is uniquely Every patient has their own individual 4
identified from entry and information or data and record.
throughout the course of
management.
9.2 The TB DOTS center Database are updated and accessible. 4
maintains a database of
patient records and related
registries and enables the
staff to easily access these
databases.
*Rating scale: 20

Rating* Rating*
9.3 Policies and procedures 4
for ensuring the security Every patient is assured of data
and confidentiality of confidentiality.
patient information are
developed, implemented
and monitored for
effectiveness.
9.4 The TB DOTS center All TB DOTS record are reported and 4
submits complete and updated accurately
accurate reports to all
relevant agencies in a
timely manner.
9.5 The TB DOTS center Every patient is monitored of progress and 4
regularly reviews its improvement and compliance
records to assess and
improve performance.
*Rating scale: 21

Goal: The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB DOTS
center.
Standard 9: Policies and procedures for managing patient information are developed, disseminated, implemented and monitored for effectiveness.
*Rating scale: 22


Rating* Rating*
Goal The TB DOTS center staff provide efficient and competent DOTS services.
10. The TB DOTS Center A medical technologist and a smearer are 4
has an adequate number available
of qualified personnel A HCW assigned in every brgy.
skilled in providing
DOTS services.

10.1 An adequate number of A HCW assigned in every Barangay for 4
qualified and appropriately update and monitoring.
trained personnel provide
and are accountable for the
following functions:
*Rating scale: 23

Rating* Rating*
10.1.1 Leadership, TB Dots center are managed by the
management and overall physician, medtech and TB coordinator 4
responsibility for the
operations, resources and
performance of the TB
DOTS center
10.1.2 Clinical patient care Sputum exam available 4
services genX and Xray-referred.
10.1.3 Diagnostic services, Medical technologist doing sputum 4
including sputum microscopy.
microscopy
10.1.4 Drug management In Coordination with NTP guidelines. 4
10.1.5 Information IEC materials provided, TB posters posted. 4
management
10.1.6 Financial Local Health Budget provided. 4
management
10.2 Personnel follow clear job Personnel are assigned of every job/ 4
descriptions, responsibilities.
responsibilities and
accountabilities.
10.3 All personnel are All personnel are trained for quality services 4
responsible for safety in and management.
the workplace and the
quality of the service they
deliver.
*Rating scale: 24

Rating* Rating*
10.4 Personnel receive up to Personnel are trained on every TB programs 4
date training based on (virtually and face to face).
training needs assessment.

Goal: The TB DOTS center staff provide efficient and competent DOTS services.
Standard 10: The TB DOTS Center has an adequate number of qualified personnel skilled in providing DOTS services.

*Rating scale: 25

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The PhilCAT/ DOH Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

5.1.1 The TB DOTS With policies and procedures implemented 4

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

for identifying and municipality and TB Dots Caraga.

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

This standard will be achieved when:

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

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