Report Year: 2020

2021
2022

A. STANDARDS ON MANAGEMENT, STRUCTURE, FUNCTIONS AND

RESPONSIBILITIES

IPC Committee

Is there an Infection Prevention and Control committee under the Office of the
A1.
Chief/ Director of the Health Facility?
Yes
No

A1_1. Does the IPC Committee formulate and update IPC policies and guidelines?
Yes
No

Does the IPC Committee disseminate information regarding IPC policies and
A1_2. guidelines?
Yes
No

Does the IPC Committee organize and provide trainings and guidance to the IPC
A1_3. Unit and all health personnel?
Yes
No

A1_4. How often does the IPC Committee meet?

More than once a month
Once a month
Quarterly
Twice a year
Once a year
IPC Committee Members

A2. Does the IPC Committee have a designated chairperson?

Yes
No

A2_1. How many are the core members of the IPC Committee?

A2_2. How many are the auxillary members of the IPC Committee?

IPC Unit

Is there an infeciton control management structure (IPC Unit) under the Office of
A3.
Chief/Director of the Health Facility?
Yes
No

A3_1. Does the IPC Unit have a designated head/manager?

Yes
No

A3_2. What is the IPC nurse to hospital bed ratio? (Answer in this format 1:XXX)
Yes
1:
100
No

A3_3. Does the IPC Unit have an IPCSO?

Yes
No

A3_4. Are there sufficient resources for the said unit?

Yes
No

IPCAT
 Does the health facility have an Infection Prevention and Control Assessment Tool
A4.
(IPCAT) containing guidelines on core components of IPC programmes?
Yes
No

B. STANDARDS ON GUIDELINES, POLICIES AND PROCEDURES

B2. Does the facility have guidelines, policies, and procedures for IPC protocols?
Yes
No

B2_1. For Hand hygiene

Yes
No

B2_2. For Standard and transmission-based precautions

Yes
No

B2_3. For Triage of infectious patients

Yes
No

B2_4. For Aseptic techniques

Yes
No

B2_5. For cleaning, disinfection and sterilization of medical devices and equipment
Yes
No

B2_6. Environmental cleaning and disinfection

Y
es

B2_7. Engineering controls relative to COVID-19

 Y
es

B2_7. Engineering controls relative to COVID-19

 Yes
No

B2_8. Healthcare waste management

Yes
No

B2_9. Safe injection practicies

Yes
No

Healthcare worker protection (occupational health and safety, including post-

B2_10. exposure prophylaxis and vaccination)
Yes
No

B2_11. Healthcare worker orientation on IPC protocols and zoning

Yes
No

B2_12. Prevention of transmission of highly communicable infections

Yes
No

Are there infection control guidelines, policies, and procedures for specific patient
B3. care areas, hospital auxillary service departments/units?
Yes
No

Microbiology Sections
Do all microbiology sections have documents that are readily available to all users
B4. of the Microbiology section, describing the organizational structure, scope of
laboratory services, standard operating procedures and working instructions?

Yes
No
 Do all microbiology laboratories follow a standard protocol on proper collection,
B5. handling, and transport of laboratory specimens?
Yes
No
Do all microbiology sections of the Clinical Laboratory have an efficient and
B6. effective Biosafety Program Management (BPM) to protect its laboratory personnel
from exposure to infectious agents?
Yes
No

Are the Biosecurity Programs instituted to prevent loss, theft or misuse of

B7. microorganisms, biological materials, and research-related information?
Yes
No

C. INFECTION PREVENTION AND CONTROL EDUCATION AND TRAINING

Are there adequate materials, updated tools, and allocated budget for IPC
C1.
education and training?
Yes
No

C2. Does the facility have training program for IPC-related topics?
Yes
No

C2_1. For Basic Epidemiology of Healthcare-Associated Infection

Yes
No

C2_2. For Hand Hygiene

Yes
No

C2_3. For Isolation Precaution

Yes
 N

C2_4. For Decontamination, Disinfection and Sterilization

Yes
No

C2_5. For Care of the Environment and Hospital Waste Management

Yes
No

C2_6. For Needle Stick Injuries and Blood and Body Fluid Exposures
Yes
No

C2_7. For proper PPE donning and doffing

Yes
No

C2_8. For Healthcare worker Infection Risks, Prevention and Immunization

Yes
No

C2_9. For Tuberculosis, HIV and Hepatitis B

Yes
No

C2_10. For Emerging and Re-emerging Infections and Pathogens

Yes
No

Are there institutional materials available for the education and training for
C3. targeted medical and clinical staff?

Yes
No

C3_1. For Healthcare-Associated Infections

Yes
 N

C2_4. For Decontamination, Disinfection and Sterilization

Yes
No

Yes
No

C3_1. For Healthcare-Associated Infections

Yes
 N

C3_2. For Ventilator-associated Pneumonia (VAP)

Yes
No

C3_3. For Central-Line Associated Bloodstream Infections (CLABSI)

Yes
No

C3_4. For Catheter-Associated Urinary Tract Infections (CAUTI)

Yes
No

C3_5. For Surgical Site Infections (SSI)

Yes
No

C3_6. For Antimicrobial Stewardship Program

Yes
No

C3_7. For Outbreak Management

Yes
No

C3_8. For Surveillance

Yes
No

D. STANDARDS ON HEALTHCARE- ASSOCIATED INFECTION SURVEILLANCE

D1. Is there a surveillance process for Healthcare-associated Infection?

Yes
No
D2. Is there a standard surveillace form/tool being used?
Yes
No

D3. How often is the result of the surveillance reported?

more than 2x a year
once a year
every 2 years

D4. Does the IPCU develop, implement, and monitor antimicrobial stewardship?
Yes
No

E. STANDARDS ON MULTIMODAL STRATEGIES

Is multimodal strategy being used in the implementation if the IPC programs and
E1. activities?
Yes
No

Are there adequate resources allocated to support the implementation of IPC

E2.
programs and activities?
Yes
No

F. STANDARDS ON MONITORING, AUDIT, AND FEEDBACK OF

INFECTION PREVENTION AND CONTROL

Is there a well-defined monitoring plan with clear objectives, targets, and activities
F1. focused on IPC indicators based on priorities identified by the facility?
Yes
No

F1_1. Hand hygiene compliance monitoring

Yes
 No

F1_2. Rational use of personal protective equipment

Yes
No

F1_3. Safe injection practices

Yes
No

F1_4. Cleaning and disinfection monitoring

Yes
No

Is timely and regular feedback of auditing reports on the state of IPC activities or
F2. performance provided to management, committees, and staff?
Yes
No

F3. Are IPC tools for systematic data collection available?

Yes
No

G. STANDARDS ON WORKLOAD, STAFFING, AND BED OCCUPANCY AT

THE FACILITY LEVEL

G1. What is the hospital's current bed occupancy rate?

G1_1. Authorized bed capacity based on DOH license is followed

Y
es

G1_2. One-to-one (1:1) ratio of patient to bed

Yes
No
G1_3. Presence of surge capacity management contingency
plan
Yes

G2. Is appropriate staffing based on patient workload implemented?

Yes
No

G2_1. Current available organizational structure and staffing standards being followed
Yes
No

G2_2. Staffing plan based on appropriate staff-to-patient ratio available

Yes
No

G2_3. There is at least one (1) Infection Control Doctor

Yes
No

G2_4. There is at least one (1) Infection Control Nurse

Yes
No

G2_5. Ratio of at least one (1) IPC Nurse for every 100 hospital beds
Yes
No

Is there a policy or plan to reduce overcrowding by optimizing operational

G3. processes?
Yes
No

G3_1. Established system for patient flow such as unidirectional foot traffic

Y
es
G3_2. Appropriate triage system at the ER and
OPD
Yes

G3_3. Patient navigation through referral

Yes
No

H. STANDARDS ON BUILD ENVIRONMENT, MATERIALS, AND

EQUIPMENT FOR IPC

Is safe and sufficient quantity of water supply from an improved source available at
H1. all times?
Yes
No

Is there a minimum of two (2) functional improved sanitation facilities available on-
H2. site, one for patient and one for staff?
Yes
No

Is there a safe management of sewage/fecal waste through use of well-managed

H2_1. septic tanks and leach fileds, disposal into functioning sewers or off-site removal?
Yes
No
Is there a minimum of two (2) functional, improved sanitation facilities for OPD
H2_2. and one (1) per 20 beds for inpatient wards, equipped with menstrual hygiene
facilities?
Yes
No

Is there an additional sanitation facility with at least one (1) toilet designated for
H2_3. women/girls to manage menstrual hygiene?

Y
es
H2_4. Is there at least one (1) toilet for people with physical
disabilities
Yes

Are there sanitation facilities adapted for infants and children, segregated by sex
H2_5. for older children?
Yes
No

Is there available functional hand hygiene facilities at points of care (with soap,
H3. water, and single-use towels or alcohol-based hand rub)?
Yes
No

Are there hand hygiene promotion materials that clearly visible and
H3_1. understandable at key places?
Yes
No

H3_2. Is 1:10 sink to bed ratio being followed?

Yes
No
Is there sufficient and appropriately labelled bins to allow for health care waste
H4. segregation (including needle and sharps disposal) in close proximity to waste
generation points?
Yes
No

H5. Are the hospital beds positioned at least one (1) meter apart?
Yes
No

Are isolation rooms provided for highly communicable or yet unknown new
H6.

infections
?
Yes
H Is there adequate ventilation through functional windows and doors?
Yes
No

H8. Is there reliable power source 24/7 with available back-up?

Yes
No

Is there available personal protective equipment at all times and in sufficient

H9. quantity for all health care workers?
Yes
No