STA.

ROSA HOSPITAL
AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
Page No.:

SRHMC-DOH-01-001

Physical Examination

1.1.1.b.2
Accounting
1.1.1.b.3
Billing

1.1.1.c
Purchasing

1.1.1.d
Property
1.1.1.e
Linen
1.1.1.f
Housekeepin
g
1.1.1.g
Security

Quality Manual
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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Hospital Administration
Staffing Plan
Recruitment and Selection
Hiring/Appointment
Orientation and Staff Development
Continuing education, and training
Performance Evaluation
1.1.1
Rotation/Transfer
Human
Succession Plan
Resources
Merit, Promotion, Awards &
Incentives
Resignation, Termination &
Retirement

1.1.1.b.1
Accounting

DOH Benchbook

Systematic recording of all financial

transactions
Preparation of financial statements
and relevant reports
Maintenance and Safekeeping of
Books of Accounts
Consolidation and preparation of the
Budget Proposal, Work and Financial/
Operational Plans
Billing of patients and Processing of
claims
Requisition, purchase, issuance and
inventory
Disposal of non-functional
equipment, instruments, supplies,
expired drugs and medicines and
reagents are in place
Receipt, storage, issuance and
conduct of inventory

EVIDENCE

Record of schedule of duties

Appointment/employment
Contract, if valid

Updated health certificate

Orientation plan/program of new
employees implemented

Implementation and monitoring by the

hospital staff concerned

Approved Work and Financial Plan and

its implementation

Proof of transactions

Cleaning and washing of soiled linens

Housekeeping
Checking for internal and external
customers including use of visitors

List of Housekeeping Supplies

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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SRHMC-DOH-01-001

DOH Benchbook

Quality Manual
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pass
Patient transport to and from the
facility

1.1.1.h
NSD (ER)

24 hour availability of ambulance for

ready use
Compliance to A.O. 2010-0003
(National Policy on Ambulance Use
and Services)

1.1.1.i
Accounting
Human
Resources

1.1.1.i.a
Medical
Records

Organized system of recording,

processing, analyzing, maintaining
and safekeeping of all patients'
records

Patient classification according to

their capacity to pay
Continuity of care
1.1.1.j
Medical
Social
Services

1.1.1.k
Nutrition and
Dietetics
1.1.1.l
Pharmacy

Counseling of patients/clients and

their families
Records of pre-admission and predischarge assessment, and
discharge plan

Nutrition and Dietetics

Pharmacy

With appropriate manpower,

equipment and supplies during patient
transport
If contracted out; note specifications in
contract or MOA
Logbook on transport of
patients/clients by ambulance to and
from the facility
Comprehensive plan of systematic
management of data and research for
the improvement of acquisition,
utilization of finances, assets and
development of human resources,
operating systems and procedures
ICD-10 reference books with additional
ICD-10 modification
Logbooks on:
Admission
OR
DR
ER
OPD
Available contract or MOA with DSWD
or the LGU whenever applicable
(for private hospitals) Allocation of not
less than 10% of its Authorized bed
capacity as charity beds.
Compliance to RA 9439, An Act
Prohibiting the Detention of Patients in
Hospitals and Medical Clinics on
Grounds of Nonpayment of Hospital
Bills or Medical Expenses, (IRR, AO No.
2008-0001)
If contracted out; note specifications in
contract or MOA
There shall be 24 hours, 7 days a week
provision of safe, affordable and
efficacious drugs and medicines in
accordance with the Generics+ Act,

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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No.:
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SRHMC-DOH-01-001

DOH Benchbook

Quality Manual
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PNDF and DOH policies, rules and
regulations.

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
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SRHMC-DOH-01-001

Quality Manual
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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Patients Rights and Organizational Ethics
Patients Rights
Right to Care
2.1.1
Right to Consent
Freedom of Choice
NSD
Right of Incompetent
Individuals
Determining and Prioritizing Patients
2.1.2
clinical needs
Administratio Determining and Prioritizing
n
Admissibility of patients
Identifying clinical services that will
NSD
best address patients clinical needs.
2.2.1.a
Facilities &
Maintenance
2.2.1.b
Safe and Efficient Direction of
Facilities &
Patients, their Families and Visitors
Maintenance
and Staff Traffic
2.2.1.c
Facilities &
Maintenance
2.2.2.a
NSD

Correctly identifying patients by their

chart

2.2.3.a
NSD

Conducting initial assessment in an

efficient and systematic manner

2.2.3.b
NSD
2.2.3.c
NSD

DOH Benchbook

Pre-operative assessment and/of

cardiopulmonary clearance
Pre-anesthetic assessment

EVIDENCE

All patient charts have signed consent.

Responsibilites of patients in their care
are in the chart.

List of services available

Presence of entrances and exits that

are readily accessible and free from
obstruction.
Presence of directional signages to
locate service areas.
Presence of alternative passageways
(ramps and elevators) that are
prominently marked and free from
obstruction for patients with special
needs.
Specific patient chart for each patient
that is readily accessible to authorized
personnel.
All patients charts have
comprehensive history and PE within
24 hours from admission:
Present Illness
Review of Systems
Past Medical History
Family History
Personal History
All patient charts have progress notes
by doctors.
Pre-operative anesthetic evaluation in
the patient chart. Pre-operative
assessment should be done for

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
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SRHMC-DOH-01-001

Standard performance and quality

control of diagnostic examinations

2.3.2.a &
2.3.2.e
NSD

Drug Administration

2.3.2.c 2.3.2.d
NSD
2.4.1
NSD
2.5.1.a
Administratio
n
All
Departments

2.5.1.a
Medical
Services

2.5.1.c
Administratio
n

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2.3.1
BioMed
Cardio-Pulmo
Laboratory
Radiology

2.3.2.b
HRD

DOH Benchbook

Training of Professionals who

administer drugs
Supervision of Professionals who
administer drugs
Evaluation of Professionals who
administer drugs
Review of prescription orders
Verification of prescriptions and
orders

patients requiring more than local

Monitoring
anesthesia.reports, e.g..utilization
review of diagnostics exams done,
audit reports, manual of procedures,
or DOH monitoring reports e.g.. Quality
control diagnostic reports (QC reports
on softwares, calibration of diagnostic
equipment, film reject analysis, etc.)
All drugs are administered in a timely,
safe, appropriate and controlled
manner to the right patient
All charts have proper documentation
of drug administration

All doctors, dentists, nurses and

pharmacists have updated licenses

Proof that the prescriptions or orders

are verified before medications are
administered.
All charts have discharge plans
Strategically Posted Vision and Mission
of all the Services
Approved Manual of Operations and/ or
Written Policies, Guidelines and
Procedures on Clinical Services Offered
Strategically Posted Functional and
Organizational Chart with Photos
Showing Names and Relationship by
Positions
Proof of the creation of all committees
within the organization which includes
the terms of reference for membership
Presence of evaluation and monitoring
activities to assess management and
organizational performance

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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No.:
Page No.:

SRHMC-DOH-01-001
6 of 15

DOH Benchbook

Quality Manual
Table of Contents

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
Page No.:

SRHMC-DOH-01-001

DOH Benchbook

Quality Manual
Table of Contents

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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Human Resources Management/Planning
3.1.1.a
Human
Hiring of Staff
Resources
3.1.1.a
Credentialing, and privileging of the
Medical
medical staff
Services
3.1.1.b
Human
Resources
NSD

EVIDENCE

Staff to bed ratio for licensed doctors,

registered nurses and
midwives/nursing aides follow the DOH
prescribed ratio.

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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No.:
Page No.:

SRHMC-DOH-01-001

DOH Benchbook

Quality Manual
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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Data Collection, Aggregation and Use
Records Management

Systematic record filing, retrieval.

retention, storage, safekeeping and
maintenance and disposal.

4.2.1.a
Medical
Records

Records management for the entire

hospital and maintain privacy,
accuracy, and prevent loss and
destruction of files

EVIDENCE

Patients chart contents include the

following:
Doctors Progress Notes
Informed Consent
Problem List
Medication and Treatment
Record
Laboratory and X-ray Reports
Dietary Assessment Clinical and
Graphic Record of Vital Signs
(TPR sheet)
Personal History and Physical
Examination records
Newborn Record and Physical
Maturity Rating, if warranted
Doctors Progress Notes
Medication and Treatment
Record
Laboratory and X-ray Reports
Dietary Assessment Nurses
Progress Notes
Records of Transfer/Referral to
another Physician or Health
Facility
Inpatient Referral/Consultation
Notes of Other Physicians
Final Diagnosis
Advance Directive, if any

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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No.:
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SRHMC-DOH-01-001

6.1.1.e &
7.1.3
BioMed
Cardio-Pulmo
Laboratory
Radiology
ER/ICU/ORDR/

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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Safe Practice and Environment
Patient and Staff Safety
6.1.1.a
Administratio
n
Hospital Wide Safety Plan
Physical Environment Safety
Waste Management Program
Hospital Emergency and Disaster
6.1.1.b
Preparedness
Bio Safety
Earthquake Management
Committee
Fire Safety
Radiation Safety
Utility System Management
Facility Security Measures
6.1.1.c
Safe and efficient use of medical
Bio Safety
equipment
Committee

6.1.1.d
Infection
Control
Committee
Facilities &
Maintenance

DOH Benchbook

EVIDENCE

The organizational environment

complies with structural standards and
safety codes as prescribed by law.

Implementation of DOH AO#2008-0021

on the gradual phase-out of mercury
Water safety - water analysis results for
the past 6 months
Exit plans, plans for earthquake and
other disasters
MOA/Contract of outsourced services
for waste management
Waste disposal system, segregation of
waste, proper labeling of waste
receptacles
Storage and disposal of reagents
Quality control programs and corrective
and preventive maintenance programs
Record of disposal of radiologic wastes
Preventive and corrective maintenance
logbook
Film reject analysis test results
Operating manual
Preventive and corrective maintenance
logbook
Qualifications of staff handling medical
equipment (Certificate of Training,
attendance sheet, Certificate of
Attendance, diploma, citation)

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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MOA/Contract for outsourced services

NICU
Maintenance

Adequate space
Adequate lighting (lights are working,
lighting is adequate enough for
conduct of
general activities)
Adequate ventilation

6.1.1.f
Facilities &
Maintenance
6.1.1.g
Risk
Management
Committee

DOH Benchbook

Risk identification, assessment and

control
Personal Protective Equipment

Presence of an appointed personnel in

charge of security.

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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SRHMC-DOH-01-001

7.1.2
Facilities &
Maintenance
7.1.4
Facilities &
Maintenance
Property

Quality Manual
Table of Contents

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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Maintenance of the Environment of Care
7.1.1
Infection
Control
Committee
Pharmacy
Medical
Services
TQAPC

DOH Benchbook

Prevention and control of nosocomial

infections

Reporting and monitoring of adverse

effects

EVIDENCE
Presence of incident reporting
system/sentinel event monitoring
system (which may include nosocomial
infections, unexpected deaths, adverse
drug reactions, flood transfusion
reactions, falls, etc).
Minutes of Leadership meeting
Incident/sentinel event reports or communications/memoranda/orders or
proceedings on sentinel events
Presence of generator/emergency light,
water system, adequate ventilation or
air conditioning.
Preventive and corrective maintenance
logbooks for generator/ emergency
light/ water tanks/ airconditioners .
Operating manual of generators, air
conditioners and other non-medical
equipment.

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
Page No.:

SRHMC-DOH-01-001

POLICY AND PROCEDURE

8.1.3.a
Infection
Control
Committee

8.1.3.b
Infection
Control
Committee

8.1.4

Table of Contents

EVIDENCE
Proof of Designation
ICC Monthly Reports (Jan - Sep 2015)
ICC Activities 2015
ICC Minutes of Meetings 2015
Healthcare Associated Infection (HAI)
Statistics 2015

8.1.1.a
Infection
Control
Committee

8.1.2.a &
8.1.2.b
Infection
Control
Committee
8.1.2.c
Infection
Control
Committee

Quality Manual

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CODE /
DEPARTMENT
Infection Control

8.1.1.b
Infection
Control
Committee

DOH Benchbook

Prevention and Control of Healthcare

Associated Infection
Rational Antimicrobial Use Based on
Antibiogram
Hand Hygiene
Personal Protective Equipment
Isolation and Standard Precaution
Isolation and Case Containment of
Healthcare Associated Infection
Programs for Protection of Hospital
Personnel

Asepsis
Prevention and Treatment of Needle
stick, Sharps Injuries and Exposure to
Blood and Body Fluids
Proper Handling and Safe Disposal of
Sharps and Needles
Isolation and Standard Precaution
Programs for Protection of Hospital
Personnel
Personal Protective Equipment
Patient Admission, Referral, Isolation
and Case Reporting of Highly
Transmissible and Notifiable
Diaseases
Hand Hygiene
Environmental Care
Healthcare Waste Management
Recycling and Reuse of Equipment
Cleaning, Disinfecting and Sterilizing

Certificate of Trainings

Infection Control Outbreak Incident

Report

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

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Infection
Control
Committee

8.1.5
Infection
Control
Committee

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of Equipment, Instruments and
Supplies
Decontamination, Disinfection and
Sterilization of Specific Medical
Equipment and Area
Housekeeping Procedure in Specific
Patient Areas
Reporting of Infections to Personnel
and Public Health Agencies
Hospital Disease Surveillance and
Reporting Systems

PIDSR Reports
STI Reports
SPEED Reports

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
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SRHMC-DOH-01-001

Quality Manual
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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Energy and Waste Management

9.1.1
Administratio
n

Safe Re-use of item

9.1.2
Waste
Management
Committee/
Bio Safety
Committee

DOH Benchbook

Reduction and Recycling in

compliance with RA 9003 and DOH
guidelines

EVIDENCE
Presence of licenses/permits/
clearances from pertinent regulatory
agencies implementing among others
the following: RA 9003, RA 6969, RA
275, PD 1586 DOH Hospital Waste
Management Manual, RA 8749 (Clean
Air Act)
Issuances - memos, guidelines on
waste disposal
Contracts with waste handlers or
disposal contractors, (if applicable)
Hospital policy that conforms to the
joint DOH-DENR circular on waste
management for LGUs
Waste Segregation
Proper labeling of waste receptacles
Recyclable waste staging areas
Proper management of temporary
storage areas prior to hauling for
disposal.

STA. ROSA HOSPITAL

AND MEDICAL CENTER
RSBS Blvd., San Lorenzo South, Balibago,
City of Sta. Rosa, Laguna, Philippines, 4026
(049) 837-0911 / (02) 520-8421 / Telefax:(049) 420-6045

Document
No.:
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SRHMC-DOH-01-001

10.1.2
TQAPC

Quality Manual
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CODE /
POLICY AND PROCEDURE
DEPARTMENT
Improving Performance
10.1.1
TQAPC

DOH Benchbook

Creating the Quality Improvement

Program

EVIDENCE

Proof of Designation
TQAPC Minutes of Meetings 2015
Patient satisfaction survey results
(January-May 2015)