Tarlac Provincial Hospital 2014 Manual New

TARLAC PROVINCIAL HOSPITAL (OVERVIEW) I. VISION: A medical center for the delivery of excellent hospital and health care services, training, teaching and research II.

MISSION: (1) To provide accessible, affordable and adequate quality health services. (2) To train and develop competent, dedicated, humane and ethical professional health workers. (3) To develop a well dynamic networking system with other government and non-government health organization. (4) To provide to its clientele clean and green environment and physical facilities by adopting measures to make the hospital well ventilated, with well-maintained buildings, well equipped for basic services, safe and clean and properly managed waste disposal. (5) To be a training and clinical research center. III. GOALS To provide sustainable short term and long term best quality medical care consisting of observational, therapeutic, curative and rehabilitative, nursing and other support services to both in-patients and out-patients and aimed at lowering hospital morbidity/mortality rate, increase of bed occupancy rate and allowing patients to have a better quality of life. IV. OBJECTIVES General: To make available health services that are safe and responsive to the needs of the community. Specific: 1 2 3 4 5 6 7 8

Improvement of revenue thru increase in universal Philhealth coverage and pay patients. Provide the best medical facilities, equipment and instrument capabilities and adequate hospital supplies and medicines for the management and treatment of patients. Provide an adequate manpower complement to allow the maintenance of a continuing 24 hrs. coverage of hospital services. To provide a continuing manpower development program for all personnel. To institutionalize culture of unity/ teamwork and responsibility among the health service providers. Encourage hospital staff to do research work related to their particular jobs. To mold hospital personnel towards the ethical practice of their professions. To develop output oriented health service providers through training of undergraduate medical clerks and interns, medical technologists, nurses, midwives, physical therapists, radiologic technologists, pharmacists, care givers and medical residencies.

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V. VALUE STATEMENTS 1 2

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To maintain a harmonious working relationship among the hospital personnel and with the general public and other government and non government organizations and private/religious organizations. Inculcate in every personnel work values like commitment and dedication to the delivery of quality patient care, loyalty to the service and other core values like integrity, excellence, compassion, professionalism, teamwork and stewardship. “A.K.O” – ATENSYON, KALINGA, OBLIGASYON

VI. PROGRAMS/ PROJECTS/ ACTIVITIES I. Delivery of Quality Patient Care 1. Clinical Services for the In-Patient Care 1

Medicine 1 2 3 4 5 6 7 8 9 10 11 12

General Medicine Nephrology Gastroenterology Pulmonology Diabetology Cardiology Intensive Care Unit Oncology Endocrinology Infectious Diseases Toxicology Physical Rehabilitation Medicine 1.1.12.1 Physical Therapy

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Obstetrics and Gynecology 1 Obstetric (Normal and Cesarean Deliveries) 2 Gynecology 3 Perinatology 4 Endocrinology and Infertility 5 Family Planning 6 Mother-Baby Friendly Program 7 Oncology 8 Ultrasonography

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Surgery 1 2 3 4 5 6 7 8 9 10

General Surgery Orthopedics Ophthalmology Neuro Surgery Head and Neck ENT Urology Pediatric Surgery Gastro Intestinal Surgery Thoraco-Cardiovascular Surgery

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Pediatrics 1 2 3 4 5 6

General Pediatrics Nutrition/ Rehabilitation Oral Rehydration Neonatal Intensive Care Hematology New Born Screening

2. Clinical Services for Out-Patient Care 2.1 Medicine 2.1.1 2.1.2 2.1.3

Consultations General Medicine Nephrology 2.1.4 Gastroenterology 2.1.5 Pulmonology 2.1.6 Diabetology 2.1.7 Cardiology 2.1.8 Oncology 2.1.9 Endocrinology 2.1.10 Infectious Diseases 2.1.11 Toxicology 2.1.12 Physical Medicine and Rehabilitation 2.1.12.1 Physical Therapy 2.2Surgery 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6 2.2.7

Consultations Breast Clinic Colorectal Clinic Orthopedic Clinic Hepabiliary Clinic ENT Clinic Eye Center 2.2.7.1 Consultations 2.2.7.2 Surgery 2.2.7.3 Diagnostic

2.3 Maternal and Child Clinic 2.3.1 Obstetrics and Gynecology 2.3.1.1 Pre-natal Consultation 2.3.1.2 Gynecology Consultation and Post Natal Consultation 2.3.1.3 Family Planning and Women Counseling 2.3.2

Pediatrics 2.3.2.1 Consultations 2.3.2.2 Well Baby Clinic 2.3.2.3 Under Five Clinic 2.3.2.4 Hematology Clinic 2.3.2.5 Immunization

. 2.4 Nutritional Counseling 3.Emergency Services 3.1 Consultation 3.2 Observation 3.3 Minor Surgery 3

4. Ancillary Support Service 4.1 Dental Services 4.2 Laboratory Services 4.2.1 Blood Collecting Unit 4.2.2 Histopathology 4.2.3 Bacteriology 4.3. Radiology Services 5. Nursing Services 5.1 Ward Services 5.2 Out-Patient Services 5.3 Emergency Services 5.4 Special Services 5.4.1 Operating Room and Post Anesthetics Care Unit 5.4.2 Intensive Care Unit 5.4.3 Delivery Room-Neonatal Intensive Care Unit 6. Administrative and Financial Services 6.1 Human Resource 6.2 Accounting 6.3 Budget and Finance 6.4 Admitting 6.5 Billing and Claims 6.6 Procurement 6.7 Property and Supply Management 6.8 Linen and Laundry 6.9 Housekeeping 6.10 Nutrition and Dietary 6.11 Security Services 6.12Motor Transport Unit 6.13 Central Information Hospital Management 6.14 Medical Records 6.15 Medical Social Services 6.16 Pharmacy 7. Training and Research Service 7.1 Residency Training 7.2 Post-Graduate Medical Rotating Internship 7.3 Clinical Clerk Ship 7.4 Radiological Internship 7.5 In Service training for all other categories of personnel 7.6 Nursing and Midwifery Affiliation 7.7 Post Graduate Nursing/Midwifery Training 7.8 Pulmonary Student Affiliation 7.9 Laboratory Student affiliations 7.10 Physical Therapy Student Affiliation 7.11 Pharmacy Student Affiliation 8. Special Project 8.1 Cataract Operation 8.2 Goiter/Thyroidectomy Operations 8.3Cleft Palate/ Hare Lip Surgery 8.4 Diabetes Control 8.5 Medical and Surgical Outreach Program 8.6 Blood Letting 8.7LinawTingin 4

9. Indigency Program 9.1 Senior Citizen 9.2 Cultural Minority 9.3 Veterans 9.4 Special Project 9.5 Indigent Patients 9.6Service Patients

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ORGANIZATIONAL STRUCTURE 1.1 The Provincial Government of Tarlac, headed by its Chief Executive, the Provincial Governor, assisted by the Provincial Health Board of which the Provincial Health Officer II is the co-chairman to the Provincial Governor’s Chairmanship, is the governing body of the TARLAC PROVINCIAL HOSPITAL, whose primary functions are the formulations of the hospital policies and procedures in consonance with the policies and programs of the national government, and to verify and approve the annual operating budget submitted by the Provincial Health Officer II who is also the Chief of Hospital. 1.2 The primary duties of the Provincial Health Officer II/Chief of Hospital, are to execute policies and procedures formulated by the governing body and to coordinate efficiently the medical, nursing, administrative, financial support/ancillary, and training and research functions of the hospital in order to provide safe treatment and care to all patients attended in the Hospital. There are six main services of personnel under him, namely: I. The Medical Service, headed by the Chief of Clinics, is primarily responsible for proper diagnosis, treatment and medical care of Hospital patients. II. The Nursing Service, headed by the Chief Nurse, whose main concern is the proper nursing care for patients, nursing education and training, and the promulgation of standard nursing procedures for the guidance of the staff. III. The Administrative Service, headed by the Administrative Officer is responsible for the efficient administrative management of the hospital, proper upkeep of the personnel, information technology, physical plant and equipment of the hospital. IV. Financial Management Service headed by the Administrative Officer , who is responsible for the effective and efficient financial management of hospital resources which includes supplies and materials, income generating facilities and the sourcing of funds for hospital operations,medical records and the provision of the dietetic, therapeutic and physical facilities compatible with safe patient care. V. Support/Ancillary Services, which provides specific clinical and diagnostic facilities which are valuable aids in the diagnosis and treatment of diseases, composed of clinical laboratory, radiology,and dental. VI. Training and Research is composed of medical specialists, resident physicians, nurses and other personnel of the five main services who participate in the various programs of the hospital like the residency training, internship, clerkship, nursing, laboratory, pharmacy, x-ray and others. The duties and responsibilities of these services are defined, maintained and limited only into medical, nursing,

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administrative, financial management, training and research and ancillary support services. It is the main responsibility of the Chief of Hospital/Provincial Health Officer II to coordinate effectively the various activities of these services toward the attainment of efficient scientific hospital patient care. The Chief of Hospital shall meet in conference these Heads of Services at least once a month to thresh out problems and plan out remedies to such problems and to improve the hospital services. 1.3 The Medical Service which is headed by the Chief of Clinics is divided into six clinical departments, namely Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, the Out-Patient Department, and Anesthesia. The above departments are headed by Medical Specialists, Medical Officers and Consultants. 1.4 The Nursing Service which is headed by the Chief Nurse together with the Assistant Chief Nurse, is manned by Nurses, ward attendants and for supervision purposes, housekeeping personnel. 1.5 The Administrative Services, headed by the Administrative Officer takes charge of General Administration which is further subdivided into Personnel, Information Technology, Motor Transport, Maintenance, Linen and Laundry, Security Service, and Housekeeping Service, is manned by Computer Programmer, Administrative Aides, Maintenance Foreman, Laundry Workers, Seamstress, etc. 1.6 Financial Management Service is headed by the Administrative Officer and subdivided into Billing and Claims manned by Administrative Aides; Collection and Disbursement manned by Administrative Aides and Detailed Revenue Collecting Clerks; Budget and Accounting manned by Administrative Officer; Admitting and Medical Records manned by Administrative Aides; Medical Social Services manned by Medical Social Worker and Administrative Aides; Dietary manned by NutritionistDietician, Cook, Food Service Worker and Administrative Aides; Pharmacy manned by Pharmacist and Administrative Aides; Supply and Property is manned by Administrative Officer, Storekeeper and Administrative Aides. 1.7 The Ancillary/Support Services include the following Services: 1. Laboratory, headed by the Medical Specialist manned by Medical Technologist, Medical Laboratory Technicians, Laboratory Aides and Administrative Aides. 2. Radiology, headed by the Medical Specialist manned by Radiologic Technologist, Medical Equipment Technicians and Administrative Aides 3. Dental Services headed by a Dentist manned by Dental Aide.

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B. DUTIES AND RESPONSIBILITIES OF KEY PERSONNEL 2.1 PHO II a. Create policies and procedures that will integrate and link the preventive, rehabilitative and promotive aspects of wellness of the public health services with the curative functions of the provincial health facilities particularly the Tarlac Provincial Hospital which serves as the referral center of the provincial health system. b. Oversee the Provincial Health Office, and formulate program implementation guidelines and rules and regulations for the operation of the said office for the approval of the governor; submits the annual budget of the Provincial Health Office and the various health facilities for approval of the Sangguniang Panlalawigan. c. Provide technical assistance and support to the governor in carrying out activities to ensure the delivery of basic services and provision of adequate facilities relative to health services in the province. d. Develop policies, plans, programs and strategies to promote the health of the people of Tarlac and upon approval thereof by the governor, implement the same particularly those that have to do with health programs and projects which the governor is empowered to implement and which the Sangguniang Panlalawigan (SP) is empowered to provide for under the Local Government Code. e. Provides leadership and strategic direction for the development of services and products for the health facilities of the PGT. f. Advise the Governor and the SP on matters pertaining to health; recommend to the SP, through the local health board, the passage of ordinances deemed necessary for the preservation of public health. g. Execute and enforce all laws, ordinances and regulations relating to public health. h. Direct the sanitary inspection of all business establishments selling food items or providing accommodations such as hotels, motels, lodging houses, pension houses, and the like, in accordance with the Sanitation Code; recommended the prosecution of violators of sanitary laws, ordinances regulations. i. Direct the conduct of health information campaigns and the rendering of health intelligence services. j. Coordinates with the DOH Representative for Tarlac Province to ensure that DOH programs are efficiently implemented in the province. k. Coordinates with other government agencies and non-govermental organizations involved in the promotion and delivery of health services. l. Exercise general supervision over health officers of component cities and municipalities. m. Be in the frontline of health services delivery, particularly during and in the aftermath of man-made and natural disasters and calamities. n. Exercise such other powers and perform such other duties and functions as may be prescribed by law or ordinance. CHIEF OF HOSPITAL a. Provides strategic direction and leadership to the Tarlac Provincial Hospital, ensuring efficient coordination of the medical, nursing administrative and other diagnostic and patient support functions of the hospital in order to provide proper treatment and care for all patients admitted and attended to in the hospital, seeking to constantly improve service delivery. b. Oversee the various services at TPH (Medical Services, Nursing Services, Hospital Operations and Patient Support Services, Finance Services) in the performance of their respective duties, ensuring that all service heads comply with and implement TPH policies and guidelines; ensures that the hospital has the 8

c. d.

e. f. g. h. i. j.

needed equipment/ facilities for the proper diagnosis, treatment and care of patients, for medical and nursing education, for scientific studies and research and for health and welfare of hospital employees. Set out the directions for TPH in terms of markets, marketing thrusts and profitability targets. Ensure adequacy in number, mix, and capability of hospital manpower to meet accreditation and licensing standards and to ensure the provision of quality health care; monitor the manpower productivity and equipment efficiency of the various units in the hospital. Endorse hiring, training and promotion of hospital personnel, and recommend disciplinary action on erring employees after due process Together with leads of services, prepare the annual budget of the hospital for submission to the governing body. Prepare submit performance reports and other documents required by management, regulatory and licensing bodies as needed, and make recommendations for the improvement of operations. Ensure that hospital operations comply with laws and other government regulations, and with accreditation standard. May disapprove any daily, weekly or periodic schedule or assignments of staff and personnel, medical and nursing or administrative, as made by the staff or department heads for a cause. Coordinate with PHO I for Public Health Services for the efficient referral and eventual management of patients from the community; collaborate with all other hospitals in the province, both government-owned and private; promote goodwill with local medical practitioners, local civic organizations and the community in general.

2.2 CHIEFS OF CLINICS a. Head of the Medical Staff and next in rank to the Chief of Hospital. b. Responsible to the Chief of Hospital for the efficient performance and ethical conduct of the medical staff of the hospital. c. Shall coordinate all the clinical activities of the hospital so as to bring out the best possible professional and scientific patient care. d. Shall stimulate research work and coordinate the care of patients with any graduate physician or nursing training programs of the hospital. e. Shall arrange and schedule scientific conferences for the professional growth of the staff and maintain a continuing program of in-service training of his staff. f. Shall take care of standardization, as much as possible, hospital clinical records and charts. g. Shall require all heads of clinical services to prepare a standard of Manual of Procedures for the guidance of staff members under them and submit the same for approval to the Chief of Hospital. h. Shall take charge of the Medical Records of the hospital and see to it that they are properly accomplished, filed and kept in such a way as to facilitate research and issuance of same whenever needed for consultation and certification. i. Shall conduct periodic medical audits of the scientific work of the hospital and suggests measures to improve patient care. j. Shall evaluate the work of the members of his staff and recommend measures for improving their efficiency. k. Shall have the power to recommend through the Chief of Hospital, appointments and disciplinary actions of the personnel under him. l. Shall assist the Chief of the Hospital in the administrative management of the hospital and shall perform the duties of the Chief of Hospital during the latter’s temporary absence or incapacity. m. Shall meet in conferences the members of his staff at least once a week and thresh out problems of the service and plan out improvements. 9

2.3 THE CHIEF NURSE a. As head of the Nursing Service, she is the over-all supervisor of the nursing service, and responsible for the implementation of proper nursing care to patients. b. Shall prepare a practical Nursing Procedure Manual to guide her staff and submit the same to the Chief of Hospital for approval; and maintain a continuing In-Service Training Program for the professional growth of her staff. c. Should conduct regular rounds of patients and nursing units to attend to their needs and improvements. d. Shall be responsible to the Chief of Hospital for the execution of rules and regulations relating to the Nursing Service and the proper care of patients, upkeep of wards, operating rooms, and delivery room. e. Shall initiate the performance evaluation of nurses and ward attendants and recommend measures to improve their efficiency. She has the power to recommend through the Chief of Hospital, appointments, promotions and disciplinary action of personnel under her. f. Should conduct immediate investigation of complaints or irregularity involving her staff and submit her findings and recommendations to the Chief of Hospital. g. Shall see to it that each sick employee under her staff is properly attended and confined in the hospital, if necessary. h. The Chief Nurse is assisted by a qualified member of her Nursing Staff, the Assistant Chief Nurse. i. Attends management meetings as representative of the nursing service. j. Performs other related functions as maybe assigned. k. Promotes and maintain harmonious relationship among the staff. 2.4 THE ADMINISTRATIVE OFFICER a. Head of the General Administrative Service. b. Assists the Chief of Hospital in coordinating hospital functions and recommends needed changes in the administrative policies and the operation of the institution. c. Regularly inspects buildings, facilities, equipments, supplies and materials to determine needs and recommends appropriate action. d. Studies procedures of hospital operations and recommends new and better ones to keep operation costs as low as possible without sacrificing service efficiency. e. Determines distribution and work schedule of personnel. f. Helps the heads of other services/groups in solving managerial problems. g. Assists the Chief of Hospital in enforcing all orders, rules and regulations promulgated by the governing body. h. Responsible for the performance evaluation as to the efficiency of the Administrative Staff for General Administration and may recommend for their disciplinary actions. i. Recommend to the Chief of Hospital for qualified applicants for hiring and promotions for qualified employees. j. Shall maintain a continuing program of the In-Service training for the professional growth of the staff. 2.5 THE ADMINISTRATIVE OFFICER FOR FINANCIAL MANAGEMENT a. Plans and directs the implementation of policies pertaining to financial management and hospital operation.

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b. Ensures the provision of uninterrupted logistic support to effectively and efficiently deliver quality service. c. Provides technical assistance to the Chief of Hospital in the promulgation and formulation of policies, standard operating procedures and strategies to improve the hospital system and its operation. d. Directs the evaluation and analysis of procedures and cost of operations and recommends changes to improve the work system. e. Recommends approval of work and financial plan and the annual procurement program of the hospital. f. Plans and directs purchase and inventory control of required resources. g. Directs the preparation and submission of required reports and official communication. h. Reviews and signs/initials financial reports and other documents. i. Identifies and recommends the need for revision of policies, system and procedures. j. Monitors programs/projects and activities. k. Shall have administrative supervision over official records of the hospital. 2.6 DIETITIAN-NUTRITIONIST III a. Shall plan, organize, supervise, and evaluate all activities of the Nutrition and Dietetics Service. b. Recommends, interpret Dietetics Service objectives, policies and standards to the administration. c. Plan an effective budget for patient. d. Plan, organize, direct and evaluate the total food service to the patient: purchasing specifications and materials: food production: sanitation and safe standards. e. Develop and maintain an organization chart of the Nutrition and Dietetic Service showing the responsibilities and authorities of all personnel. f. Supervise the maintenance of cost control, personnel, record and reports. g. Participate in conferences of department head meetings. h. Prepares work schedule of staff. i. Prepares Performance Evaluation System of personnel. j. Provides counseling and in service training in principles of nutrition. k. Report all concerns to the Administration. 2.7 HEADS OF CLINICAL DEPARTMENTS a. Shall be responsible for proper diagnosis, treatment and medical care of patients under his/her service. b. Shall have immediate technical supervision of all physicians, resident staff (Medical Officers) and adjuncts and technicians under him. c. Shall conduct regular rounds of all patients under his service with members of the house staff and discuss with them problems in diagnosis and treatment. d. Shall prepare a standard Manual of Procedures for the guidance of his staff members and attend to their periodic assignments in the service and submit such Manual to the Chief of Hospital. 11

e. Shall evaluate the work of members of his staff and recommend measures for their improvement to the Chief of Hospital through the Chief of Clinics, all appointments, promotions, and disciplinary action on personnel under him. f. Shall verify all statistical reports of the Medical Officers under him. g. Shall attend to the needs of his service and see to it that they are properly provided for. h. Shall meet his staff in conference at least once a week to discuss administrative and medical problems and plans out remedies of such problems in his service. i. Shall cooperate in maintaining admission into the hospital service within the authorized bed capacity and appropriations of his department. j. Shall stimulate research work and coordinate any graduate physician or nursing training program in his service. 2.8 CONSULTANTS a. Responsible for the diagnosis, treatment and medical care of all patients under his department or service, to the Head of Department and also for patients referred to him by the Medical Officers. b. Shall assist the Head of the Service in the supervision and training of Medical Officers/Resident Physicians, adjuncts, observers, nurses or technicians under his service. c. Shall make regular rounds of patients under his care and participate in staff medical conferences and research. d. Should make general rounds of patients and must be available to consultation when on 24 hours duty as consultant of the department. 2.9 SENIOR RESIDENT PHYSICIAN a. Shall assist the Head of the Service, Chief of Clinics, Chief of Hospital in the technical and administrative supervision of all resident physicians and technicians. b. Shall make daily rounds of patients; attend to their needs, diagnosis and treatment. c. Shall see to it that the patients’ charts are properly accomplished by all concerned within the required period from admission to discharge and properly coursed to the Medical Records for safekeeping. d. Shall be responsible for reporting all statistics and may do other duties when needed in the exigencies of service. e. Shall be in charge of the ambulance service pertaining to the transport of patient to other hospital. 2.10 SENIOR HOUSE OFFICER (SHO) a. Shall be responsible in the whole operation of the hospital after office hours in the absence of the Chief of Hospital, Chief Nurse and Administrative Officer. b. Shall be responsible for the presence of the Triage Officer and resident/intern-induty for each department which includes the Emergency room. c. Shall be responsible for the availability of Emergency Drugs in the Emergency Room at all times, as well as in the procurement of blood as needed for inpatients. d. Shall see to it that all patients brought in especially emergency cases; be attended to immediately, by any resident / intern-on-duty regardless of department. e. Shall be responsible for the approval of all emergency procedures/operations, after office hours on regular days, and on Saturdays, Sundays and Holidays and may however call on the department head concerned in controversial cases. f. Shall be responsible for the disposition of the patients in the Emergency Roomas well in the Observation Room and may call on the department head concerned in the controversial/difficult/serious cases. 12

g. Shall have the discretion to decide on emergency administrative matter when such could not be transmitted to the Administrative Officer or to the Chief of Hospital. h. Shall VISIT ALL SERVICES during his/her 24 hours tour of duty, check and monitor attendance of hospital personnel in the afternoon and night shift. i. Shall be responsible for the coordination of all activities in the Emergency Room and must see to it that orders are left in the care of patients, arrangements of admissions and other related functions shall be carried out or endorsed to the incoming SHO. j. Shall make rounds of all floors before going off-duty in the following morning, as well as collect the daily reports of residents-on-duty of all departments, consolidate and submit them to the Chief of Hospital. k. Shall be responsible for the implementation of the policies on the admission and care of patients in the Emergency Room. 2.11 RESIDENT AND JUNIOR PHYSICIANS a. Shall attend to the diagnosis, treatment and medical care of patients assigned to him but under supervision of the Head, Senior Resident and Consultant of the Service. b. Shall be responsible in accomplishing the history and other pertinent data in the chart and performing all routine laboratory examinations within the required time. c. Shall do charting of the daily observation regarding the progress of patients during their stay in the hospital. d. Shall make daily rounds of all patients and upon call at anytime whenever required to do so. e. Shall follow all assignments and perform other required duties to meet the needs of the Service by the Head, Consultant and/or Senior Resident Physician. 2.12 ADJUNCT RESIDENT PHYSICIAN (VOLUNTEER) a. Shall assist the resident physician in the performance of the latter’s duties. b. All services are limited for one year, without compensation and must observe strictly the office hours of the hospital, comply with the 24 hours duty and attend all conferences called for by his superior. 2.13ASSISTANT CHIEF NURSE a. Responsible in assisting in the administration and supervision of the Nursing Service, being next in rank to the Chief Nurse b. Acts as the administrative head in the absence of the Chief Nurse. c. Assists in the administrative and supervisory activities as delegated, such as preparation of the schedule, requisitioning supplies and equipment, keeping records, supervision of personnel and the nursing services to patients. d. Assists in the orientation of new personnel and in conducting education program in coordination with the Training Officer of the hospital e. Assists in all other functions of the Chief Nurse. 2.14 NURSE SUPERVISOR a. Operates at a level between the Chief Nurse and the Senior Nurse and is in charge of one or more units. b. Plans for the effective management of the units assigned. c. Analyzes and evaluates the nursing services required in the department in cooperation with the Senior Nurses. d. Supervises all nursing activities of the assigned units. e. Interprets hospital and ward policies and assure their implementation. 13

f. Helps Senior Nurses plan assignments and duties to nursing personnel that will ensure support, prompt and effective performance. g. Analyzes and evaluates the educational resources of the department and make these resources available for the related learning experiences of the affiliates. h. Plans and participates in programs of staff development. i. Participates in research activities to advance nursing and other services. j. Prepares and submits required reports. 2.15

SENIOR NURSE

a. One to who is delegated authority to provide nursing care to patients in a given unit, the immediate supervisor and unit manager responsible for the effective management of the nursing services. b. Plans for adequate provision for nursing care of patients in the assigned unit. c. Assigns specific duties of staff nurses, nursing aids and helpers. d. Evaluates nursing services rendered to patients. e. Assists in the orientation of new members and students. f. Plans teaching programs in cooperation with the clinical instructors utilizing all opportunities to enrich clinical experiences of students. g. Directs, coordinates and evaluates activities of professional and non professional workers. h. Requisitions and distributes supplies and equipments and conduct periodic inventory of the time. i. Acts as supervising nurse in the absence of supervisor j. Rotates with or relieve Staff Nurse if necessary. k. Prepares and submits required reports 2.16

STAFF NURSES

a. Responsible for rendering bedside care to patients in their assigned units. b. Assessment of its problems and needs, prepare, implement plan and evaluates result. Provides direct patient care. c. Observes, records and reports symptoms and conditions of patients. Administers medication, treatment and notes reaction. d. Assists physicians in administering highly specialized therapy with complicated equipment. e. Bath and feeds acutely ill patients. f. Assists in the orientation, provides incidental teachings. g. Supervises non-professional workers. h. Plans and give health education to patients. i. Acts in the capacity of the Senior Nurse the latter’s absence. j. Coordinates with other services regarding patient’s management and treatment. k. Does other related work as delegated. 2.17

NURSE TRAINING OFFICER

a. Responsible in planning the training program for all levels of personnel in the Nursing Service b. Plans, organizes, conducts, training programs and other activities related to staff development in cooperation with the supervisors and senior nurses, c. Acts as liaison between the nursing service and affiliates. d. Conducts orientation programs for new personnel and affiliates. e. Secure instructional materials and resource persons for the training. f. Evaluates results of training. g. Does other related work as delegated. 2.18

SUPERVISING OPERATING ROOM NURSES 14

a. Responsible for the management and supervision of nursing and related Operating Room activities b. Directs and supervises nursing and related activities of the Operating Room. c. Plans assignments of staffs d. Supervises layout of table for various operations considering surgeon’s requirements and supplies available. e. Prepares general procedures and list requirements of each type of operations performed and standardized packs and draping of patients for each operation. f. Informs staffs of new procedures, administrative charges, special instruments or sutures required of scheduled operations and problems in asepsis by issuing daily reports, conferences, and other methods. g. Periodically discusses their staff major problems and proposes solutions to the same. h. Conducts orientation and in-service training programs to provide good patient care and efficient aid to surgeons i. Ensures that Operating Room is kept clean always. j. Coordinates operating room activities with other units and services of the medical staff. k. Coordinates with Supply section in selection of new instruments, supplies and equipments. l. Participates in the formulation of administrative/personnel policies pertaining to operating room activities. m. Directs and maintains required records and reports including working performance. n. Evaluates performance of personnel and service of the department. 2.19

SENIOR OPERATING ROOM NURSE

a. Responsible for extending assistance to various types of surgical operations, during the pre-operative, intra-operative and immediate post-operative phases; b. Plans, organizes, directs and coordinates activities in the operating room and evaluates performance. c. To ensure that effective nursing services is maintained at all times. d. Provides guidance to medical and nursing students. e. Operates or supervises operation of complicated equipment. f. Requisitions of supplies, materials and equipment. g. Assists in research work related to improvement of surgical nursing. h. Observes strict compliance/implementation of aseptic techniques in the Operating Room. i. Provides assistance to surgeons during the operations. j. Assists as supervisor in the absence of the latter. 2.20

OPERATING ROOM NURSE

a. Responsible for extending assistance to the various types of surgical operations and does related jobs/works. b. Provides care to surgical patients during the pre-operative, intra-operative and immediate post-operative phases. c. Acts as a scrub or sterile nurse;  Prepares supplies and instruments according to type of operation to be done.  Directly assists surgeon during operations.  Observes patients during surgical procedures for unusual manifestations.  Checks all materials, instruments used during operations. 15

 Wash, dry and packs the instruments used after the operation for sterilization. d. As circulating nurse: Maintains proper positioning of patients Prepares table and other devices required Prepares operative area by sterilizing skin Prepares specimen for laboratory analysis Observes progress of surgery and provides additional needs of surgeons and scrub nurse.  Regulates I.V. fluids  Accompanies patients to and from the Operating Room.     

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DIETITIAN NUTRITIONIST II / DIETITIAN NUTRITIONIST I

2.21.1 Nutritionist Dietitian II- assists in the supervision of all ND service activities particularly in the management of the food service. a. Evaluates food the management of the food service b. Inspect and accept all deliveries of foodstuff for accurate quantity and proper quality in accordance with the specification set by the service. c. Maintain complete and accurate records of daily purchase inventories of food supplies and requisition; equipments and utensils. d. Supervise and evaluate preparation, cooking and apportioning of food for patients and staff. e. Maintain and improve high standards of sanitation, safety and accuracy. f. Recommends improvement of facilities and equipment. g. Provide counseling and in service training principles of nutrition. h. Report all concerns to supervisor. 2.21.2 Nutritionist Dietitian I- assist in the supervision of all ND Service activities. a. b. c. d. e. f. g. h. i. 2.22

Inspect and accepts deliveries of food stuffs for accuracy. Supervise food production and serving of meal in the ward. Record meal census. Conducts nutrition education to patients referred by physicians Verify accuracy of diet served to patient. Maintain high standard of sanitation. Participate in the in-service education for ND staff Assist in the preparation and completion of reports and other supporting papers. Report all concerns to supervisor. CHIEF PHARMACIST

a. Prepare and submits Project Procurement Management Plan (PPMP) for drugs and medicines and supplies. b. Prepare list of drugs and medicines and supplies to be procured quarterly. c. Monitors stock level of drugs and medicines and supplies. d. Assure compliance with all legal and regulatory requirements to effectively render hospital services (FDA and PDEA). 16

e. Prepare and submits semi-annual report to PDEA. f. Review and submits the prepared monthly statistical (number of filled and unfilled prescriptions), malaria and consumption report. g. Participate actively in the implementation of the medication policies and procedures of the hospital. h. Orient pharmacy interns on the hospital policies, hospital organization and on the Standard Operating Procedures (SOPs) of the pharmacy. i. Instruct, train and supervise employees of the hospital pharmacy. j. Check, evaluate and approve performance ratings of the pharmacy staff. k. Prepares monthly pharmacy staff schedule of duties. l. Perform other related functions. 2.23MEDICAL TECHNOLOGISTS III / II a. Shall monitor all work performed in the laboratory and determine that reliable data are being generated; b. Ensure that there are sufficient qualified personnel with adequate documented training and experience to meet the needs of the laboratory. He/ she shall convey to the Head, the need for additional staff as the need arise c. Address complaints, requests or suggestions from users. d. Must be in active communication with the Head of the Laboratory on the various concerns that need to be immediately addressed e. Shall be aware of the basic principle of the test or part of the test he/she is doing; f. Shall perform the test as described in the manual for standard operating procedure g. Must comply with all safety and bio-safety policies; h. Must report unsafe practices and accidents to his/her immediate supervisor; i. Shall monitor laboratory equipments. j. Shall foster and adopt Professional work ethics with peers 2.24 RADIOLOGIC TECHNOLOGISTS a. Overall supervision of the Department activities – Radiology, Ultrasound and Administrative Services, including mobile unit. b. Recommend policies and procedures relative to the Department’s operation; c. Develop and implement training program for radiology staff; and d. Accomplishes performance appraisal and ratings of supervisors and reviews/ confirms performance rating of staff; e. Prepares propose budget of the Department; f. Reviews and updates existing Department Guidelines, Standard Operating Procedures and Policies; g. Review and approve work schedule of the Department;

17

h. Establish and maintain effective communication system within and inter Department; i. Ensure completion and compliance with requirements to operate X-ray facility; j. Conduct Quality Circle of the Department; k. Perform other related functions that may be required. 2.25 a.

c. d.

DENTIST III

Establishes department procedures and methods of operations; b. Conducts dental examinations and makes diagnosis, performs oral prophylaxis, including removal of calcium deposits, secretions and stains from exposed surface of the teeth; fills cavities with composite fillings and does other minor surgery; Requisitions dental equipment and supplies; Maintains proper cleanliness or clinic, equipment and supplies. C. HOSPITAL POLICIES AND PROCEDURES HOSPITAL SUMMARY FLOW CHARTS I. FLOW CHART -ADMISSION TO DISCHARGE HOSPITAL OPERATIONS SUMMARY FLOW A patient may enter the hospital system through the OPD or ER. From these two units, a patient may be sent home, advised to stay for observation or admitted to the wards. In the ward, the patient receives care from doctors and nurses and services from different support units like Pharmacy, Dietary, CSR, Laboratory, Radiology, Medical Social Service and Medical Records, upon admission or while in the ward, the patient is classified in terms of his capability to pay. Before the patient is discharged, he must pass through the Billing Section and Collection Unit for his financial obligations to the Hospital. In case the patient cannot afford to pay his bills, he may seek the help of the Medical Social Worker / Indigency Committee of the Hospital which Committee has the power to decide on how much payment the patient will be obliged to shoulder based on his classification, then said patient returns to the Collection Clerk for payment. A clearance certificate will be issued thereafter.

18

II. OUT-PATIENT DEPARTMENT POLICIES AND PROCEDURES RULES AND REGULATIONS POLICIES: 1 2 3 4 5 6 7 8 9

Residents of the different department assigned at the OPD must be at their post at all times. All interns and clerks must bring their own medical instruments, i. e. stethoscope and sphygmomanometer, etc. New patients must be registered in the patients record book for their assigned number which must be presented whenever their medical record is needed; Patients must be attended to on first come first served basis. All problems pertaining to the inability to pay should be referred to the Medical Social Worker; Minor surgical procedures must be done in the afternoon. All OPD records must be signed/countersigned by the resident on duty; Locator card should be properly indexed; Out-Patient Department clinical records should be managed as follows: a b

c d e

Only authorized personnel of the OPD should be allowed in the OPD Clinical Records and Hospital Medical Records Section to secure records of patients; It is the responsibility of the Medical Records Officer for the OPD safekeeping of all medical records and answerable to the Chief of Hospital designate and/or Chief of the OPD for losses and unauthorized issuance of information pertaining to patients clinical records and data; The contents of the clinical records of patients should not be divulged to anybody without proper request from authorized person; Medical Certificate is issued only upon request of the patient concerned properly signed by the attending physician with the seal of the hospital affixed to the certificate; Only the Medical Records Section can issue medical certificates;

10 Consultation hours and days: Services Hours Pre-Natal 8:00 AM -12:00 PM 1:00 PM - 5:00 PM Post-Natal 8:00 AM -12:00 PM 1:00 PM - 5:00 PM 19

Days Mondays, Wednesday, Friday Tuesday Thursday

Gynecology Family Planning Internal Medicine Pulmonary Clinic (TB DOTS) Surgery (Orthopedic, ENT) Pediatric Well Baby Clinic Sick Babies Immunization Under Five Clinic Dental Clinic Medical Social Service Physical Therapy Ultra Sonography Service Blood Collecting Unit

8:00 AM -12:00 PM 1:00 PM - 5:00PM 8:00 AM - 12:00PM 1:00 PM - 5:00PM 8:00 AM - 12:00 PM 1:00 PM - 5:00 PM 8:00 AM - 12:00 PM 1:00 PM - 5:00 PM 8:00AM - 12:00PM 1:00PM - 5:00PM 8:00AM - 12:00PM 1:00PM - 5:00PM 8:00AM - 12:00 PM 8:00AM – 12:00PM 1:00PM – 5:00PM 1:00PM – 5:00PM 8:00AM –12:00PM 1:00PM – 5:00PM 8:00AM –12:00PM 1:00PM – 5:00PM 8:00AM -12:00PM 1:00PM - 5:00PM 8:00AM -12:00PM 1:00PM - 5:00PM 8:00AM -12:00PM 8:00AM - 5:00PM 8:00AM - 5:00PM 8:00AM - 5:00PM

Thursday Monday Monday to Friday Monday to Friday Monday to Friday Monday to Friday (AM only on Wednesday) Monday to Friday Tuesday and Thursday Monday, Wednesday, and Friday Tuesday and Thursday Every last Thursday of the Month Monday to Friday Monday to Friday Monday to Friday Saturday Monday to Friday Monday to Friday Monday to Friday

Consultation fee is P50.00 PROCEDURE: I 1

PROCEDURES OF THE OUT-PATIENT DEPARTMENT Blood Donor

a

Responsibilities of a nurse: Assists the possible donor in filling up of blood donation form.

b

Take vital signs and weight of donor.

c

Accompany patient to the laboratory for blood typing and hemoglobin count.

d

If donor is physically fit and qualified to donate blood, prepare him for extraction. -

Place him in comfortable lying position.

-

Prepare the blood bag extraction site.

-

Assist physician during extraction, observe proper asepsis during procedure.

-

Observe donor’s reaction during and after extraction of blood.

20

2

3

a b c d

Label blood bag with donor’s name, blood type and date of extraction.

-

Forward to the laboratory.

Minor Operations a

Secure consent of patient (legal age) or nearest kin and explain the procedures to be done.

b

Check and prepare the medicines and instruments needed for the procedure.

c

Prepares the operative site and drape patient properly.

d

Performs minor operations.

e

Assists the Surgeon during the operations.

f

Collect specimen for pathological examination such as biopsy, if any.

g

Advice on prescribed medication, wound care and follow-up check-up.

Vaginal Examination a Secure consent of patient or nearest relative and explain the procedure to be done. b Performs vaginal examination. c If the procedure is assisted by the nurse: -

4

-

Prepare the perineum, paint it with antiseptic solution. Drape patient properly. Have all instruments ready. Collect specimen for pathological examination. Label specimen properly and send to laboratory.

SERVICE PROCEDURE PROCEDURE Register name and other patient data in the record section Prepare chart and issue OPD card (new patient) Retrieve patient chart (old patient) Record the chart in the OPD logbook. Collection of fee

e Bring the chart to the assessment area

PERSON RESPONSIBLE Records clerk Records clerk

Records clerk OPD Collector Patient OPD nurse/ Nursing aid

*Call patients’ name *Get the vital signs *Classified patients based on their complaints 21

*Give/ provide number to Specific unit/clinic f

Forward OPD chart to the respective OPD clinic

patient/nurse/nursing aide

Examines patient, evaluates and determines the medical care needed. Asses the patient for any medical or surgical invention needed. *If the patient is for medical care, give prescription and provide g instruction. *If the patient is for work-up orders ECG and CXR etc., Once result is available, evaluate document and give appropriate management and instruction. *If patient is for referral, refer accordingly. Record observation impression, diagnosis and treatment rendered to h OPD chart. Advised follow-up PRN Discharge patient with proper instructions. i Filling of charts / records

Resident on Duty

physician/OPD nurse

physician/nurse

III. EMERGENCY ROOM POLICIES AND PROCEDURES 1. General Policy: a. b.

There should be at least one resident physician per department at all times; There should be adequate supplies, medicines, materials and other things needed for the management of cases; c. No follow-up of out-patient cases; d. To be of service to the sick should be the primary guiding principle; e. Proper decorum should be exercised at all times; f. A triage officer coming from the Department of Surgery must always be available. 2. Policies in the Care of Patients: a. All patients who come to the emergency room for emergency medical evaluation or treatment will receive care in a timely manner consistently and must be attended to immediately. b. In emergency cases, whether the patient has money or none should not be prejudiced by administration of medicines, fluids and other therapeutic and supportive measures (lab., x-ray, etc.); c. The need for blood should be referred to the laboratory department. 22

d. In case of difficult administrative controversies in the admission, management of disposition of patients in the ER must be referred by the Resident on duty to the Senior House Officer. e. The clinical management, admission or disposition of patients in the ER which are considered controversial in nature should be referred to department head/chairman. f. All medico-legal cases should be referred to and must be seen by the resident on duty. g. During mass casualties residents from different clinical departments are required to assist. h. Administrative concerns should be referred to Senior House Officer after office hours. 3. Observation Room: a. To avoid congestion, if within four hours patients are unable to recover from their complaints, they should be admitted to the corresponding ward. No cases of communicable diseases should be placed at the observation room; b. The disposition of patients in the observation room as to whether to admit or not into the ward, shall be referred to the Senior House Officer, the SHO may further refer the case to the department head concerned, but in no case shall the resolution of such controversy exceeds twenty-four hours. 4.Admission: a. No patient seeking admission ,must be refused regardless of: 1. financial status 2. availability of space (except for pay patient with private physician) b. The patient/patient’s relative who refuses admission shall sign the waiver form. REFUSED ADMISSION must be annotated on the doctor’s order sheet. 5. Policies regarding Use of Minor Operating Room: a.

Only emergency cases should be done. 6. ER Procedures:

PROCEDURES

PERSON/S RESPONSIBLE

a. Attends to the patient immediately for emergency measures; b. Obtain and record vital signs, and refers patient to the physician on duty; c. Examines patient and writes down orders for medication/medical care; d. If vital signs are absent, gives resuscitative measures and refers to physician on duty; d.1. If resuscitative measures fail, pronounces patient as dead on arrival (DOA) d.1.1 Perform post-mortem care.

ER Nurse

Physician ER Nurse/ER Staff Physician Nursing Attendant

23

d.2. In case of medico-legal refer to Resident on Duty d.3. If patient is for admission, writes and signs admitting orders and instruct relative to proceed to the admitting unit. d.3.1 Instruct relatives to go back to E.R with room assignment given to patient. d.3.2Notifies the ward regarding admission.

Nurse Physician/ Nurse

Admitting Clerk

Nurse d.3.3 If needed, patients who are not emergency cases must be brought to laboratory for blood extraction and X-ray. d.4 If patient is for surgery, writes stat orders on the patient’s chart for immediate work-up like complete blood count, urinalysis and/or special procedures; d.5 Prepares and signs request and gives it to the nurse; d.6 If patient is for referral to other health facilities, prepares referral documents; and d.7If patient is for discharge, instructs patient/relative to comply with the discharge requirements.

Physician

Physician Physician Physician

IV. ADMISSION POLICIES/PROCEDURES 1

Admission of patient is centralized at the Admitting Section. Patients for admission come from: a. b. c.

2

Out Patient Department referred by the resident on duty, Emergency Room for patients with emergency conditions. Patients brought in by visiting physicians.

Only patients with doctor’s order for admission and with complete charts are admitted to the Clinical Units: a. b. c. d. e. f. g.

Patient Data Sheet is completely filled up; Admission number and case no. recorded; Consent for hospitalization is signed by responsible relative of the patient; Hospital rules and regulations are explained; Room accommodation and hospital charges are explained; Consent for admission is signed for all admissions, Informed consent is signed by the authorized nearest of kin, if the patient is for surgery and witnessed by a hospital staff. 24

h. 3

Stat orders are implemented by nurses before patient is transferred to the room of choice.

Patient’s data is recorded at the Patient’s Admission Book. If patient has a health insurance, privileges are explained and supporting papers are required to be submitted within 24 hours.

4. The Admitting Clerk notifies the Emergency Room nurse of the availability of rooms.

V. WARD PROCEDURES I. Admission to Ward: Upon notice of admission:

a

b

PROCEDURES prepares assigned bed, individual patient’s need for supplies and materials based on the information from the E.R nurse. prepares patient’s unit like bed, linen, bedside table, etc.

PERSON/S RESPONSIBLE Ward Nurse

Nursing Attendant

Upon arrival of the patient in the ward:

PROCEDURES

PERSON/S RESPONSIBLE 25

a. accompanies patient to his/her designated unit;

Nurse

b. Assess patient’s condition and records findings in the chart;

Nurse

c. Orient patient/relative about the hospital policies;

Nurse

d. Plans nursing care of patient, performs admission and carry out orders.

Nurse

e. Follow-up results to other units such as the laboratory, pharmacy, x-ray, etc. of the need and requirements of the patients. f. Discuss with the patient or relative the medical/nursing care and the extent of his participation; g. Checks chart to ensure that consent for medical/surgical intervention has been signed by the patient or his/her nearest of kin;

Nurse/ Nursing Attendant

Nurse/ Nursing Attendant

Nurse/ Nursing Attendant

h. Record observations, treatment and medications administered to patients;

Nurse/ Nursing Attendant

i. Encode patient’s name in the daily ward census, Kardex and Diet List;

Nurse/ Nursing Attendant

j. Updates ward directory and prepares diet list and forwards to the Dietary Service.

Nurse/ Nursing Attendant

2. Carrying out Doctor’s Orders: PROCEDURES a. after doctor’s rounds, receives and copies medical management from the patient’s chart to the nurse book or Kardex; b. Prepares Drug Utilization Form to be forwarded to the pharmacy; c. carries out medication/treatment orders;

PERSON/S RESPONSIBLE Ward Nurse

Ward Nurse Ward Nurse

3. Daily Patient Care PROCEDURES

PERSON/S RESPONSIBLE 26

a. Endorses to the incoming nurse the shift’s activities and special procedures, medications, which need to be carried out;

Ward Nurse – (Outgoing Nurse)

b. Makes rounds with the incoming nurse and introduces the latter to newly admitted patients and those needing intensive care;

Ward Nurse – (Outgoing Nurse)

c. Takes note of patients needing special attention and care;

Incoming Nurse

d. Endorses drugs to the incoming nurse and signs out; e. Reads Kardex and analyzes reports;

Outgoing Nurse Incoming Nurse

f. Prepares plan of work and determines resources and priorities;

Incoming Nurse

g. Provides nursing care and carries out medical treatment;

Incoming Nurse

h. Records patient care activities and observations made;

Incoming Nurse

i. Refers patient to the physician on duty when necessary;

Incoming Nurse

j. Discusses management of the patient to the physician; k. Monitors activities and patient’s status;

Incoming Nurse Incoming Nurse

l. Makes round of patients;

Supervising/ Senior Nurse

m. Supervises nursing care provided by the ward nurse

Supervising/ Senior Nurse

n. Observes the ward nurse to determine their level of competency;

Supervising/ Senior Nurse

o. Observes utilization of ward supplies and equipment; and,

Supervising/ Senior Nurse

p. Assists ward nurse in carrying out patient care when needed.

Supervising/ Senior Nurse

4. Pre-operative Procedures A day before the operation:

27

PROCEDURES

PERSON/S RESPONSIBLE

a. Prepares elective schedule for surgery and forwards it to the ward nurse;

Surgeon / Ob Gyne

b. Forwards schedule for surgery to OR Nurse, Anesthesiologist and Chief of Hospital for approval;

Ward Nurse

c. Inspects chart to see that the consent for surgical intervention has already been signed by the patient or his nearest kin.

Ward Nurse

d. Forwards approved schedules to the OR Nurse;

Ward Nurse Operating Room Nurse

e. Ensures that all OR needs are complete f. Prepares patient psychologically and spiritually, and orients his/her on the procedures to be done;

Physician/Nurse

g. Instruct patient/watcher on NPO (Nil per Orem) starting at midnight,

Ward Nurse

h. Checks preparation made for patient’s operation; i. Prepares patient: - Performs procedures as needed, (e.g. enema) - Conducts preliminary preparation for the operative site; - Reminds patient on NPO; - Reassures the patient;

Supervising Nurse Senior Nurse Ward Nurse/ Nursing Attendant

j. Fills up and signs checklist of preoperative preparations and gives it to Nurse II (Senior Nurse)

Ward Nurse

l. Attached checklist in the patient’s chart

Ward Nurse

Hours before the operation:

PROCEDURES r. Removes jewelleries, contact lenses, prosthetic teeth, etc. and gives them to patient’s companion for safekeeping;

PERSON/S RESPONSIBLE Ward Nurse

28

s. Gives cleansing enema, if ordered; t. Inspects operative site and checks completeness of pre-operative medications;

Ward Nurse

u. Rechecks the checklist of pre-operative medications;

Ward Nurse

v. Takes vital signs (BP/ temperature/ Pulse rate/ Heart rate/ respiratory rate/ and level of consciousness;

Ward Nurse

w. Gives pre-operative medications as scheduled;

Ward Nurse

x. Transfers patient to the OR with the chart and other needed medications and supplies and with Ward Nurse endorses to OR.

OR Attendant/ Ward Utility Worker

VI. OPERATING ROOM POLICIES & GUIDELINES SERVICE

I.

OPERATING ROOM AVAILABILITY 1. The Tarlac Provincial Hospital has 3 functioning Operating Rooms which will be used for all Emergency and Elective surgical cases of the hospital. 2. One (1) Operating Room will be allotted each for Surgery and OB-Gyne Departments respectively wherein they will do their Elective Service Cases. One (1) Operating Room will be allotted exclusively for Emergency cases. Operating Room I – Surgery Elective Cases Operating Room II – OB-Gyne Elective Cases Operating Room III – Surgery Elective Cases

II.

POLICIES FOR ELECTIVE PROCEDURES 1. Operating Rooms for Elective Procedures shall be available Monday to Friday (except on official non-working holidays) from 8:00am to 2:00pm. 2. Time table for Elective Procedures will be as follows and shall be STRICTLY observed: 7:00 am – Patient received at the Operating Room 29

7:30 am – Anesthesia Induction Time 8:00 am – Surgical Procedure Cutting Time (1st Case) 2:00 pm – Cut-off time 

 

Surgery Safety Checklist will be done at all times by the surgical team a. Before induction of anesthesia (Sign in) b. Before skin incision (Time out) c. Before the patient leaves the Operating room (Sign out) Surgeons should be within the Operating Room premises at the time of Anesthesia Induction Residents are expected to be punctual however this may not be possible in some instances. Thus, cases (especially the 1st scheduled case for the day) are allowed to have a maximum of 30 minutes delay. If the residents in charge of the case are not yet around after this allowable time of delay, the case will either be deferred or bumped-off and be done as the last case provided it is still within the allotted elective time (8:00am-2:00pm).

3. Surgeons are expected to make reasonable schedules of their Elective Procedures i.e. potentially long cases and Pediatric cases should be scheduled first and minor cases scheduled last. 4. The duly approved ELECTIVE SCHEDULE FORM must be submitted by the Chief Residents (or their designated representative) of the respective departments to the Operating Room Head Nurse before 12:00nn of the day prior to the scheduled procedures. Otherwise, NO ELECTIVE SURGERIES will be scheduled for the day; instead “EMERGENCY BACKLOGS” can be done. 5. Department Conferences should be prioritized over cases on Wednesdays. As such, one elective procedure isscheduled to be done from 8:00 am to 12:00 nn.To give time for Residents to prepare and attend department conferences. 6. Should there be No Elective cases scheduled on the Operating Room on a particular day, Emergency cases can be done upon the discretion of the respective departments (Surgery and OB-Gyne) concerned provided it is within the time allotted for Elective Cases i.e. 8:00am is cutting time; 2:00pm is cut-off time. 7. Each department can do Emergency procedures in their respective OR’s in lieu of their Elective cases, however, OR time shall not be extended to let them finish their bumped-off cases. III.

POLICIES FOR EMERGENCY PROCEDURES 1. One (1) Operating Room shall be allotted for elective operations and one (1) for Emergency operation. 2. Surgeons should notify the Operating Room nurse on duty of their proposed procedures. The nurse on duty, on the other hand, shall inform the Anesthesiology Resident on duty regarding the said procedure. 3. In cases of Disasters, rules of the Hospital on “Disaster Preparedness” shall be followed. 30

4. Procedures previously scheduled as Elective cases cannot be done as Emergency unless extremely warranted and with permission from their respective Department Chairman and/or Training Officer. IV.

POLICIES FOR POST-ANESTHESIA CARE UNIT (PACU)

The Post-Anesthesia Care Unit (PACU) is as important as any other unit of the hospital (i.e. Intensive Care Unit, Emergency Room, and Operating Room). It is where majority of post-anesthetic morbidities and mortalities happen. This is the reason it is imperative that the PACU should have a 24/7 PACU Nursing Service. 1. Service Cases, Elective or Emergency, shall not be induced by the Anesthesiology Resident unless there is at least one (1) nurse on duty exclusively at the PACU. 2. All Post-operative patients (except those given only local anesthetics without any form of sedation) are required to stay at the PACU for a minimum of 2 hours for observation and monitoring. 3. Problems concerning patients admitted in the PACU should be referred to the Attending Anesthesiologist and/or the Anesthesiology Resident on duty. 4. Patients shall not be discharged from the PACU unless the patient is properly assessed by the Attending Anesthesiologist &/or Anesthesiology Resident on Duty and a written order for transfer to ward/room was given. 5. PACU Nurse shall prepare and forward Drug Utilization Form (DUF) to the Pharmacy for replacement of the used drugs and medicines and supplies.

V.

SANCTIONS All personnel who continually disregard the approved policies shall be reported to OR Supervisor for proper notation in the logbook. Their names shall in turn be submitted to their respective Department Heads and the Chief of Hospital for proper disciplinary actions.

VI. OPERATING ROOM PROCEDURES 1

Preparation for Operating Room

PROCEDURES

PERSON/S RESPONSIBLE

Disinfects OR before and after use

Nursing Attendant

Opens OR pack

Operating Room Nurse

Prepares set-up for the particular 31

operation;

Operating Room Nurse

Arranges pack on top of the instrument table; e

Operating Room Nurse

Opens additional packs needed for the particular operation;

Operating Room Nurse

f. Continuous setting up as needed; Operating Room Nurse g. Prepares suturing set and sponges; Operating Room Nurse h. Counts and writes on the board the number of sponges, instruments and needles; and

Operating Room Nurse

i. Rechecks counting. Operating Room Nurse

2

Patient Care in the Operating Room:

PROCEDURES a. Receives patient and checks if all the pre- operative requirements are administered;

PERSON/S RESPONSIBLE OR Nurse/Anesthesiologist

b. Checks patient’s operative site, sterilizes the skin, and drapes the patient; c. Places patient in the prescribed position to protect nerves from undue pressure;

OR Nurse

d. Sets instruments and supplies according to the specified order and the type of operation to be performed.

OR Nurse

OR Nurse

e. Counts sponges and instruments and dictates to Circulating Nurse who writes on the board the number of sponges and instruments to be used; f. Anticipates other needs;

OR Nurse

OR Nurse g. Checks medicines needed for the operation. Anesthesiologist h. Prescribes substitutes for medicines which are not available; Anesthesiologist i. Inducts anesthesia; Anesthesiologist 32

j. Anticipates the needs of the surgeon during the operation.

OR Nurse

Before the surgeon closes the operation:

PROCEDURES a. Checks all, tallies number of the instruments and sponges used;

PERSON/S RESPONSIBLE OR Nurse

b. Checks vital signs and logs them in the anesthesia records;

Anesthesiologist

c.Record vital signs in the patient’s chart; OR Nurse

3. Post-operative Procedures:

PROCEDURES a. Removes all straps, cleans, and covers the patient;

PERSON/S RESPONSIBLE OR Nurse

b. Takes vital signs of the patient; OR Nurse c. Takes patient to the Recovery Room;

With Nursing Attendant

d. Disinfects Operating Room after use Nursing Attendant e. Specimen/tissues removed from patient must be place in appropriate container with proper labelling for histopath examination.

Nursing Attendant

4. Recovery Room (RR)

PROCEDURES a. Monitors patient’s condition and records in the patient’s chart all observations made;

PERSON/S RESPONSIBLE RR Nurse

b. Refers to the physician on duty when needed.

RR Nurse

c. When patient regains consciousness informs Ward Nurse on the Patient’s

RR Nurse 33

transfer to the ward; d. With the Nursing Attendant/Utility Worker, endorses patient to the Ward Nurse.

RR Nurse

VII. STANDARD OPERATINGPROCEDURES IN LABOR/DELIVERY ROOM/NEONATAL INTENSIVE CARE UNIT Preparation of the LR/DR:

34

PROCEDURES a. Disinfects LR/DR before and after use; b. Open packs for DR use;

PERSON/S RESPONSIBLE Nursing Attendant/Utility DR Nurse/ Nursing Attendant

c. Prepares set-up for the particular procedures;

DR Nurse

d. Opens and arranges additional packs on top of the instrument table.

DR Nurse

e. Counts and writes the number of sponges, instruments and needles;

DR Nurse

Admission of Patient to the Labor Room PROCEDURES a. Patient must be accompanied and transported via wheelchair/stretcher to the DR/LR by hospital personnel and properly endorsed. b. Interview patient and do initial assessment. Check the chart for completeness of data.. c. Check the following if already done in the ward.  perineal shaving  nail polish removed  jewelries removed  dentures removed Jewelries and dentures must be given to relatives immediately. d. Monitor and record data, vital signs, and progress of labor. Note FIID:  Frequency  Interval  Intensity  duration e. Monitor and record fetal heart rateFHR. f. Require patient to urinate to empty the bladder. Distended bladder may impede progress of labor. g. Develop and display a helpful and accommodating attitude and provide emotional support all throughout the patient’s stay in the unit. Do not leave patient’s unattended. h. Prepare sterile instruments needed for 35

PERSON/S RESPONSIBLE D.R. Nurse

D.R. Nurse

D.R. Nurse

D.R. Nurse

D.R. Nurse D.R. Nurse

D.R. Nurse

delivery including the diapers for the baby and medicines needed during and after delivery.

D.R. Nurse

Patient Care

PROCEDURES a. Assess and records patient’s condition including vital signs, POL and FHT. b. When patient is ready for delivery, call the Obstetrician

PERSON/S RESPONSIBLE DR Nurse DR Nurse

c. Records medical intervention/management. d. Carry out Doctor’s order.

Obstetrician DR Nurse

Intrapartum PROCEDURES a. Transfer patient from L.R. to the DR. via wheelchair/stretcher.

PERSON/S RESPONSIBLE DR Nurse/Attendant

b. Place patient on a lithotomy position. DR Nurse c. Clean perineum and paint with antiseptic solution, include vulva, upper inner thighs, pubis and anus.

DR Nurse

d. Place St. Mary’s drapes. DR Nurse e. Assist during the process of delivery, cutting of the cord and episiotomy if applicable. * Suction new born if needed. * APGAR scoring f. Routine Early care of Normal Newborn Infants 

Deliver on mother’s abdomen



Dry thoroughly with dry warm cloth then remove all wet linen



Place on uninterrupted skin to 36

DR Nurse

DR Nurse

skin contact in prone position 

Sterile cord clamping once pulsation stops



Encourage breastfeeding once with feeding cues



After 60 mins of skin-to-skin contact and adequate latching on:

DR Nurse

o Erythromycin ophthalmic ointment OU o Vit K 1mg IM (0.5mg for preterms) o Hepa B 0.5 ml IM o Anthropometric measurements and record o Initial P.E. and Maturity Scoring and record 

Minimize handling of the newborn unless necessary



Room in with mother



Keep with mother on skin to skin contact and cover with warm dry blanket & bonnet



Encourage direct breastfeeding per demand



Keep normothermic at all times



Bathe only after the 6th hour of life



Watch out for difficulty of breathing, early jaundice, feeding difficulties



Refer accordingly

g. New born screening after 24 hours of life.

NICU Nurse

Episiotomy PROCEDURES

PERSON/S RESPONSIBLE 37

a. Explain to patient what will be done and what she can expect to feel.

DR Nurse

b. Prepare the instruments and anesthetics. c. Perineal flushing and cleaning with antiseptics.

DR Nurse DR Nurse

d. Place sterile drape.

DR Nurse

e. Assist obstetrician during the procedure.

DR Nurse

Health Teachings        

Encourage breast feeding Personal hygiene Diet Proper care of the newborn to include: precautions regarding hypothermia, aspiration precautions, feeding per demand and burping OPD visits for check up Immunization for baby Family planning for mother Medicines to be continued if available.

Umbilical Catheterization

a. b. c. d. e.

PROCEDURES Secure consent of mother, explain procedure. Prepare umbilical catheterization set Assist the Pediatrician during the procedure. Asses respiratory rate, colortemperature and general condition of the baby. Evaluate effectiveness of procedure.

PERSON/S RESPONSIBLE

NICU Nurse

Gastric Lavage PROCEDURES a. Prepare feeding tube Fr. #8 for term babies and Fr. #5 for pre-term babies; sterile syringe. Normal Saline Solution and sterile gloves b. Insert feeding tube gently thru the nose to the stomach. c. Check if the tube is in the stomach by:  aspirating gastric content, using a syringe  introducing 2-3 cc of air using a syringe. Auscultate with stethoscope and if there is a 38

PERSON/S RESPONSIBLE

NICU Nurse

gurgling sound the tube is in stomach. d. Introduce 2.5 cc Normal Saline Solution then aspirate it. Repeat the procedure until the return flow is clear. Gastric Gavage PROCEDURES a. Wash hands aseptically

PERSON/S RESPONSIBLE

b. Have the things needed ready such as gloves, syringe and milk and the feeding tube (If not yet in place). c. Insert the tube gently thru the nose to the stomach. d. Check if tube is in place by aspirating gastric content or by use of the stethoscope listen for the gurgling sound after introducing 2-5 cc air thru nasogastric tube.

NICU Nurse

Care of High Risk Neonate. PROCEDURES a. Maintain patent airway b. Maintain body temperature to 36.5 to 37.2 degree centigrade c. Monitor and record vital signs and report to pediatrician for any abnormalities d. Suction secretions as necessary e. Monitor HGT as per doctor’s order. f. Regulate I.V. fluids as ordered. g. Frequent hand washing by healthcare worker. h. Promote parent-child bonding by allowing mother to visit/hold baby encourage breast feeding.

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PERSON/S RESPONSIBLE

NICU Nurse

POLICY ON ADMISSION OF NEWBORN AT THE NEONATAL INTENSIVE CARE UNIT 1. Pediatric resident on duty will catch the baby whether a simple or complicated case. 2. Pediatricians will be notified by the Nurse on duty. 3. Direct rooming-in policy of the Department of Health is implemented, for babies delivered via Normal Spontaneous Delivery and 2 hours for those delivered by Caesarean Section. 4. Pediatricians are advised to attend all deliveries especially the high risk ones.

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VIII. CENTRAL SUPPLY ROOM PROCEDURES Requisition of Supplies from Supply Office to Central Supply Room PROCEDURES a. Checks stock levels or supplies and their availability; a.1 For supplies below 50% stock level, prepares a consumption report and Requisition and Issue Voucher to be submitted to the supply officer. b. Prepares requisition and issue voucher and forwards to Administrative Officer or Chief of Hospital for approval. c. Release the approved RIV

PERSON/S RESPONSIBLE CSR Head CSR Head

Supply Officer Supply Officer

Requisition of Supplies from Central Supply Room to Different Wards

Policy a. Issuances of supplies are strictly made between 7:00 AM to 9:30 A.M except for emergency cases.  Issuances of requests to offices are strictly made on Tuesday.  Stock level of at least 30% must be maintained in the ward.  Instruments borrowed must be signed out by the person taking it and signed in when returned.  All supplies transaction will be recorded on the requisition slip.  Items that are lost or stolen must have an incidental report for replacement.  End user shall prepare daily consumption report.

Procedure

PROCEDURES a. Receives supplies from Supply Officer

PERSON/S RESPONSIBLE Nursing Attendant (CSR Personnel) Nursing Attendant

b. Fill up requisition slip for supplies 41

c. Issues items requested by the different wards.

CSR Personnel

d. Encode items requested from the CSR.

CSR Clerk/ Encoder

Receiving and Sterilization of Used Articles PROCEDURES a. Brings used articles to the CSR from different clinical areas; b. Receives and checks used articles;

PERSON/S RESPONSIBLE Nursing Attendant/Borrower

b.1Indicates missing items, if any in the borrowers slip b.2 Acknowledges missing items, if any; b.3 Rewashes, dries and packs articles;

CSR Personnel

c. Labels packs indicating the contents and the date of sterilization

CSR Personnel

d. Arrange articles inside the autoclave for sterilization;

CSR Personnel

e. Sorts sterilized pack articles;

CSR Personnel

f. Informs units / end-users that sterilized articles are ready for use.

CSR Personnel

g. Records returned and borrowed items for documentation;

CSR Personnel

Issuance of Sterile Articles PROCEDURES

PERSON/S RESPONSIBLE

a. Prepares articles and supplies listed in the logbook;

CSR personnel

b. Issues articles to the Ward Nursing Attendant/borrower; c. Receives and checks sterilized items.

CSR personnel Nursing Attendant Ward Nursing Attendant/Borrower

d. Sign returned/borrowed items in the logbook.

Articles for Condemnation

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PROCEDURES a. Delivers items to be condemned to the CSR with proper documentation; b. Lists condemned articles and return to the Supply Office with proper documentation. c Updates inventory logbook.

PERSON/S RESPONSIBLE Ward Nursing Attendant/ Borrower CSR Personnel CSR Recorder / CSR Clerk

IX. REFERRAL PROCEDURES Referral to Other Health Facilities

PROCEDURES

PERSON/S RESPONSIBLE

a.

Physician Coordinates with referring institution Prepares clinical abstract, accomplishes referral form and gives it to the nurse.

Physician

If necessary arranges for ambulance conduction of patient.

Nurse

Follow discharge procedures.

Nurse

To Other Departments within the Hospital

PROCEDURES

PERSON/S RESPONSIBLE

a. Accomplishes interdepartmental referral form.

Physician

b. Forwards the referral form to concerned department

Nurse

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X. DISPOSITION OF PATIENT PROCEDURES Discharge of Patient PROCEDURES a) Examines and evaluate patient;

PERSON/S RESPONSIBLE Attending Physician

b) Indicates, in patient’s chart that he/she may go home; c) Prepares discharge plan and prescriptions needed for home treatment; d) Completes final diagnosis including the necessary documents needed for patient’s discharge.

Attending Physician

Attending Physician Attending Physician

e) Reviews chart for completeness; f) Gives health education discharge instructions to the patients/ relatives. g) Presents duly accomplished clearance. h) Sees to it that all equipment/items previously issued to the patient are returned;

Ward Nurse Ward Nurse Patient/Relative Ward Nurse

i) Discharges patient, cancel name from the ward directory and diet list;

Ward Nurse

j) Attaches Clearance Certificate to the patient’s chart

Ward Nurse

Discharges of Patient against Medical Advice PROCEDURES a) Requests discharge against medical advice b) Refers request to attending physician; c) Explain to patient/relative on the implications and consequences of discharge against medical advice

PERSON/S RESPONSIBLE Patient/Relative Ward Nurse Attending Physician 44

d) Indicates HAMA on patient’s chart

Attending Physician

e) Fills up HAMA form and request patient/ relative to sign;

Ward Nurse

f) Signs HAMA form. g) Reviews chart for completeness; h)Follow discharge procedures

Patient/relative Ward Nurse Ward Nurse

Discharge Procedures

PROCEDURES a) Writes discharge orders and forwards to the Ward Nurse; b) Checks patient’s record for discharge instructions and physician signature; c) Prepares Clearance;

PERSON/S RESPONSIBLE Physician Ward Nurse Ward Nurse

d) Forward the clearance to the other units concerned for signature to check patient’s accountabilities e) Forward clearance to the billing section. f) Prepares, computes patients bill g) Forwards to collecting clerk for payment. h) Receives payment and indicates OR number in the Clearance Certificate;

Nursing Attendant Nursing Attendant Billing Section Billing Section Collecting Clerk

i) Issues Official Receipt (original copy) to the patient/relative and signs and issue Clearance Certificate in quadruplicate;

Collecting Clerk

j) Instruct patient/relative to forward Clearance Certificate to the Ward Nurse, Ward, Central Post and Main door Guard ;

Collecting Clerk

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XI. DISPOSITION OF CADAVER PROCEDURES Preparation of the Cadaver in the Ward:

PROCEDURES a. Removes everything attached to the patient and endorses personal belongings to the relative/ watchers; b. If unidentified, deposits personal belongings to the Cashier;

PERSON/S RESPONSIBLE Nursing Attendant

Nursing Attendant

c. Provides post-mortem care;

Nursing Attendant

d. Sends cadaver to the morgue; d.1 For abandoned cadaver coordinate with the Medical Social Service for appropriate action.

Nursing Attendant

Cadaver Disposal

PROCEDURES

PERSON/S RESPONSIBLE

a. Prepare the cadaver, perform post mortem care. Attach name tag to the body.

Nurse Attendant

b. Prepare and sign cadaver disposition form. Handover the same to the nurse attendant.

Nurse on Duty

c. Bring cadaver to the morgue//Cadaver Holding Room. d. Give the cadaver disposition form to the central post guard on duty.

Nurse Attendant

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Nurse Attendant

e. Verify the entries on the form with the cadaver’s identity. f. Attach signature to the form and forward the same to the laboratory personnel on duty. g. Inform the relative to settle the account and contact funeral service of choice. *As extension of service, the Laboratory personnel on duty may contact the funeral service in behalf of the relative. But it should be t he relative who will negotiate with the funeral service. h. Submit forms and clearance to the central post guard on duty.

Central Post Guard on Duty Central Post Guard on Duty

Central Post Guard on Duty

Laboratory Personnel

i. Settle the hospital bill. Secure clearance. * Billing/Pharmacy/MSS/SHO

Patient’s Relative

j. Verify hospital bill clearance. k. Verify and release the cadaver to the nearest kin. Let the relative sign the form and affix signature. Issue clearance form duly signed by laboratory personnel and relative. Retain duplicate copy of the clearance form.

Laboratory Personnel

l. Inform admitting section.

Laboratory Personnel

Laboratory Personnel

m. Receives the cadaver. Give clearance (hospital bill & clearance) to the guard.

Patient’s Relative

n. Receive clearances o. Assist the relative in loading the cadaver p. Check and retrieve the linen used.

Central Post Guard on Duty Central Post Guard on Duty Central Post Guard on Duty

Autopsy

PROCEDURES

PERSON/S RESPONSIBLE

a. Prepares and secures consent of the patient’s Relative for post-mortem examination;

Ward Nurse

b. Informs pathologist;

Ward Nurse

c. Takes cadaver to the Autopsy rooms;

Nursing Attendant

d. Performs autopsy on the cadaver; prepares autopsy report and files it;

Pathologist

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explains autopsy report to the family of the deceased; and e. Follow disposition of cadaver procedure. Nursing Attendant XII. LABORATORY – CLINICAL LABORATORY

1.

MANAGEMENT OF PHYSICAL FACILITIES The laboratory shall provide physical facilities with adequate space for the services rendered and ensures the safety and security of the staff, patients and visitors.

2.

LABORATORY SPACE AND FACILITIES The laboratory shall have adequate functional space commensurate its workload and related activities. These are provided in a well outlined and structured architectural design, scaled, labeled and identified.

3.

FACILITIES FOR PATIENT AND PERSONNEL Areas in the laboratory shall be properly designated and identified for patients comfort. The patients are not allowed to directly go inside the laboratory unless given authority to get inside by the senior medical technologists for a specific purpose in the laboratory. A pantry for personnel shall be allocated for their meals.

4.

FACILITIES FOR STORAGE Facilities for storage space and conditions shall be provided for laboratory specimens, documents, records, manuals, equipment, reagents, supplies, slides and blocks. These are properly labeled and identified sections in the laboratory.

5.

WASTE MANAGEMENT ON HAZARDOUS MATERIAL The laboratory shall follow standards and procedures set by the hospital for the proper disposal of waste and hazardous / infectious substances. The Laboratory maintains a monthly budget allocation on maintenance material such as disinfectant spray / solutions, garbage plastic, etc. and ensures availability at all times.  DISPOSAL OF BIOLOGICAL WASTE - All biological waste except urine must be placed in appropriate containers labeled with Biohazard symbol. This includes not only the specimen but also all the necessary materials with which the specimens come in contact. The waste is then

48

decontaminated following institutional policy like incineration, autoclaving or pick-up by a certified hazardous waste company.  SHARP HAZARDS - Sharp objects in the laboratory such as needles, lancets, and broken glass wares must be disposed in a puncture-resistant container that is conveniently located within the work area.  CHEMICAL HAZARDS - The same general rules shall apply for handling bio-hazardous materials to chemically hazardous materials. Every chemical in the work place should be presumed hazardous. The laboratory ensures that the policy on waste segregation of wet, dry and infectious material shall be done in accordance with the government laws and properly informed the garbage collector at all times.

EQUIPMENT AND INSTRUMENTS

The laboratory shall have an adequate number of operational equipment and instruments required for the provision of services. There shall be a system of technical validation, procurement and acquisition of equipment and instruments used in the laboratory. Technical validation shall be accomplished by the provider in the presence of the end users who shall signify the truthfulness of the technical validation of the machine. Procurement and acquisition of the equipments and instruments used in the laboratory. Shall be upon the recommendation of the Head of the Laboratory with proper documentation of the endorsement stating herein the need, usefulness and accuracy of performance of the equipment. As entered into a contract with the suppliers, the preventive maintenance will be scheduled or as the need arises. Upon installation, the equipment shall be checked, calibrated and undergo performance validation before it shall be put into use. The calibration schedule shall be documented on a logbook and or folder located in the section where the machine is placed and the performance validation shall be certified by the provider. Calibration of the equipments shall be done every six months or on a case to case basis. Repair shall be maintained by the provider as scheduled in the stipulated contract. Only authorized and trained personnel shall operate all equipment and shall calibrate and maintain them periodically and whenever indicated though sound management requires multi- tasking, each section of the laboratory shall be headed by a Medical Technologist who shall oversee the performance, calibration and quality control of the equipments and reagents. 49

Up-to-date instructions on the operation and maintenance of the equipment ( including manufacturers manuals) shall be readily available for the use of by the appropriate laboratory personnel. These are appropriately assigned in the section where the machine is and periodic review of said manual shall be done. There shall be written procedures for proper care, maintenance and cleaning of all laboratory equipment performed by trained personnel. The cleaning and maintenance of the laboratory and laboratory equipments shall be within the area of the responsibility of the section head or his designate. For proper monitoring the following policies shall be followed: a. Adequate lightning of the laboratory and the sections must be maintained b. Floors should be cleaned daily with appropriate cleaning agents. Walls are to be cleaned regularly. c. Drains should be of an adequate size and provided with adequate traps to prevent back sippage d. All refrigerators and freezers should be defrosted and cleaned thoroughly at least once a month or as necessary. Appropriate temperature shall be maintained at 2-6 degrees. Food and other drinks shall not be stored in refrigerators intended for reagents.

e. Electrical equipments necessitating grounding following manufacturer’s instructions. All electrical plugs, outlets and cords must be left in goodcondition. Frayed cord, exposed wires and damaged outlets shall immediately be repaired. f. Fire extinguishers shall be located in an accessible place. g.

Fire exits should be clearly identified and an evacuation plan should be in place.

Any equipment that is reported as defective and non-functional shall be taken out of service and shall be clearly labeled as being out of service, until it has been repaired and functional. It shall be the responsibility of the Department Head to turn in the condemned equipment to the DISPOSAL COMMITTEE for proper disposition. REFERRAL OF EXAMINATIONS OUTSIDE OF THE CLINICAL LABORATORY. (OUTSOURCING) To assure that laboratory tests requested by attending physicians are carried out although the laboratory does not offer such assay, the medical technologists on duty shall 50

still draw blood sample to the patient, properly labeled the blood sample and give the sample to the relatives of the patient. The attending physician may give suggestions where the relatives of the patient could send their blood sample for the specified test that is not available in the local laboratory.

SERVICE DELIVERY CUSTOMER NEEDS AND REQUIREMENTS Laboratory services shall select that will meet the needs and requirements of patients, doctor and other users of service The laboratory has a document that describes the following: 1) Range and scope of the services 2) STAT services available 3) Type of sample and amount needed for each type of test 4) Containers and preservative to be used for each test 5) Special preparation of patient, if any 6) Conditions of transport The document is distributed to all users of the services, and available in hospital nursing units, emergency room, and out-patient departments and physicians’ offices This document is updated on a regular basis (at least once a year).

CONTRACT Agreement with another clinical laboratory regarding provision of services shall be documented in a contract (MOA).

If another licensed laboratory provides laboratory services to the clinical laboratory, a procedure for the selection of and documenting contracts with a laboratory is established. This procedure ensures that requirements, including methods to be used, are adequately defined, documented and understood. Policy

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The head of the laboratory with the chief medical technologists shall review annually all existing Memorandum of Agreement to make sure that both parties are faithfully following the agreement. If another hospital or laboratory refers lab examinations to the clinical laboratory, a procedure to ensure the quality of laboratory services is followed. In the instances where inter laboratory referrals are received the Laboratory ensures that appropriate specimen sample identification and preparation is met before acceptance of the sample. The receptionist shall be responsible for this and makes sure that all pertinent data are herein provided in the request. Receiving of Laboratory Request The laboratory request shall contain all the information pertinent to the patient and his laboratory needs. The receiving of laboratory requests assures that pre analytical variables are intact meaning there is a one is to one correspondence with the patient identification and the specimen received. Hence forth, proper reception must indicate the following ; a. Name, age and sex of the patient b. Indicate OPD or In patient with the room number for in patient indicated c. Attending Physician d. Date and time request was received e. Date and time sample was collected f. State whether the test is a routine, STAT, ASAP g. Type of test procedure/s to be done h. For fasting specimens, indicate the time of last meal i. When appropriate current medications taken Rejection Criteria The sample collected should be sufficient to meet the amount of specimen required for the test. The laboratory reserves the right to reject the following The amount of the specimen should be proportional to the mount of anticoagulant If the specimen does not conform to the quantity required by the test like 5-10 ml for urine, pea sized for stool exam If the collection receptacle is not appropriate like matchboxes or cotton diapers for stool, contaminated urine sample Hemolyzed, icteric, lipemic samples as the same will interfere with certain laboratory determination For histopathologic examinations, in appropriately fixed specimens or non formalinized specimens 1 Improperly filled request 2 All grossly contaminated samples

3

In all of the above cases, the patient shall be informed immediately concerning his sample and repeat collection shall be suggested If the patient refuses to have the repeat collection all charges shall be reimbursed and apology is in order

SAMPLE COLLECTION 52

Sampling plan (e.g. timing, frequency ) and procedure for sampling will be developed and made available to laboratory staff and customer as can be reflected from the standard operating procedures (SOP) per section. The following standards shall be adapted for the purpose. 1 2 3

The phlebotomist shall introduce himself to the patient and state his purpose. The patient’s name should be asked directly to the patient, ask assistance of a relative or refer to the name tag in cases where the patient cannot verbalize. The patient shall be asked if she has complied with the preparations needed for the test.

SAMPLE COLLECTION PROPER The following guidelines shall be followed 1 The phlebotomy technique will be performed after locating the site of extraction 2 A 70 % Isopropyl alcohol will be applied at the site of puncture 3 A tourniquet will be applied on the forearm 4 Blood extraction proper will be done and the sample is placed on color coded tubes for the intended test 5 Pressure on the venipuncture site shall be applied after extraction for ten minutes 6 Samples should be labeled appropriately after extraction 7 Time of collection and the person who took the sample must be indicated in the request 8 The sample is thus directed to the appropriate section where the test will be performed 9 Details of the request shall be entered in the worksheet 10 After specimen processing preservation shall be done according to the sample type and in accordance with SOP It is imperative that the Chain of Custody shall be maintained Sample Custodian An authorized person(s) will be identified as the sample custodian. This person will be responsible for sample receipt and sample storage, and for assuring that chain of custody requirements are met. Sample custodian includes the following;  Phlebotomist - a registered medical technologist who will perform blood extraction of Out-Patients.  Warder – a registered medical technologist who will perform blood extraction of In-Patients.  MTOD – a registered medical technologist on duty to a particular section who will receive the laboratory request and specimen, and who will also perform the requested laboratory test to a particular specimen.

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 Section Head – a registered medical technologist who is responsible in monitoring the implementation of standard protocol for specimen handling to ensure specimen integrity. LOGGING AND RELEASING OF LABORATORY RESULTS 1

Laboratory results should be logged on the corresponding record book provided for each test. The complete details of the result should be indicated including pertinent data concerning the patient.

2

After logging the result in a record book a result form shall be properly filled up and signed by the medical technologists who performed the assay. Any questionable laboratory result shall be referred to the chief medical technologists or the head of the laboratory.

3

Panic values should be immediately verified and official results released to the receptionist.

4

The patients should present their official receipt when claiming their result.

SECURITY AND CONFIDENTIALITY OF LABORATORY RESULTS Security and confidentiality of laboratory results 1

Laboratory results are strictly confidential and only attending physician, nurses, floor attendant and patients’ relatives are allowed to get the patients result.

2

Out-Patients should present their official receipt and ID in claiming their result. Letter of authorization should be preferably given by the representative of the patient including the official receipt and ID in case he is not available or is not ambulatory.

3

Laboratory results for In-Patients are logged-out and properly signed by floor nurse as well as floor attendants on duty to make sure that the result is received and in good hands.

4

To preserve the integrity of laboratory results and ensure its confidentiality, unauthorized person is strictly prohibited inside the laboratory. This can be read on the entrance door of the laboratory.

5

Records of entry and exit of personnel/visitors and related data can be reflected on the logbook and time card located on the side gate and front lobby.

The guards are

responsible in monitoring the personnel and visitors of the hospital. 6

Laboratory personnel are not authorized to release laboratory results on other purposes without the permission of the patient and the Department Head. As the need arise, this should be referred to the Department Head.

7

Only Medical Technologists and Consultants of the department are allowed to handle laboratory procedures and records.

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8

Laboratory result logbooks and worksheets shall not be borrowed by unauthorized personnel and are not allowed to be brought outside the laboratory even by laboratory personnel. Documents needed to be prepared at the Tarlac Provincial Hospital, Department of Pathology and Laboratory Medicine shall include quality control manual (QCM), standard operating procedure (SOPs), worksheets, log books, equipment preventive maintenance, calibration records and training records. All documents relevant to the laboratory system shall be uniquely identified to include; a Title of document b date of issue; c edition; d the current revision date and/or revision number; e number of pages and f prepared by: g reviewed by: h approved by: It is required that: a. All documents issued to laboratory personnel as part of the quality system are reviewed and approved by authorized personnel prior to issue; b. A list or equivalent document control log that identifies the current valid revisions and their distribution is maintained; c. Only most recent versions of appropriate documents are available at locations where operations needed for effective functioning of the laboratory are performed; invalid or obsolete documents are promptly removed from all points of use, or otherwise assured against unintended use; and d. Documents are periodically reviewed, where necessary revised and approved by authorized individual(s).

MONITORING PERFORMANCE The laboratory shall have a system for collecting, recording and analyzing data to monitor quality performance. INTERNAL QUALITY CONTROL 55

The laboratory shall establish an internal quality control program to verify that, for every batch of examinations, the intended quality of results is achieved.

Performance of Internal Quality Control The laboratory runs appropriate control samples with every batch of examinations, reviews the results and releases the results if the control samples are within the control range.

Action when results of control samples are within control When the results of the control samples are within control range, the results of the batch are reported.

Action when the results of the control samples are out of control When the results of the control samples are outside the control range, the results of the batch of examinations are held and an investigation is done on the reagents, technique, calibration, control, etc. to determine the cause(s) of out of control. A LeveyJennings or the Multiple Westgard Rules shall be consulted for sources of errors.

Elimination of cause(s) of out of control When the cause(s) is (are) found, action is taken to eliminate the cause(s) and examinations on the batch are repeated. When the results of the control samples of the repeat examinations are within control range, the results of the batch are reported.

PERFORMANCE INDICATORS There shall be regular monitoring of performance indicators such as turn-aroundtime. Monitoring of turn-around-time of laboratory procedures The turn-around-time of selected laboratory procedures are monitored. Agreement of turn-around time with the users 56

The turnaround time set for each test group is acceptable to the Medical Staff and these is conveyed to the users.

INTERNAL QUALITY AUDIT There shall be a system for Internal Quality Audit (IQA) Policies and procedures for Internal Quality Audit To ensure accurate laboratory results Internal Quality Audit shall be performed regularly. Designation of Internal Quality Audit personnel The chief medical technologists shall randomly perform internal quality audit by checking the logbook and randomly verifying results with elevated values. Internal audit criteria, scope and method As mentioned above the internal audit will deal mostly on elevated results for such result may cause panic to the clinician as well to the patients. Such random review of the logbooks of different sections shall be performed to assess the accurateness of the results.

Internal Quality Audit Checklist An Internal Quality Audit checklist shall be formulated and be used in the future.

Internal Quality Audit Plan and Schedule The other units of the hospital may also perform internal quality audit to the laboratory as the need arises. This is to remove the bias between auditors and the department being audited.

Conduct of IQ Audits The IQ Audits are conducted according to IQ Audit plan and schedule set by the management. The management of the Department that has been audited ensures that actions are taken without undue delay to eliminate detected nonconformities and their causes.

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Internal Quality Audit Reports Reports on Internal Quality Audits conducted by other units shall be kept on file. Summaries with recommendations are submitted to management for appropriate action.

EXTERNAL QUALITY ASSESSMENT SURVEYS The laboratory shall participate in External Quality Assessment Surveys Participation in External Quality Assessment Surveys The laboratory applies and participates in the External Quality Assessment Surveys (EQAS) conducted by the National Reference Laboratories (NRL) and the Philippine Council for Quality Assurance in Clinical Laboratories(PCQACL) There is a record of receipt of samples for EQAS from the NRL/PCQACL. Performance of appropriate tests on EQAS samples The laboratory performs appropriate examinations on the EQAS samples received Submission of Results from EQAS samples The laboratory submits the results from EQAS samples to the organization running on the EQAS.

Action after receipt of analysis of laboratory performance in EQAS report Upon receipt of the EQAS report, the evaluations of the performance of the laboratory are reviewed and corrective actions are taken when needed. QUALITY IMPROVEMENT ACTIVITIES The laboratory shall develop and implement a system for quality assurance through continuing quality improvement activities. MANAGEMENT OF QUALITY IMROVEMENT ACTIVITIES The clinical laboratory shall establish a system for Managing Quality Improvement Activities.

Plan for Quality Improvement

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The clinical laboratory documents its plan for quality improvement which includes policies and procedures for identifying problems. Problem solving and primary preventive measures are herein established. Identification of problems or poor delivery of services The clinical laboratory shall establish a system for identifying problems or poor delivery of services. Records of complaints and negative customer feedbacks Records of negative customer feedbacks shall be kept and regularly reviewed. Reports on Monitoring Laboratory performance The clinical laboratory monitors indicators of laboratory performance Continuous Quality Improvement (CQI) or problem solving The clinical laboratory shall develop and implement a system for continuous quality improvement Structure for Quality Improvement The clinical laboratory designates a Quality Improvement Committee to perform QI studies Training of staff in QI Methodology The clinical laboratory sends designated staff for appropriate training in Quality Improvement methodology. The clinical laboratory shall participate in an EQAP administered by designated NRL or in other local and international EQAP approved by the DOH. The following are the designated NRL; 1. Research Institute for Tropical Medicine – Infectious 2. East Avenue Medical Center- Drug Testing 3. Heart Center of the Philippines – Cardiac 4. SACCL- HIV/AIDS 5. National Kidney Center – Hematology

Performance of QI studies The QI teams undertake QI studies to continually improve the quality of laboratory. Under this the laboratory shall maintain Inspection tools/SOP manual, Quality Control Reagents, Calibrated machines. Every activity shall be monitored and recorded in appropriate log books. Submission of Recommendation to the Management The QI teams submits its recommendation for the improvement of services to management. Implementation, Monitoring and Institutionalization 59

The QI team shall implement the approved recommendations, monitor the implementation and institutionalize of the successful recommendations Implementation of approved recommendation The QI team implements the approved recommendations for corrective measures Monitoring of implementation of approved recommendations The QI team monitors the implementation of the approved recommendations through appropriate indicators Analysis of monitoring data on indicators The QI team records and analyzes the monitoring data on indicators and submits recommendations on successful corrective measures Action of management for institutionalization of successful corrective measures The clinical laboratory management reviews and takes the necessary action for the institutionalization of successful corrective measures Primary Preventive Measures The clinical laboratory shall establish a system for the development and implementation of primary preventive measures

INFORMATION MANAGEMENT CUSTOMER RELATIONS The laboratory shall develop, establish and implement a system for ensuring proper communications with customers To achieve these there are memo/letter that communicate to the floors the available tests done in Tarlac Provincial Center, Department of Pathology and Laboratory Medicine. 60

There are policies and procedures that support the provision of services to the physicians. To communicate laboratory services to its Physician stakeholders, sample request forms are provided in each clinic to assure and assist Physicians in their decision when and what to use diagnostic modalities in the treatment of their patients. Such request shall be duly accomplished and signed by the attending physician There are policies and procedures that support the provision of services to patients. Similar request forms are provided in the out- patient division of the laboratory. To communicate laboratory services to its Patients stakeholders, the same are provided in a laboratory request on an out-patient basis and accompanied by appropriate instruction for patient preparation based on the specific test. The same shall be processed in the reception area and check for conformity with standard operational procedures. There are policies and procedures for promoting customer satisfaction. The laboratory provides for a customer satisfaction questionnaire form at its out-patient. To assist the laboratory of its systems and processes, a patient and stakeholder’s customer satisfaction form is provided by the hospital. The same are collected on a daily basis, evaluated and assessed based on a point score. All aspects in the customer satisfaction form that do not meet a satisfaction rating above 8 shall be subject to Department review in a regular and or in a special meeting. The same shall be acted upon with dispatch with a letter of apology and corrective measures done to the concerned stakeholders. There are policies and procedures for measuring and ensuring customer satisfaction. A feedback form may be asked at the hospital information area for assessment of the different unit of the hospital. Such is important for the development and improvement of services of the different unit of the institution.

COMMUNICATION The laboratory shall establish, implement and monitor a system for ensuring appropriate and effective External and Internal Communication External Communication (Inter- department communication) For the purpose of orderliness in Laboratory processes, it is a policy that all official results are conveyed in a duly authenticated, verified, signed by the Medical 61

Technology staff and validated by the Chief Medical Technologist/ Senior Staff and or Head Pathologist. This will ensure that post analytical processes have been completed and certified to be correct. Any discrepancy in the original and final drafts of the report shall be immediately corrected. Should a result has inadvertently reached the attending physician, an immediate cell/ phone call be made before any untoward and inappropriate management is rendered. INTERNAL COMMUNICATIONS (intra- department communications) The laboratory shall maintain a system of communication in a special log book provided for in the form of an endorsement log book. All that transpired in the shift shall be legibly written and if an endorsement needs emphasis an asterisk be appropriated before the said concern. Such endorsement shall contain the following information WHO is endorsing – ex. Section Head of Clinical Microscopy WHAT is being endorsed – ex. repeat stool specimen collection WHEN should the endorsed activity be accomplished – ex. as soon as the specimen is submitted WHY is the endorsed activity not accomplished – ex. previous specimen is insufficient and or contaminated HOW should the endorsed activity be completed- ex. notice to the floor nurse be followed up

A monthly meeting shall be conducted by the Head of the Laboratory and the minutes of the said meeting be transcribed for documentation and future reference. All corrective measures for laboratory procedures and processes that do not conform to the standards set by the Department shall be reviewed and acted upon. Any new laboratory tests shall be assigned to a staff for presentation. All immediate communications shall be documented by the Chief Medical Technologist and the same be communicated to the Head for appropriate action.

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DOCUMENT AND RECORD CONTROL There shall be a system for the management and control of all policies, procedures , laboratory forms and results Material/Record General Laboratory Accession log Maintenance/instrument maintenance records Quality control records

Period of Retention 2 years 2 years 2 years

Surgical Pathology (including bone marrows) Wet tissue Paraffin blocks Slides Reports

2 weeks after final report 10 years 10 years 10 years

Cytology Slides (negative-unsatisfactory) Slides (suspicious-positive) Fine needle aspiration slides Reports

5 years 5 years 10 years 10 years

Non-Forensic Autopsy Wet tissue Paraffin blocks Slides Reports

3 months after final 10 years 10 years 10 years

Clinical Pathology Records Patient test records 2 years Serum/CSF/Body fluids (except urine) 48 hours Urine 24 hours Peripheral blood smears/body fluid smears 7 days Permanently stained slides – microbiology (gram, trichrome, 7 days etc) Cytogenetics Records Permanently stained slides Final reports Diagnostic images (digitized, prints or negatives)

3 years 20 years 20 years

Blood Bank Donor and recipient records 10 years Patient records 10 years Records of employee signatures, initials, and identification 10 years 63

codes Quality control records 5 years Records of indefinitely deferred donors, permanently deferred Indefinitely donors, or donors placed under surveillance for the recipient’s protection (e.g., those donors that are hepatitis B core positive once, donors implicated in a hepatitis positive recipient) Specimens from blood donors units 7 days post-transfusion and recipients

XIII. RADIOLOGY DEPARTMENT POLICIES AND PROCEDURES RADIATION SAFETY MANAGEMENT Purpose: To provide a safe and effective environment of care consistent with the hospital’s mission, services and with statutory legislations by managing the risks associated with radiation. To provide a framework for the conduct of assessment of radiation exposure. To provide a mechanism for the education and training of hospital personnel on radiation safety. Policy: 1. Shall have a radiation safety officer responsible for the conduct of the radiation safety program. 2. Shall have a radiation program, procedures to ensure the protection of patients, personnel and the general public. 3. Shall provide for the training and education of its personnel in regards to radiation safety. 4. Shall have and maintain adequate equipment and facilities to ensure the safety of individuals. 5. Shall conduct periodic review and assessment of hospital facilities and equipment adequacy as part of the overall plan on the hospital safety manual. 6. Shall put into place a system to document and record all radiation safety activities. 7. Shall have and maintain adequate communication and coordination systems with local authorities in regards to radiation safety. 8. Radiation safety policy and plan shall remain consistent with and serve as a part of the Hospital Safety Manual. Procedures and Guidelines: Preventive Maintenance Program 1. A monthly inventory and assessment of equipment shall be conducted by the imaging head with the admin staff. 2. Problems noted such as malfunctioning shall be immediately reported and requested for action. 3. Corrective measures are to be undertaken immediately and documented. 4. Complete documentations are to be submitted to the Supply Officer. 64

Hazard Surveillance and Risk Assessment 1. The Safety Committee together with the imaging Head and maintenance staff shall conduct a semi-annual walk through of the facility and its surrounding premises to determine hazards and identify risks associated with this. 2. A comprehensive report on the findings of the walk through shall be prepared by the team with recommendations on the team. 3. If need be, professional consultation shall be made. 4. Corrective actions to reduce the risk shall be made. 5. A monthly inspection of the identified hazards shall be done in order to determine risk level. 6. Documentation for all activities shall be done. Personal Protective Equipment 1. Personal protective equipment shall always be used by radiology staff whenever an exposure shall be made. 2. Patients must also be instructed to wear / use applicable personal protective equipment. Radiation Protection: a) A “RED” warning light bulb that is automatically illuminated when x-ray machine is switched on shall be installed outside the x-ray examination room above the room door. b) Door leading to the x-ray room shall be closed during examination. c) The useful beam shall be collimated to the area of clinical interest. d) In order to minimize the intensity of unintentional irradiation of the embryo or fetus. This advisory notice should be posted “IF IT IS POSSIBLE THAT YOU MIGHT BE PREGNANT NOTIFY YOUR PHYSICIAN BEFORE YOUR XRAY EXAMINATION.” e) Radiography of areas remote from the fetus, such chest, skull or extremities, can be done safely anytime during pregnancy. If the x-ray equipment is properly shielded and if proper x-ray beam is used. Sensitive body organs (LENS OF THE EYE, GONAD) shall be provided that such shielding does not eliminate useful diagnostic information. When patient must be held during examination, all efforts shall be undertaken to avoid having assistance provided by the person who works with in the x-ray department. No pregnant woman or person under the age of 18 years old shall be permitted to hold the patients. Person holding the patient shall wear protective aprons and gloves. Even in protective clothing is worn make sure as far as practicable that no part of their body is in the path useful beam. For The Protection of The Patient: abcdefghi-

Proper choice of exposure factors. Correct positioning of the patient. Limiting the beam to the area of clinical interest. Use of gonadal shielding. Use of lead rubber apron. Use of x-ray filters. Use of intensifying screen. Proper instruction to the patient. Proper darkroom procedure. 65

The Protection of The Radiation Workers: 1) 2) 3) 4) 5)

Avoid repeat examination. Proper collimation of the beam. Use of protective barrier. Use of lead rubber apron. Never nor hold the patient during diagnostic examination unless in an emergency.

For The Protection of The General Public: A- Design of x-ray facility. B- Location of x-ray room. SAFETY POLICIES 1. Door leading to x-ray room should be always closed specially during examination. 2. Useful beam shall be collimated to the area of interest. 3. Sensitive body organ shall be shielded whenever they are likely to be exposed to the beam provided that shielding does not eliminate useful diagnostic information. 4. Person holding the patient shall wear protective aprons and gloves. 5. When performing fluoroscopy procedures protective aprons shall be worn by each person with in the exposure areas, except the patient. 6. No person below 18 years old or pregnant is allowed to hold patient. 7. When pregnant women are to undergo x-ray procedures the following are to be noted: a. X-ray examination in which the beam irradiates the fetus directly, special care to be taken to ascertain that the examination is indeed indicated at that time and that it should not be delayed until after pregnancy. Greater than the usual care should be taken to minimize that absorbed dose in the fetus for each irradiation. Alternations of technique should not be reduced unduly the diagnostic value of x-ray examination. b. Radiography of areas remote from the fetus such chest, skull, or extremities, can be done safely at anytime during pregnancy, as long as the equipment is properly shielded and proper x-ray beam limitation is used. 8. A Red warning light bulb is illuminated when the x-ray machine is switched on and it also warns the people “NOT TO ENTER WHEN THE RED LIGHT IS ON”.

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XIV. DENTAL

DENTAL SERVICE POLICIES AND STANDARD PROCEDURE Policies 1. The affairs of the service shall be conducted in accordance with the established administrative procedures of the hospital. 2. Dental operative and surgical work shall be performed if it will aid the physical and general conditions of the patient as determined by consultation with the attending physician. Accurate and complete dental records shall be incorporated in the history of the patient. The attending dentist should know the medical condition of the patient and should have a working knowledge of the drugs administered or previously taken by the patient. 3. Treatment of patients shall be on a” first come, first serve” basis except in cases of emergency which should be treated in the order of priority or exigency. 4. Shall be on call in cases of emergency. 5. Reports and records, in addition to hospital records shall be kept. 6. Shall not diagnose cause of death or sign the death certificate. 7. Shall provide emergency treatment for traumatic injuries involving the jaw or the temporary fixation of fractured facial bonesbefore transfer of patient to a more specialized hospital. TREATMENT OF PATIENTS

PROCEDURES 1. Present registry card.

PERSON/S RESPONSIBLE Patient

2. Fill out Individual Dental Health Record (IDHR) 3. Give Dental Health Record to Dentist 4. Examine patient and determine treatment needed. 5. Accomplished IDHR indicating treatment to be given and give to Dental Aid. 6. Prepare Charge Slip and give the original to patient.

Dental aid

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7. Instruct patient to pay amount corresponding to the treatment to be given as indicated in the charge slip.  If patient cannot afford to pay, refer him to Medical Social Worker.  Interview and classify patient Medical Social Worker  Indicate in the charge Slip amount patient agreed to pay. If fully indigent, have the certificate of indigency signed. 8. Pay required amount to the cashier.

Patient

9. Received payment and issue official receipt 10. Indicate official receipt number and amount on the charge slip.

Cashier

11. Present official receipt or certificate of the indigency to the Dental Aid. 12. Refer patient to Dentist

Patient Dental Aid

13. Treat or perform extraction as the case may be. 14. Fill out the prescription for the medicine and indicate on the individual dental health record the dental treatment done.

Dentist

15. Record in the logbook the service or treatment rendered. 16. Give the official receipt to patient. 17. Leave chart and charge slip for file.

Dental Aide

Reporting Procedures PROCEDURES 1.Consolidate daily record or treatment and examination. 2. Submit reports to the Dental Head,

PERSON/S RESPONSIBLE Dental Aide

3. Review and sign submitted report. 4. Give to dental Aide

Dental Head,

5. File documents for reference.

Dental Aide

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XV. FINANCIAL MANAGEMENT SERVICES FINANCIAL MANAGEMENT DIVISION PURPOSE: To manage the hospital financial activities and keep administration (provincial health officer) informed of financial condition of institution for purpose of hospital planning and control, and to admit patients to hospital in accordance with policies and regulations established by local government unit and administration (provincial health officer).

RESPONSIBILITIES:  Responsible for the financial activities of the hospital which encompass receipts of revenues and expenses.  Responsible for the preparation of income and expense comparisons of gross earnings and costs of revenues producing department and is also responsible for preparation of reports to outside agencies (local government units).  Responsible for developing administrative systems and procedures; this can include responsibility for determining a patient’s ability to pay, established rates for services, and making necessary financial adjustments if patient cannot meet his full obligation. ROLE AND IMPORTANCE OF FINANCE DEPARTMENT  Ensure that there are adequate funds available to acquire the resources needed to help the organization achieve its objectives.  Ensure costs are controlled, adequate cash flow; establish and control profitability levels. FUNCTION: 69

The financial management services ensures adequate and timely financial report by providing services related to accounting, billing, budget, cashiering and health maintenance. GENERAL POLICIES:  Existing government budgeting, accounting and auditing rules and regulations shall govern the financial transactions and operations of the hospital.  Existing government directives on patient’s rights, benefits and privileges, whenever applicable, shall be incorporated in the patient’s billing and claims.  Income shall be properly monitored.  For purposes of cost recovery, proper cost-finding and rate-setting of services shall be done. BUDGET FUNCTION: Directs and coordinates with the different departments concerned in the consolidation and preparation of the budget proposal, work and financial / operational plans including its implementation and monitoring.

POLICIES:  Expenditures of government funds shall be in accordance with the commission on audit rules and regulations.  Availability of allotment shall be certified in accordance with the general appropriations act.  All financial transactions shall be based on the work and financial plan with duly supported documents.

RESPONSIBILITIES:  Prepares annual budget calendar by coordinating department schedules, complying with laws requiring special notifications and time periods.  Recommends strategies and works with departments to develop schedule and instruments to facilitate departmental budget preparation and serves as the liaison with finance and other departments to implement budget objectives.

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 Monitor budget and financial reports and completes detail account analysis for irregularities, account limits, to ensure fiscal goals set by management are being met.

 Designs, develops and implements system and procedures for projecting, monitoring and analyzing budgetary expenditures.  Assists in projecting revenues for the budget, analyzes projections for consistency, completeness and accuracy for each department.  Coordinates with departmental representative to review plans, determine budgetary needs, gather information, monitor programs, and make recommendations on budget preparation, presentation, implementation and interpretation.  Prepares reports on departmental budget activities, and provides support in the development of short and long term budget plans.

STANDARD OPERATING PROCEDURES RECEIVES / RECORDING OF ALLOTMENT:

PROCEDURES

PERSON/S RESPONSIBLE

1. Receives / Records the approved budget.

Releasing Staff

2. Prepares / Posts the allotment in the corresponding registries.

Budget Officer

REQUEST FOR FUNDING:

PROCEDURES

PERSON/S RESPONSIBLE

1. Receives / Records Purchase Requests, Payroll and et al.

Budget Officer

2. Examines / Verifies completeness of supporting documents.

Budget Officer

3. Determines / Verifies the availability of funds.

Budget Officer

4. Assigns appropriate expense code.

Budget Officer

5. Forwards all documents Administrative Officer for initial.

to

the 71

Budget Officer

6. Forwards to the Chief of Hospital for signature.

Administrative Aide III

7. Forward to the Provincial Capitol for processing and final approval.

Liaison Officer

BUDGET PREPARATION:

PROCEDURES

PERSON/S RESPONSIBLE

1. Arranges Budget Meeting with Administrative Officer, Provincial Health Officer, and Units/Section Heads.

Budget Officer

2. Give instructions on the details of the budget call

Budget Officer

3. Request Unit/Section Heads to submit their respective plans of operations to the Supply Officer.

Budget Officer

4. Submits plans of operation based on specific objectives including justification for proposals to the Budget Officer.

Units/Section Heads

5. Discuss plans and proposals with the respective Units/Section Heads to ensure conformity with hospital objectives and targets.

Budget Officer

6. Prepares and submit final plans and proposals to the Budget Officer.

Units/Section heads

7. Reviews and consolidates plans and proposals and accomplishes Budget Preparation Forms, then forwards such forms to the Administrative Officer.

Budget Officer

8. Recommends approved and forwards to the Provincial Health Officer for approval.

Administrative Officer

9. Signs Budget and returns to the Budget Officer.

Chief of Hospital

10. Gets file copies and submit them to the Provincial Budget Officer.

Budget Officer

PREPARATION OF THE WORK AND FINANCIAL PLAN

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PROCEDURES

PERSON/S RESPONSIBLE

1. Prepares Work and Financial Plan for the Hospital using appropriate forms, then forward to the Administrative Office for review.

Budget Officer

2. Initials the Work and Financial Plan and forwards to the Chief of Hospital.

Administrative Officer

3. Reviews and signs work and financial plan and return it to the Budget Officer.

Chief of Hospital

4. Gets file copies and submits to proper authorities, Provincial Budget Officer.

Budget Officer

PREPARATION OF COMMUNICATION / REQUESTS ON BUDGETARY MATTERS: PROCEDURES 1. Prepares draft of request for additional / allotment / realignment of funds. 2. Forwards the draft to the Chief of Hospital 3. Receives / Records the correct draft.

PERSON/S RESPONSIBLE Budget Officer Budget Officer Budget Officer

4. Finalize the request and forwards to the Chief of Hospital for approval. 5. Forwards to the Provincial Capitol for final approval.

Budget Officer Budget Officer

ACCOUNTING

FUNCTION: Directs and coordinates the systematic recording of all financial transactions, preparations of financial statements and relevant reports. POLICIES:  Shall be accountable in safeguarding government resources against loss or shortage.  All financial transactions shall be supported with complete documents in compliance with existing accounting and auditing rules and regulations.  Public accountability shall be strictly observed in the conduct of government activities and operations.

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RESPONSIBILITIES:  Implements the generally accepted accounting and auditing principles.  Implements and monitors a systematic recording of financial transactions.  Ensures that the implementation of accounting practices as to disbursements of funds is in accordance with commission on audit rules and regulations.  Provides data to the budget section, the analyzed financial statement.  Provides financial information that would help in making decisions involving the effective and efficient allocation and control of government resources.  Provides financial statements, income statements and cost reports to reflect financial condition of hospital. Traces errors and records adjustments to correct charges or credits posted to incorrect accounts.

STANDARD OPERATING PROCEDURES Processing of purchase requests and order / market order and other supplies:

PROCEDURE

PERSON/S RESPONSIBLE

1.Receives / Records Purchase Requests Order / Market Order and other supplies.

Supply Officer

2.Reviews completeness and appropriateness of supporting documents.

Administrative Aide III

3.Checks and verifies computations.

Administrative Aide III

4.Forwards to the Administrative Officer for initial.

Administrative Aide III

5.Forwards to the Chief of Hospital for signature.

Administrative Aide III

6.Forwards to the Provincial Capitol for approval.

Liaison Officer

PROCESSING PAYMENT / CLAIMS: 1. Processing of payroll, first salary and other personnel benefits.

PROCEDURE

PERSON/S RESPONSIBLE

1. Reviews appropriateness of supporting 74

documents as to computation and in compliance with Commission on Audit rules and regulations.

Administrative Aide III

2. Reviews ALOBS and amount in the voucher / payroll.

Administrative Aide III

3. Forwards the documents to the Administrative Officer for initial.

Administrative Aide III

4. Forwards to the Chief of Hospital for signature.

Administrative Aide III

5. Forwards to the Provincial Capitol for processing.

Liaison Officer

b. Processing of Vouchers and Bills 1. Training and Travel Expense PROCEDURE

PERSON/S RESPONSIBLE

1. Attachment of necessary documents from different agencies regarding seminars, conventions and meetings. 2. Approval of Travel Order

Administrative Aide III

Governor

3. Submission of Official Receipts, Certificate of Appearance/Attendance, Accomplishment Report and approved Travel Order.

Different Department

4. Prepares Appendix A and B, Obligations Request and Disbursement Vouchers and duly signed by Chief of Hospital/Provincial Health Officer.

Budget Officer

5. Forwards to the Provincial Capitol for processing.

Liaison Officer.

2. Billing Statements/ Statements of Accounts PROCEDURE

PERSON/S RESPONSIBLE

1. Receives Billing statement

Administrative Aide III

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2. Prepares Obligations Request and Disbursement Vouchers and duly signed by Chief of Hospital/Provincial Health Officer. 4. Forwards to the Provincial Capitol for processing.

Administrative Aide III

Liaison Officer.

BILLING AND CLAIMS

FUNCTION: This section implements proper charging system, by recording all hospital procedures, services, medical supplies, drugs and medicines including claims fees and use of facilities incurred to patients regardless of patients classification.

POLICIES:  Proper billing of patients and hospital services shall be based on applicable policies, rules and procedures. a. TPH and PHO Personnel are directed to refrain from following up of patient’s bill; personally accompanying patients / relatives to the Medical Social Service and making unauthorized transactions with hospital patients. b. Discount for Pay Patients – 5% to10% discretion of the Chief of Hospital. b.1. Pay ward except private room b.2. House case (attending doctor is a resident or employed consultant of the hospital). b.3. Immediate members of the family i.e. children, husband or wife if not covered by the PhilHealth Insurance. Basis – Lack of Funds – Courtesy accommodation to Public Officials and Members of the Media. c. Senior Citizen – Base on Senior Citizen Law. Admitted Patient: Pay Patient – 20% discount Service Ward – Full discount Out Patient – 20% discount d. Cultural Minority and Malnourished patient – full discount e. PhilHealth – PhilHealth requirements e.1. Excess Bills

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- no excess payment on PhilHealth Sponsored Program (PhilHealth Sa Masa program) - for TPH employees 20% discount.  For admitted patients all drugs, medicine and supplies shall be provided for the 1st 24 hours regardless of their classifications.  Philhealth patients/members should comply with the requirements within 24 hours, non compliance are obliged to pay for their daily bills.  Patient / client shall be assured of prompt access to billing information (progress billing) for all services provided.  All hospital diagnostic and therapeutic procedures and other services rendered including drugs, medicine and supplies issued to patients shall be properly charged. RESPONSIBILITIES:  Posts and records the actual bill rendered and actual amount paid in accordance with their category classification – level I, level II, service, pay, Philhealth, veterans, cultural minority and senior citizens.  Prepares the monthly, quarterly, semi-annual and annual report.  Prepares the monthly census.  Monitors and evaluates the monthly consumption report of different department.  Prepares periodic analysis of receivables versus collections.  Reviews and processes PHIC and other claims  Monitors account receivables and follow up outstanding and overdue accounts.

STANDARD OPERATING PROCEDURES DISCHARGING OF PATIENT

PROCEDURES

PERSON/S RESPONSIBLE

1. Receives all clearance for discharged for the day, duly signed by the Pharmacist, Laboratory & X-Ray to make sure that all charges of the patient are already forwarded to the Billing Office.

Billing Clerk

2. Receives discharge notice of patients from nurse station.

Billing Clerk

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3. PhilHealth patients are required to submit all necessary documents. 4. Computes the patient’s bill.

Admitting Clerk Billing Clerk

5. Forwards the bill to the collector 5.1. Pay patients can settle their obligations anytime during office hours. 5.2. Service patients – in case the patient cannot afford to pay their bills he/she is advised to go to the Medical Social Worker for evaluation. 6. Issues statement of accounts of the patient. ( as per request)

Billing Clerk

Billing Clerk

PREPARATION OF REPORT

PROCEDURES

PERSON/S RESPONSIBLE

1. Prepares monthly, quarterly, semi-annual and annual reports

Designated Staff

2. Reviews / Certifies as to the correctness of the report.

Administrative Officer

3. Forwards to the Chief of Hospital for approval.

Designated Staff

PREPARATION OF PHIC CLAIMS

PROCEDURES 1. Submit PhilHealth supporting documents.

Form

PERSON/S RESPONSIBLE and

other

Patients Relatives

2. Receives and checks forms and other supporting documents.

Reviewing Clerk

3. Computes the allowable PhilHealth benefits of patients.

Billing Clerk

4. Fills up the required data in the PHIC form as to the breakdown of drugs, medicine and others.

PhilHealth Clerk

5. Received medical chart to be paired with the PhilHealth claims for processing.

PhilHealth Clerk

6. Process PhilHealth Claims

PhilHealth Clerk

7. Forwards the PhilHealth Claims to the

PhilHealth Clerk

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Administrative Officer for signature. 8. Transmit and submit the signed claims to the PHIC.

Liaison Officer

COLLECTION AND DISBURSEMENT FUNCTION: This section directs controls and ensures the proper disbursement and collections transaction of the hospital. POLICIES:  All collecting / disbursing officers shall be properly bonded.  All collections shall be properly receipted, safe kept and deposited intact daily.  Records of all monetary transactions shall be properly maintained in the cash book.  Preparation and submission of required reports shall be observed before dead line.  Official receipts should be recorded in numerical sequence; cancelled official receipts should be reflected.  Cash advance and its liquidation shall be in accordance with the commission on audit rules and regulations.  No officer or employee shall be granted a cash advance unless he/she is properly bonded. RESPONSIBILITIES:

 Implements the prescribed disbursement systems and procedures.  Monitors the receipts of collection and deposits  Pays other monetary benefits of hospital employees.

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 Maintains records of cash collections, deposits, disbursements and other related transactions.  Verifies the accuracy of the cash collections.

STANDARD OPERATING PROCEDURES RECEIPTS / REPORTS OF COLLECTION AND DEPOSITS PROCEDURES

PERSON/S RESPONSIBLE

1. Issues Official Receipts to acknowledge receive of cash / check.

Collecting Clerk

2. Indicates OR number in the Order of Payment

Collecting Clerk

3. Prepares report of collection

Collecting Clerk

PAYMENTS OF CLAIMS PROCEDURES

PERSON/S RESPONSIBLE

1. Receives payroll

Cashier

2. Verifies the completeness and correctness of the signatories and source of funds.

Cashier

LIQUIDATION

PROCEDURES 1. Checks / Reviews completeness correctness of documents

PERSON/S RESPONSIBLE and

Cashier

2.

Checks the appropriate boxes for received portion and signed.

Cashier

3.

Stamped ‘PAID’ of disbursements.

Cashier

ADMITTING SECTION FUNCTION: Directs and controls the centralized registration and documentation of admission and discharges of patients and ensures the confidentiality of documents. 80

POLICIES:  The hospital shall designate a room for patient registration to be known as admitting section.  The admitting section shall be provided with adequate staff and facilities to effectively perform the required functions.  The hospital shall implement a centralized documentation system of admission and discharged patients.  All important documents shall kept in the admitting section pertinent to DOH and PHIC requirements.  Patient’s rights shall be respected at all times.

RESPONSIBILITIES:  Encodes the personal data of admitted patient and assigns hospital I.D. Number.  Coordinates with the ward nurses in updating the status of the patient and monitors the vacant beds for immediate use/assignment to facilitate admission of new patient.  Coordinates with the concerned department/sections, namely:

-

Medical Social Service – classification and the capacity of the patient/family to pay.

-

Medical Records – statistics

-

Billing and Claims – supporting documents of Phil Health and Patients Bill.

-

Nursing Service – Availability of beds and completion of important documents/charts.

 Provides relevant information to authorized persons.

STANDARD AND OPERATING PROCEDURES ADMISSION OF PATIENT PROCEDURES

PERSON/S RESPONSIBLE

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1. Receives notice of Admission.

Admitting Staff

2. Verifies patient’s record:  If old, retrieves Patient’s Record to get the Case # of previous confinement.  If new, assigns and/or issues patient’s Hospital I.D. # and prepares patient’s data.

Admitting Staff

3. Prepares patient’s data in 2 copies for distribution to Medical Records and file copy.

Admitting Staff

4. Records the patient’s admission.

Admitting Staff

5. Collects and records patient’s admitting diagnosis in the Clinical Cover Sheet.

Admitting Staff

6. Validates information and secures signature of patient/informant in the Clinical Cover Sheet.

Admitting Staff

7. Coordinates with the ward nurses for bed assignment/patient’s admission.

Admitting Staff

8. Coordinates with the Medical Social Service patient classification and the billing and Claims for billing requirements.

Admitting Staff

RESERVATION Policy:  Reservation can be done anytime. On a first come first serve basis.  Reserved room should be paid in advance and is non-refundable. PROCEDURES 1. Informs the patient/relative availability of rooms and room rates.

PERSON/S RESPONSIBLE of

the

2. Advice the patient/relative to pay the reservation fee at the billing section.

Admitting Staff Admitting Staff

DISCHARGED OF PATIENT PROCEDURES

PERSON/S RESPONSIBLE

1. Receives Discharged Clearance Slip from the Billing Section.

Admitting Staff

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2. Records patient’s discharged.

Admitting Staff

MEDICAL RECORDS SECTION Function Provides an organized system of measuring quality patient care and ensures that sufficient data is written in sequence of events to justify the diagnosis, evaluates the treatment and end results. This section is responsible for the processing and analyzing, maintenance and safekeeping of all medical records created/maintained in the hospital in the course of giving medical care to patients. Policies    

The Medical Records Section shall serve as an archive of all patients’ records in accordance with the principles and practices of efficient and effective medical records management. It shall be maintained with complete statistical and clinical data of patient for future references in accordance with legal, accrediting and regulatory requirements. The confidentiality of patient’s medical records shall be strictly observed. Aging of medical records for appraisal and disposal shall be done in accordance with approved Records Disposal Schedule.

Responsibilities     

Prepares and implements a Comprehensive Medical Records Management Plan. Maintains all patient records in accordance with the principles of an effective and efficient medical record management and safeguards the confidentiality of the medical records. Reviews records for completeness and accuracy and ensures that all reports and results are promptly and accurately filed in the corresponding patient record. Provides records of patient data for use in approved research programs as an educational tool in the training of and feedback to the staff, Responds to subpoenas issued by regular court of law and other competent authorities.

Standard Operating Procedures (based on DOH Manual) A. An accurate record is maintained to facilitate optimal patient care and allow for evaluation of the care provided.  The record is sufficiently detailed to enable: 83

    

The patient to receive continuing care Effective communication within the health team The Attending Physician to have available information required for the consultation Other medical practitioners and health personnel to assume the patient care Concurrent or retrospective evaluation of patient care

 Entries into the records are made only by duly authorized persons of the facility and are dated and signed, containing designation.  All entries, including alterations, must be eligible.  Only abbreviations and symbols approved by the Medical Record Committee are tobe used.  If possible, original copies of all reports made by medical, nursing, and allied healthprofessionals are filed in the record.  Each record should at least contain the following data:      

A unique medical record number or reference Patient’s full name Address Date of birth Sex F. Person to notify in case of an emergency

 An “ALERT” notation, for the conditions such as allergic responses and drugreactions, is prominently displayed on the face sheet of the record.  The record contains a written admission diagnosis by the medical practitioner.  The record contains a patient’s history, pertinent to the condition being treated, including relevant details of:   

Present and past medical history Family history Social considerations

 A sufficiently detailed report of a relevant physical examination (PE), performed by a medical practitioner, should be included for the purpose of admission.  Evidence that the patient has given informed consent is available.  Drug orders are written in the record by the medical staff.  Therapeutic orders and orders for special diagnostic test are noted in the record.  There is evidence in the medical record that patient care plans were made. 84

 Progress notes, observations, and consultation reports are written by medical, nursing, and allied health staff to record all significant events such as alterations in the patient’s condition and responses to treatment.  The front sheet is completed at the time of discharge or as soon as the relevant information is available. It contains all relevant diagnoses and procedures using the terminology of a current revision of the International Classification of Diseases(ICD).  A discharge summary for each patient should be completed within 48 hours of patient’s discharge, with a copy remaining in the medical record. The discharge summary should at least include the following:     

Discharge diagnosis Procedures performed Follow-up arrangements Therapeutic orders Patient instructions (where necessary)When a patient is transferred to another facility, a discharge summary should accompany him/her.

 When an autopsy is performed, a provisional diagnosis is noted in the medical record within 72 hours and the medical record is completed within 15 days following the death. A copy of the autopsy report is filed in the medical record. RECORD COMPLETION  The medical record should be completed within 48 hours after the discharge of the patient.  Complete History and PE should be completed within 24 hours after admission.  An incomplete chart, not completed within 15 days after patient’s discharge, shall be considered a delinquent chart.  The attending physician has the final and major responsibility for completeness and accuracy of the data entry in the record. He is also encouraged to raise the level of quality of the individual health record and sustain high level of recording.  Residents and interns may be delegated the duty of recording medical information as history, PE, and discharge summaries. Their entries have to be reviewed, corrected, and countersigned by the attending physician.  The Medical Record Officer assists the attending physician in reviewing records for completeness by checking for omissions and discrepancies and helps ensure that medical records comply with set policies and standards. RELEASE OF INFORMATION

85

Release of health information is a very sensitive issue in several respects. The confidentiality of the medical records should always be the concern of people involved in the release of health information. General Policies  The hospital shall safeguard all information contained in the health record against loss, destruction, or unauthorized use.  All information in the health record shall be treated as confidential and shall be disclosed only to authorized individuals.  It shall be the policy of all government hospitals not to use the medical record in any way which will jeopardize the interest of the patient. But the hospital may use the record to defend itself against any accusations.  The release of information is delegated to the Medical Records Officer. But in cases where the medical record officer encounters problems regarding the release of information, the matter should be referred first to Administrative officer (AO), or to the Chief of Hospital (COH) for proper solution.  No release of information with clinical value shall be done without written Consent from the patient himself.  The medical record is the physical property of the hospital. However, since the information written on the record is the patient’s personal history, he/she also has a right to the said record.  In cases where litigation is likely to happen and is intended against the hospital or any other personnel or the health care facility, the COH may refuse or deny access to the record even with the patient’s written authorization, until the court declares otherwise.  Request for medical certificate or clinical information when the patient is still confined shall be referred to the attending physician.    

Should the AP decide to release the certificate while the patient is still confined, a Certificate of Confinement shall be issued. No Certificate of Confinement shall be issued where the patient concerned is already discharged, instead, a medical certificate shall be issued. No medical certificate shall be released without the signature of the attending physicians and the hospital seal. On the other hand, no medico-legal certificate shall be released without the signature of the attending physicians and the hospital seal.

Information of no clinical value can be disclosed by the staff of the healthcare facility. However, hospital policy should first be consulted and utmost care taken into consideration before the release of non-clinical information includes the following:   

Name Address Attending Physician 86

 

Name of relative with patient during admission Admission and Discharge dates

 Where the patient is a minor, consent of either one of the parents or the legal guardian shall be secured before any information of clinical significance is released.  The record shall not be taken out of the hospital premises except on court orders. 

Those authorized to do research and studies shall use the records inside the Medical Records Section.  Incomplete medical records shall be referred to the attending physician before entertaining any request to access and review the medical record.  In cases where the patient is in critical condition and does not have someone with him/her to give consent, the medical record officershall release information only after consultation with the Chief of Hospital.  Verbal request for clinical information shall be discouraged in favor of written requests.  The staff of the Medical Social Service (MSS) shall have access to the medical records for purposes of establishing patient classification. They may also reveal the social content of the record to organize and reputablesocial agencies who have a legitimate reason for inquiry.  Information may be released to other health care facilities, upon writtenrequests, that the patient is now under care.  Hospital management may, at its discretion, permit the use of medicalrecords for research and studies, only stressing that no information whichwill directly identify the patient shall be published.

POLICIES FOR DOCTOR’S RELEASE OF INFORMATION  Doctors and members of the allied health profession may review records of patients presently under their care.  Doctors who are members of the medical staff but not members of the team assigned to the patient shall be armed with a written authorization signed by the patient before they are given access to the record.  The privilege against disclosure belongs to the patient and not the treating physician, therefore, the patient has the right to claim for it or waive it. In which case, the approval is technically not necessary. But it would be a good practice to notify the doctor prior to release of any information, as a sign of courtesy.  The hospital management may permit use of the medical record for research and studies, the medical record being the physical property of the hospital. The hospital may also withhold access to the medical record until a subpoena is issued.  Outside doctors intending to do some research/studies in a particular hospital shall seek the written approval of the management before they are given access to the medical record.

87

 Insurance company doctors shall need proper written authorization from the patient, a duly accomplished insurance waiver, before they are given access to medical record.  Company physicians who are presently caring for a patient shall be given medical information only upon presentation of a formal request addressed to the Medical Records Section.  Consultants shall have access to records of patients referred to them.  Resident doctors and the rest of the medical staff may request the Medical Records Section for records needed for their research and studies. But in cases where there is suspicion that their wish to access will jeopardize the right of the patient, doctor, and the institution, access shall be denied by the medical record staff.  It shall be the responsibility of the attending physician to inform his patient about his medical condition.

POLICIES FOR NURSES ON RELEASE OF INFORMATION  Nurses may borrow/sign-out old records per doctors instruction for ward use.  In the ward, student nurses shall have access to the records of patients assigned to them.  Private Nurses shall only be allowed to review records of those patients assigned to them.  All staff nurses may be given access to medical records not assigned to them for purposes of conferences and case presentations. After the conference, the record shall be returned to the Medical Records Section.  Ward nurses may review all records for purposes of compliance to requirements before forwarding said records to the Medical Records Section.  Ward nurses should always see to it that charts are in a secure place away from the patients or patient’s relative. OTHER PEOPLE CONCERNED  The lawyer representing a patient shall only be given access after presenting a written authorization duly signed by the patient.  An insurance verifier shall be required a waiver before being given access to the record/information about a patient. The original copy of the waiver shall also be filed with the record.  Researchers from other medical institution could again access to medical records only after complying with requirements set by the institution concerned.  Patient’s relative making inquiries about their patient shall be referred to the attending physician.  Law enforcement agents shall need a written request duly signed by the Chief/Director of their respective agency before being given access to the record. Should it be possible however, to get the written consent of the patient and attending physicians.

88

 Patients also have a right to their record. But to prevent misinterpretation of medical information which may lead to litigation, patient may not be allowed access to his own record. However, his physical and mental condition shall be explained only by the attending physician.  The health care facility may, in some situation, release health information even without the written authorization. Such situations are as follows:



Court Order A hospital or other health care facility must release health information in response to court orders.



Administrative Agency Order A provider must release health information when there is an adjudicative order from an administrative agency authorized by law.



Subpoena In a court proceeding, a party or an administrative agency may issue a subpoena, subpoena duces tecum, or notice to appear covering health information held by a health provider. Where the subpoena is valid, the hospital must disclose the health information. Arbitration Order Either an arbitrator or an arbitration panel may issue an order authorizing the discovery of health information in an arbitration proceeding.





Search Warrant A government law enforcement agency which has been issued a search warrant is entitled to receive any health information covered by the warrant.



Medical Research Health information may be disclosed to public agencies, clinical investigators, health care research organizations or accredited education or health care institutions for purposes of bonafide research. But before the medical information is released, the medical record staff should take reasonable steps to ensure that the research is legitimate, and proper safeguards in the release of information are instituted.

Preparation of Hospital Census PROCEDURES a) Collates 24-hour census forwarded by the Nursing Service; b) Prepares census report (4 copies);

PERSON/S RESPONSIBLE Administrative Aide III

c) Reviews and signs census report; d) Enters report in the worksheet for the monthly report; and

Medical Records Officer

e) Files hospital census report.

Administrative Aide III

Issuance of Medical and Medico-Legal Certification PROCEDURES

PERSON RESPONSIBLE 89

a) Receives formal request for medico-legal certification from authorized party or law enforcement agents; b) Retrieves medical records from file; c) Seeks clearance from the attending physicians; d) Instructs requesting party to pay fee to the Cashier; e)Types certification on the Medical Certification Form in triplicate; f) Forwards it to the attending physician and other physicians concerned for review and signature; g) Signs certification and returns to the Medical Records Section; h) Affixes seal of the hospital on the certification and forwards it to the COH (only for Medico-legal certification) i) Attest and signs certificate and returns it to the Medical Records Section: j) Presents official receipts to the Medical Records Section Clerk; k) Indicate the official receipt number and releases the certificate to the Authorized Party; and l) Files copy on the patient’s chart.

Administrative Aide III

Administrative Aide III

Attending Physicians &Other Physicians Concerned Administrative Aide III Chief of Hospital Requesting/ Authorized Party Administrative Aide III

Preparation of Birth Certificate a) Fills up draft form; b) Interviews parents and verifies data; c) Signs blank official birth certificate form; d) Types data into the official form and forwards to the Ward Nurse; e) Checks the official birth certificate form and forwards to the attending physician; f) Signs birth certificate and return to Ward Nurse who in turn gives the BC back to the Medical Records Section; g) Prepares list of BC and transmittal letter to the Local Civil Registrar duly signed by the Medical Records Officer. h) Forwards BC and transmittal to the Local Civil Registrar; and i) Upon receipt of the registered BC files the copy in the patient’s medical record.

Administrative Aide III

Ward Nurse Attending Physician Administrative Aide III Administrative Aide III

Issuance of the Death Certificate PROCEDURES

PERSON RESPONSIBLE

a) Prepares Death Certificate and forwards it to the attending physician; b) Completes and signs death certificate and returns It to the nurse; c) Checks accuracy and completeness of the data and forwards it to the Releasing Medical Records Clerk; 90

Nurse on Duty Attending Physician Administrative Aide III

d) Records and released to the official logbook e) Acknowledges acceptance of the Death Certificate and signs in the logbook; f) Advises patient’s relative to register the Death Certificate to the Local Civil Registrar; g) Files Death Certificate accordingly.

Patient’s Relative Administrative Aide III

Release of Information to Insurance Verifier PROCEDURES

PERSON RESPONSIBLE

a) Receives written request (waiver) from the authorized insurance verifier. b) Retrieves patient’s chart from the permanent files; c) Authentic signature of the patient on the waiver d) Informs the attending physician of the request; e) Determines whether or not the information may be released; f) Authenticates photocopy, affixes hospital’s seal; g) Records and release photocopied information to the insurance verifier in the official logbook; h) Files waiver/request in the patient’s permanent file after insurance verification acknowledges the receipt of the information.

Administrative Aide III

Retrieval of Patient’s Chart for Requesting Party/Authorized Borrower PROCEDURES

PERSON RESPONSIBLE

a) Submits duly accomplished request to the Medical Records Clerk; b) Verifies patient’s number from their master’s index for patients; c) Retrieves chart from files; d) Records in the book/logbook, indicating the name of the patient, the requesting party/authorized borrower, the date when borrowed, and the name of recipient of the patient’s chart. e) Signs logbook.

Requesting Party/Borrower

Administrative Aide III

Authorized borrower

7. Processing of Medical Records Received for File PROCEDURES

PERSON RESPONSIBLE

a) Checks all charts received against the list of discharges reflected in the Daily Census Report; b) Records all charts received; c) Prepares the master patient index based on the list of admission d) Rearranges the record according to the standard format e) Analyses data on patient’s chart; f) If data are incomplete, fills in the deficiency 91

Administrative Aide III

slips, attaches it to the chart and returns it to the Ward clinical concerned. f.1 Upon receipt of incomplete chart and deficiency slip (Medical) Ward Nurse fills in the data required and returns to the Medical Records Clerk,however, most of the time the Medical Records Clerk does the procedure herself; g) Completes the data and forwards completed chart to the Coding and Indexing Clerk;

Administrative Aide III

h)Codes and indexes diseases and operations as per prescribed code tools; i) Forwards coded chart to the Filing Clerk;

Administrative Aide III

j) Sorts out coded chart according to the terminal digit filing system and prepares folders; and k) Files chart

Administrative Aide III

NUTRITION AND DIETETICS SERVICE POLICIES AND PROCEDURES FUNCTIONS As a major aspect of total health care and as integral part of hospital organization, the Nutrition and Dietetic Service is committed to perform Administrative, Clinical, Education and Research functions. Administrative functions are aimed at:       

Establishment of policies and standards. Implementation and procedures concerned with budget and financial control. Developing and planning menu. Purchasing, receiving and proper storage of food. Production and provision of safe, sanitary, nutritious and palatable food. Utilization of available man power and other resources. Accuracy of update records and report.

Clinical functions are aimed at: Provision and promotion of high quality nutritional care. Nutrition screening and assessment. Interpretation and implementation of diet prescription. Provision of individual and group counseling to patients. Monitoring the calorie and other nutrient intake of patients either orally, on tube feeding or parenteral nutrition.  Documentation in the patients chart. Example: nutrition care, patients tolerance to prescribe diet, nutritional status.     

Education and research functions aimed at: 92

 Nutrition education of the patients and hospital personnel.  Research and development in nutrition and dietetics.  Update on the knowledge and skills of personnel in the food service management and nutrition and dietetics.  Training of student affiliate on nutrition and dietetics service. STANDARDS To achieve the vision and mission of the Nutrition and Dietetics Service standards are established in order to serve as a guide or tool in the evaluation and monitoring of the performance of the said service. RECORDING AND DOCUMENTATION All pertinent nutrition and dietetics information shall be recorded in the patients chart (Nutrition Progress) PROCEDURES Confirmation of diet orders

PERSON RESPONSIBLE Doctors

Dietary history/ nutrition assessment

Nutritionist Dietitian

Assessment of patient nutrient intake and tolerance Description of the diet instruction given to the family.

Nutritionist Dietitian Nutritionist Dietitian

MENU PLANNING: Is the basic and essential activity in the ND Service. Important policies and procedures as well as guidelines should carefully be considered. POLICY: All must be planned to ensure that patients receive nourishing meals that a variety of food is provided and that efficient economic use is made of supplies, labor and equipment. The following tools are needed in menu planning:  As set standardized recipes arranged according to categories ( soups, entries, vegetables, salads, and desert)  A copy of the Food Pyramid, RENI for different age groups.  Market quotation sheets showing current prices of food commodities available in season. MENU PLANNING PROCEDURES:  Take into account the time, day, weather and temperature  Consider food supplies available in the market.  Avoid repetitive menus. 93

 Consider the appearance of food on the plate.  Utilized correct menu patterns.  Price menu items correctly.  Maintain proper balance between high and low cost items.  Consider the type and amount of labor for various menu items.

PURCHASING Is an operational procedure through which food items and other goods needed in the service are required. POLICY: All foodstuffs for use in the Dietary Service are requested at least 30 days before the period covered. Quality is the first consideration. Foodstuffs ordered should be according to specifications. PURCHASING PROCEDURES:  Purchase sufficient supplies  List detailed set of specifications for quality  Maintain proper cost budgets for purchasing  Use fixed orders instead of flexible orders RECEIVING Is a management responsibility which involves making certain that items ordered are satisfactorily received in terms of quantity and quality. POLICY: All food deliveries for inspection must be in at 8:00 in the morning every Monday, Wednesday and Friday. The inspection team comprises of Nutritionist-Dietitian on duty and Supply Officer. RECEIVING PROCEDURES:  Install measures to prevent theft among receiving personnel  Have an updated record of price trends  Receive items according to set specifications  Observe proper receiving methods and procedures  Use adequate facilities and proper receiving equipments such as weighing scales 94

 Record and check goods received diligently STORING: The proper storage of food immediately after it has been received and checked is an important factor in the prevention and control of loss or waste. GUIDELINES:  Trained reliable ND Staff shall be in charge of the store room, under the supervision of the ND.  Upon delivery, foodstuffs shall be properly labeled before storage. Perishable items should be placed in the refrigerated storage and non-perishable items in a dry storage.  All storage areas should be kept locked for adequate control against loss and pilferage.  Dry storage areas should be cleaned and well-ventilated. Windows should be screened, walls and floors should be rat proofed.  Overcrowding of foods stuffs should be avoided, to avoid circulation of cold air.  The storeroom should be cleaned and sprayed regularly. STORAGE FOR SPECIFIC FOODS A. STAPLES AND CANNED GOODS 1. Groceries and canned goods should be stored in shelves and grouped. “First-in First-Out” policy must be followed. FOOD SERVICE A. Meals are included in your room accommodation.



Meal Distribution Tray collection Breakfast: 6:30-7:30 am 8:00 am Lunch: 11:30-12:00 pm 1:00 pm Supper: 5:00-6:00 pm 6:00-6:30 pm Consume your meals after delivery. If you prefer to take it later, you may have it transferred to your personal china wares.



Return all dining wares and utensils after each meal these are being checked for inventory purposes. Do not bring your tray outside your rooms, our food service worker will pick it up after an hour.



Hot water is provided daily at the Dietary Service every 6:00-7:00 in the morning.

ISSUING  Observe proper control in the recording foods issued from the storeroom

95

 Identify proper authorities or persons responsible for requisition and issuances of foods the storeroom  Ensure proper pricing of foodstuffs and supplies issued  Update record book PREPARING  Provide adequate mechanical equipment, for deboning, slicing, cutting, curving, trimming and peeling  Avoid excessive trimming of vegetables and meats  Check raw yields properly  Utilized leftover foodstuff properly

COOKING  Use standardized recipes to avoid over production  Use proper cooking equipment and utensils  Clean in small batches, if possible  Cook at proper temperature  Avoid long cooking time SERVING  Use standard portion sizes  Use standard size utensils for serving  Consider leftovers for recycled menu  Record food served before it leaves the kitchen  Bring or serve food to consumers on time  Avoid spoilage, waste, etc.  Maintain desirable temperature of food before serving MEAL SERVICE FOR PATIENTS A. DIET LIST Different diet list are printed out on the following schedules: Breakfast – 5:00 am Lunch – 10:00 am Supper – 3:00 pm  The diet list should be clear including the full name of patient, his diet, ward, bed number and pertinent information. 96

 The diet list and all subsequent changes are signed by the person who prepared it and should always be countersigned by the nurse on duty.  A check by the ND should be made with the wards for erroneous and/incomplete diet list. B. ADMISSIONS, CHANGE OF DIET, DISCHARGES  The diet of new admissions, after the diet list has been printed out, takes effect immediately upon receipt of notice.  The ND’s should be notified by the nurse on duty of the discharge of the room and bed of their patient before meal hours to facilitate effective food distribution.  Change of diet received between: 6:00 – 10:00 am will take effect on lunch 11:00 – 3:00 pm will take effect on supper 5:00 – 6:00 pm will take effect immediately if there is still food available for specific order C. PATIENT MEAL CENSUS AND NOURISHMENT  Patient’s diet follows the prescription of doctor. A diet as prescribed appears in the diet list  No trays served to patients on NPO (nil per orem) and MF (milk formula)  Meal hours o Breakfast: 6:30 – 7:30 am o Lunch: 12:00 – 1:00 pm o Supper: 5:00 – 6:00 pm  An allowance is given for each, after which all trays are collected and brought back to the Nutrition and Dietetic Service.  All the personnel assigned in the tray line refrain from talking. They must be wearing mask and plastic gloves. They must start only in the presence of ND assigned to supervise that everything conforms to the QA policy. D. DIET ORDER PRESCRIPTION  Diet orders requiring computation should be calculated by referring the chart and interviewing patients. The computation is filed and copy should be accessible to dishing area for reference.  All diet orders should be preferred to existing diet guide or NDAP diet guide.  Doubtful diet prescription should be clarified with the attending physician. E.

DISHING OUT AND FOOD PREPARATION 97

 Food should be tasted before dishing out particularly the therapeutic diet by the ND on duty.  All diets should be dished out on individual trays/lunch box except those in isolation and psychiatric room where we use disposable containers.  All trays/lunch boxes should be covered.  Patients name are called to receive their food trays. F.

LUNCHBOX COLLECTION

 All food trays should be collected after an hour.  Patient name shall be called to return their empty food tray.  Patients who prefer to eat late are requested to transfer their food to their own personal container.  All food waste in the wards are collected and packed in green bag containers.  All trays collected should tally the number of trays distributed. G.

DISHWASHING

 All food particles should be removed from food containers.  Rinse the food containers with little water in a basin. Collect all fluids and throw it back at the back of the compost pit.  Wash it with dish washing liquid with anti-bac and water.  Rinse twice with flowing water.  Rinse once with hot water.  Arrange and dry. H.

RECORDING OF DAILY CENSUS

A daily census of full, soft, liquid and other therapeutic diets must be recorded in a logbook. The census should be posted on the bulletin board every meal. REQUEST FOR PURCHASE OF FOOD ITEMS/INGREDIENTS OBJECTIVES: SCOPE:

To ensure required ingredients and food stuff are promptly requested to be purchased. This procedure covers activities in requesting for ingredients and food stuffs to be used in preparing daily menu for patients.

ACTIVITIES

PERSON RESPONSIBLE

a. Checking of Menu for the day

Nutritionist – Dietitian 98

b. Checking of ingredients and foodstuffs

Nutritionist – Dietitian

c. Prepare Market order and purchasing request d. Submit PR, ALOBS, SAI to Supply Office, Budget, PHO II, Capitol

Nutritionist – Dietitian Nutritionist-Dietitian

NOTE: Determine the requirements for various types of diets Check any leftover cooked/uncooked foodstuffs Check patients census NOTE 2: Determine quality to be purchased based on the data gathered above

RECEIVING AND STORAGE OF PURCHASED FOOD ITEMS Objectives: Scope: food items.

To ensure safety of food and ensure that food products or ingredients passed the Inspection and is properly stored. This procedure covers activities in receiving and storage of purchased

ACTIVITIES

PERSON RESPONSIBLE

a

Check items received

Assigned Nut-Dietitian

b

List all items on the Statement of Daily Market Purchases

Assigned Nut-Dietitian

c

Inspect Items

Dietary Section Head

d

Record all purchased items and amount incurred Store food items in their proper places

Dietary Section Head

e

Assigned Dietary Staff

FOOD PREPARATION Objectives: Scope:

a b

To ensure adequacy and appropriateness of food for the patients. This procedure covers activities in preparation of food and post preparation activities.

PROCEDURES Determines number of persons and types of diets to be served Determines equivalent quantity of food to be prepared or cooked

PERSON/S RESPONSIBLE Nutritionist – Dietitian Nutritionist – Dietitian

99

c d e

Requisition all items needed cooking Prepare and cook menu item Clean the cooking area

for

Cook Cook Cook

NOTE 1: Determine number of persons and types of diets to be served, based in daily meal census. NOTE 2: Instruct Cook/Food Service Worker/Utility on the quantity of food and the menu to be prepared. SERVICE AND DISTRIBUTION Objectives: SCOPE:

To ensure that patients are served with food and that food is delivered to the right person. This procedure covers activities in the distribution of food during meal time.

a

PROCEDURES Check meal census

b

Prepare diet tags accordingly

Administrative Aide

c

Administrative Aide

e

Dish out and apportion cooked food on the patient’s tray Load, dish – out trays to the respective food conveyors Distributes food to patients

f

Monitor Distribution

d

PERSON/S RESPONSIBLE Nutritionist – Dietitian

Administrative Aide Administrative Aide Nutritionist – Dietitian

MEAL SERVICE FOR PATIENTS PROCEDURES a. Review approved meal census b. Coordination

PERSON/S RESPONSIBLE Nutritionist-Dietitian Nutritionist-Dietitian& Project Coordinator Nutritionist-Dietitian

c. Posting/Scheduling of Special d. Quantity food cookery e. Meal Preparation

Nutritionist-Dietitian& cook Administrative aide/cook

f. Meal Presentation and Service

Administrative aide & Nutritionist-Dietitian

MEAL SERVICE FOR GUEST PROCEDURE PROCESSING TIME 1. Review the approved meal 5 – 10 Minutes request. 100

PERSON RESPONSIBLE Nut. Dietitian

2. Coordinate with the assigned coordinator for the: - Date - Venue - No. of guest 1 Hour - Food preferences - Meal time - Type of service (dine in or take out) 3. Posting of special functions in the bulletin board. 4. Quantity food cookery 5. Meal preparation 6. Meal presentation and service

Nutritionist – Dietitian Coordinator of said project

Nutritionist-Dietitian Nutritionist-Dietitian/Cook Administrative Aide Administrative Aide

INFECTION CONTROL / FOOD SAFETY POLICY: Safe and sanitary handling practices should be observed in entire food service operation to prevent serving contaminated food. STANDARD OPERATIONS THAT MUST BE OBSERVED IN DIFFERENT AREAS 1. RECEIVING *Food is inspected immediately upon receipt for spoilage or insect infestation *Perishable food is immediately put inside refrigerator and freezer. *Empty containers and packages are promptly discarded at disposal area. *The receiving area is kept clean and free of food particles and debris. 2.

DRY AND COLD STORAGE AREA *All food particularly rice should be stored at least six (6) inches off the floor. *The floor must be clean and dry. *Shelves are high enough off the floor away from the wall to permit cleaning and ventilation. *Food supplies are stored in a manner to insure “first in first out” rule and to avoid overcrowding. *Empty cartons and trash are removed regularly. *There should be no evidence of insects or rodents. *Refrigerator and freezer should be clean and free from objectionable odor.

PHARMACY PROCEDURE PRODUCT RECALL

PROCEDURES a. Once a notice of product recall has been received, an immediate action should be done. 101

PERSON/S RESPONSIBLE Pharmacist

b. The product should be returned by taking them out of the shelves and be recorded for proper identification. c. Shall be the one responsible for reporting and demanding the reason for the recall of the product from client to supplier.

Pharmacist

Chief Pharmacist

PROCUREMENT OF STOCKS PROCEDURES a. Must provide a list of drugs and medicines needed by their department to the pharmacy and must be based on the Project Procurement Management Plan and on the PNDF. Once a product is not included in the PPMP, a justification letter coming from the department is required. b. Consolidates drugs and medicines by their generic name with complete specification and submits to the supply officer.

PERSON/S RESPONSIBLE

Department Heads

Chief Pharmacist

c. Prepares the purchase request and other documents and forwards it to the pharmacist for initial and then to the Administrative Officer.

Supply Officer

d. Reviews and prepares recommendation to the Chief of Hospital.

Administrative Officer

e. Approves the request and forwards it to the Supply Officer.

Chief of Hospital

f. Forwards the approved request to General Services Office for procurement.

Supply Officer

REPORTING OF ADVERSE DRUG REACTION/ADVERSE DRUG EVENT

PROCEDURES

PERSON/S RESPONSIBLE 102

a. If in case an incidence of ADR/ADE has occurred the first thing to know is the cause of the ADR/ADE. b. The product/s should be identified properly and sample of the same product should be kept for further investigation.

Nurse

Pharmacist

c. An investigating team lead by the Therapeutics Committee shall conduct an investigation.

Therapeutics Committee

d. All possible finding should be documented and filed.

Therapeutics Committee

e. Shall be responsible for the report of ADR/ADE.

Therapeutics Committee

DAMAGED STOCK a. Once a damaged stock has been encountered, the pharmacist should track down and record the incident and notify the supplier.

Pharmacist

b. A replacement then of the stocks should be made by the supplier. c. If in case the damaged happened during dispensing, then the pharmacist should take the sole responsibility of replacing or paying for the damaged medicine.

Pharmacist

RETURNED PROCEDURES a. Once an item is returned at the pharmacy, the pharmacist should first check properly the item according to the batch and lot number of the drug .its label and how long it had been dispensed from the pharmacy together with the charge slip if it was from a Philhealth patient and receipt if it was been bought. b. If the item corresponds to its proper identification and it was 103

PERSON/S RESPONSIBLE Nurse/ Pharmacist

from philhealth patient, then it would be deducted from their account .If it was a cash transaction, the receipt should be surrendered together with the returned item. c. If it was bought on the same date, the receipt will be cancelled and corresponding amount paid will be returned. If a day after or more, then a stub shall be issued on the returnee containing the patient name, cost of the medicine returned, Official Receipt and charge slip number to be deducted from the hospital bill of the patient.

Pharmacist

Pharmacist/ Collecting Clerk

STACKING OF VACCINES AND BIOLOGICAL PRODUCTS

PROCEDURES a. Should ensure that the biological or pharmaceutical refrigerator thermostat is maintaining the required temperature for the proper storage of products.

PERSON/S RESPONSIBLE Pharmacist

b. The different vaccines and biological products should be properly stored according to temperature requirement. c. The vaccines and biological products must be stacked in such a way that the products with near expiration dates are the first to be taken out.

Pharmacist

Pharmacist

d. Biological products and vaccines should be properly and nearly arranged in the shelves of the refrigerator.

Pharmacist

e. The shelves in the door of the refrigerator should not be used for stacking.

Pharmacist

f. Proper care of the vaccines and biologicals should be done during defrosting of the refrigerator.

Pharmacist /Utility Worker

PROPER DISPOSAL OF EMPTY USED VIALS

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PROCEDURES a. Responsible for properly collecting the empty used vials on all wards every other day and transports it directly to the MRF for proper recording, crashing is done every month and transported to landfill. b. Empty vials that are used as specimen bottle for laboratory must be properly recorded.

PERSON/S RESPONSIBLE

c. All inventories and disposal shall be done under the supervision of the Chief Pharmacist and duly authorized representative of the waste management committee.

Utility Worker / Chief Pharmacist/ Representative Health Care Management Committee

Utility Worker

Utility Worker

MAINTENANCE AND CARE OF THE BIOLOGICAL OR PHARMACEUTICAL REFRIGERATOR PROCEDURES a. Should ensure that the bio refrigerator is intended only for such biological or pharmaceutical products, thus food and beverages should be strictly prohibited for storage.

PERSON/S RESPONSIBLE Pharmacist

b. A representative from the supplier should check the condition of the bio refrigerator quarterly or as necessary.

Maintenance Staff

c. There should be a yearly calibration done with corresponding certificate of calibration. d. Proper cleaning of the refrigerator should be done by the utility worker as needed. e. Proper temperature monitoring should be recorded twice a day and that should only range from 2 degrees to 8 degrees Fahrenheit.

Supplier Utility Worker Utility Worker / Pharmacist

COLD CHAIN PROCEDURE EMPLOYED IN DISPENSING PROCEDURES a. Must ensure that the vaccines and biological products are place in a plastic bag with ice pack before giving to the Medication Nurse.

105

PERSON/S RESPONSIBLE Pharmacist

b. Responsible for receiving and transferring the vaccines and biological products for proper storage.

Nurse

MONITORING AND ADJUSTING OF TEMPERATURE OF THE BIOLOGICAL OR PHARMACEUTICAL REFRIGERATOR PROCEDURES a. The vaccines and biological products should be stored in accordance with the temperature requirement. b. The temperature of the bio refrigerator sets between 2 degrees to 8 degrees Fahrenheit.

PERSON/S RESPONSIBLE Pharmacist Pharmacist

EMERGENCY AND SAFETY MEASURE IN CASE OF BREAKAGE OR OTHER INCIDENT THAT MAY ARISE DURING HANDLING AND STORAGE PROCEDURES a. In case the pharmacist, nurse and patient accidentally break an ampoule or vial, he / she should inform the utility worker to clean the mess to prevent improper handling and disposal. b. If the breakage happens during delivery, the pharmacist should record and inform the supplier immediately for the replacement. c. Proper handling and disposal of the breakage.

PERSON/S RESPONSIBLE Pharmacist

Pharmacist/Supplier

Pharmacist / Utility Worker

DISTRIBUTION OF STOCKS TO DIFFERENT DEPARTMENT DONATED PRODUCTS PROCEDURES a. Issue medicines that are considered emergency on each ward. b. Receive the medicine with a copy of the listing and shall affix his/ her signature in the list of medicines issued to them. c. Every 15th and end of the month a designated pharmacist 106

PERSON/S RESPONSIBLE Pharmacist

Nurse Supervisor

will make an inventory on the medicine stocked in their emergency kit for proper accountability. d. If there are lost items in the emergency kit, the pharmacist will charge the lost items among the nurse supervisor of the section. e. Must provide a regular utilization report to the pharmacy to ensure availability of supply at all times.

Pharmacist

Nurse Supervisor

Nurse Supervisor

DONATED PRODUCTS

PROCEDURES a. Record and file the Requisition and Issue Voucher of all donated medicines and its corresponding donors. b. Shall file and record all prescriptions of donated products for proper accountability purposes. c. Must make sure that it is registered with the FDA.

PERSON/S RESPONSIBLE Pharmacist

Pharmacy Clerk

Pharmacist

CONTIGENCY PLAN IN CASE OF COLD CHAIN EMERGENCY PROCEDURES a. Once a mechanical or power failure occurs, the pharmacist on duty should automatically transfer the vaccines at the biological / pharmaceutical refrigerator stored at the supply room for proper storage. b. Small quantities of each product should be stacked at a properly temperature monitored cold carrier with ice pack for dispensing and be refilled by the pharmacist on duty. c. Strict temperature monitoring of the cold carrier with ice packs should be done on a regular basis. d. A staff from the supply office and from maintenance department should be available all the time for emergency 107

PERSON/S RESPONSIBLE Pharmacist

Pharmacist

Pharmacist Supply Office Staff

situation. GOOD STORAGE PRACTICE PROCEDURES a. The storage area of the pharmacy and the main pharmacy provided with an air condition unit with digital thermometer monitored and recorded twice a day. b. Biological products and vaccines are stored in the Bio refrigerator with calibration certificate done quarterly, monitored and recorded twice a day. c. Pharmaceutical products are stored in a condition which assures that the quality is maintained. We strictly follow the FEFO principle. First to Expire First Out. d. Pharmaceutical products are stored off the floor with pallets, provided with wall shelves.

PERSON/S RESPONSIBLE Pharmacist

Pharmacist

Pharmacist

Pharmacist / Utility Worker

e. Narcotic drugs are stored in a double locked cabinet.

Pharmacist

f. Main pharmacy, (2) stock rooms provided with adequate lighting.

Pharmacy Personnel

g. Clean, dry and free from vermin.

Utility Worker

GOOD DISPENSING PRACTICE PROCEDURES a. Orders drugs based from the CPG and PNDF only. Only in extreme circumstances, a non-CPG – non-PNDF drug may be used. A written consent from the Chairman/ Training officer allowing Residents the use of such drug.

PERSON RESPONSIBLE Physician

b. Orders drug for the patient on a daily basis. Note: Orders such as “Same IVF”, “For 1 week”, “Continue Meds” are not acceptable.

Physician

c. Accomplishes the Drug Utilization Form (DUF) based on the Doctor’s order in the chart. d.Directly forwards the DUF to the 108

Ward Nurse

Pharmacy.Trainees are not allowed to bring DUF to the Pharmacy. No Drug Utilization Form (DUF) must be given directly to the patient/watcher. The number of DUF is per doctor’s order. e.Informs the Medication Nurse of the changes in the patient’s medication such as “Shifted to/ D/C / Defer”. f.Oral medications are given for the first 24 hours, cases of NSD. Wherein cases of Caesarean Section, oral medications are given for the first 48 hours g. NICU patients needing more than 1 dose of Prophylactic Antibiotic must be admitted. h. All drugs to be administered to the patient must come from the hospital Pharmacy. checks the DUF with the name of the patient, ward, classification, dose, dosage form, frequency must be properly checked, otherwise DUF will not be dispensed. i.Issues all the drugs needed by the patient within 24 hours upon admission. If the patient did not comply with the Philhealth requirements within 24 hours, the Pharmacy would then refer to the Medical Social Worker/ Medical Director, and beyond office hours, Saturday, Sunday & Holidays to the Senior House Officer if the Pharmacy can still issue medicines for the patient. j. A 24-hour supply of drugs, except IV fluids, IV sets & Emergency medicines are prepared for each patient based on individual drug profile. They can be replaced every shift or as needed. Nurses should use their emergency medicines including IV fluids at the ward and shall be replaced every shift or as needed. k. Medicines are delivered in the medication room counter checked with the use of charge slip and DUF. l. In case of unavailability of the medicine in the hospital Pharmacy and inform the Doctor who ordered the drug. m. Makes the necessary prescription of the 109

Ward Nurse / Nursing Attendant

Ward Nurse Medication Nurse

Medication Nurse

Pharmacist

Pharmacist

Pharmacist

Pharmacist/Medication Nurse

Pharmacist

unavailable drug that will be purchased outside of the Pharmacy. n. Instructs the patient’s watcher to buy outside, return it back to the pharmacy for checking & recording and forwards it to the medication room. o. In Emergency cases, will be the one to procure the drug for the patient. p. Returns the unused drugs to the Pharmacy for proper accounting. Discontinued and unused medicines are returned to the pharmacy and deducted in the patient’s account. A log book for returned medicines properly signed are required when patients are for discharged. If the medicine was bought in cash in TPH Pharmacy, they must present the official receipt and deducted to their hospital bill. q. Narcotics are excluded in the daily distribution of medicines. It can be obtained from the pharmacy with Requisition for Dangerous Drug Preparation form together with the empty used ampules, vials and S2 license of the physician.

Medication Team Doctor

Pharmacist

Pharmacy Personnel/Encoder

Medication Nurse

Nurse/Nursing Attendant

GOOD HOUSEKEEPING PROCEDURES a. Cleaning must be done daily.

PERSON/S RESPONSIBLE Utility Worker

b. Proper segregation and disposal of waste, including vials, ampoules, and needles strictly followed.

Utility Worker

c. For Pest management, this treatment is done by spraying insecticide as needed.

Utility Worker

EXPIRED STOCK PROCEDURES a. Once an expired drug has been encountered, the pharmacist should track down and record all expired drugs. b. Inform the supplier about the incident and proper disposal should be made.

PERSON/S RESPONSIBLE Pharmacist

Pharmacist / Supplier

PRODUCT COMPLAINT 110

a.

PROCEDURES Should know the reason of the complaint.

PERSON/S RESPONSIBLE Pharmacist

b.

Should take appropriate action.

c.

If the situation is regarding defective products, it should be replaced immediately returning back the defective product for proper reporting to the supplier.

d.

An incident report should be submitted to the Chief of Hospital thru the Pharmacist on duty for proper action.

Pharmacist Supplier

Physician/ Pharmacist/ Chief of Hospital

MEDICAL SOCIAL SERVICE FUNCTIONS  Is primarily concerned with helping patient and their families affecting illness and which interferes in obtaining maximum benefits from medical care.

 Does casework to patient referred with social, emotional and environmental problems through interview with patients and members of the families.

 Consultation with other discipline in the setting concern with patient’s problems.  Skilful use of community resources to meet the medical needs of patients and their families which is not available in the hospital.

 Classify patients according to their ability to pay. PURPOSE OF THE SERVICE  To help the patient in adjusting himself to the hospital situation as to it scope of services limitations, policies, rules and regulations.

 To help the patients solve his/her problem that directly or indirectly affects their medical condition while in the hospital.

 To promote continuity of family relationship to present family maladjustment during and after illness.

 To assist the physician and other members of hospital staff on further understanding of patient’s social, emotional, environmental and financial condition for earlier diagnosis and suitable medical management. 111

PROCEDURE FOR OUT-PATIENT PROCEDURE

PERSON/S RESPONSIBLE

a. Seeks assistance

Patient / Relative

b.

Orient patients / relative about the purpose of the classification system. c. Evaluates and classifies the patient using the hospital approved protocol d. Informs patients and/ or relative of the approved action e. Stamps charge slip with classification and indicates discount. f.

Receives charge slip and collects payment if there is any and issues an official receipt to the patient and/ or relative.

Medical Social Worker

Billing / Cashier

EMERGENCY ROOM PATIENT PROCEDURES a.

PERSON/S RESPONSIBLE

Seeks assistance

Patient / Relative

b. Receives referral, provides crisis intervention, and if necessary performs advocacy role for the patient. c. Orients patient/relative about the purpose of the classification system. d. Classifies patient based on hospital approved protocol or other issuance. e. Informs the patient/family and ER Staff of the approved action. f. Makes proper endorsement to the different services/units concerned using the Assessment and Referral. g. Taps resources for other needs of the patient. h. Documents all activities and files them accordingly.

IN-PATIENT PROCEDURE 112

Medical Social Worker

PROCEDURES a. b.  

PERSON/SRESPONSIBLE

Conduct ward rounds. Determine if the patient is “new or old” if “new” conducts intake interview if “old” update the record

c. Classifies the patient according to their economic status d.

Interviews, classifies patients and registers in the logbook

e.

Informs / orient the patient/ relative about their bill and the coverage of MSWD assistance.

Medical Social Worker

f. Family counselling to relatives / patient. g. Evaluates and approves patient’s hospital bill. h. Records evaluation of patients for documentation. SUPPLY AND PROPERTY FUNCTION  Procurement, storage, inventory, distribution and disposition of hospital supplies, materials and equipment.  Accounts for all hospital properties, supplies and equipments.  Directs and coordinates the conduct of regular physical inventories of supplies materials and equipment.  Directs and coordinates the maintenance and updating of all records of hospital properties, vehicles, equipment, facilities and other related items.  Directs and coordinates the registration and/or insurance of hospital vehicles, equipment and other properties.  Recommends and coordinates the disposal of unserviceable properties and waste materials. POLICY  Accountable Officer should be properly bonded  All procurement shall be based on the approved Annual Procurement Program. Items not included in the APP maybe amended as the need arises, subject to approval.  RIV’s shall be numbered so that all requisition are accounted for. It shall be posted on the stock cards on the day the items were issued.  First-in first-out method of costing and issuances shall be adopted.  Monthly supplies adjustment report shall be prepared to summarized actual consumption of supplies.  Physical inventories of equipment, supplies and materials, drugs and medicines shall be done monthly, quarterly, semi-annually and annually. Preparation of Annual Procurement Program: 113

a) b) c) d) e) f)

PROCEDURE Require different departments to submit their annual needs. Reviews and evaluates the submitted request based on their annual consumption. Prepares a draft and coordinates with units on the final annual procurement program. Makes the final copy of the annual procurement program on the appropriate LGU form. Reviews and signs the program, together with all the unit/section heads concerned. Submit to the Administrative Officer IV.

g) Reviews and recommends the approval of the program by affixing his/her initials and forwards to the Chief of Hospital. h) Signs the program.

PERSON/S RESPONSIBLE

Administrative Officer III

Administrative Officer V

Chief of Hospital

Purchase Request Procedures PROCEDURE

PERSON/S RESPONSIBLE

a. Prepares the quarterly Purchase Request based on the Annual Procurement Plan with duly supported Obligation Request. b. Forwards the Purchase Request and the Obligation Request to the Administrative Officer IV for funding. c. Forwards the documents to the Administrative Officer V for review and initial. d. Forwards to the Chief of Hospital for approval. e. Forwards to the General Services Office for processing.

Administrative Officer III

Receipt/Acceptance – Procedures PROCEDURE

PERSON/S RESPONSIBLE

a. Properties are delivered to the supply warehouse with the attached transferred document of supplies, materials and equipment 114

General Services Office

b. Checks inspects, accepts, signs the transfer document. c. Returns transfer documents. d. Records the accepted items and pertinent information and endorses the delivered item to the Hospital Storekeeper if for Hospital consumption and to the Public Health Storekeeper if for Field Health consumption. e. Identifies if the delivered items are equipment or semi-expandable and endorses to the Property Clerk. f. Arranges them properly in the warehouse cabinets and posts the delivered items to their individual supplies ledger cards.

Administrative Officer III

Storekeeper/Administrative Aide III

Issuances/Distribution PROCEDURE

PERSON/S RESPONSIBLE

a. Submit list of items to be requested with attached consumption report b. Evaluates consumption report and prepares RIV

Different Departments Administrative Officer III

c. Approves Requisition and Vouchers

Chief of Hospital

d. Issues items base on approved RIV

Administrative Officer III

e. Files and posts in their individual supply ledger card

Storekeeper/Administrative Aide III

PROCEDURES ON DISPOSAL OF UNSERVICEABLE PROPERTY  Notifies the Maintenance personnel to check the status of the defective hospital, medical and office equipment.  Checks and recommends on the status of the equipment.  Considers property as condemned if found beyond economical repair.  Return the defective equipment to the Supply Office.

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POLICY ON DISPOSAL OF SUPPLIES OR PROPERTY  The Accountable Officer is responsible for the return of the Unserviceable Properties to the Supply Officer for the cancelation of Memorandum Receipt.  The Supply Officer shall be responsible for the inventory of all condemned properties to be approved by the Chief of Hospital.  The Supply Officer shall be responsible for the return of the Inventory and Inspection report of Unserviceable Properties to the General Services Office.

XVI. ADMINISTRATIVE SERVICES PERSONNEL UNIT FUNCTION: To develop and administer comprehensive Human Resource Management Plan which includes recruitment, selection, promotion, separation, welfare and benefits, training and other personnel actions and transactions. POLICIES:  Recruitment and Selection Plan shall be consistent with the standard and guidelines set up by the Civil Service Law and Rules and shall provide equal opportunity to all qualified applicants;  Permanent and casual employees shall be rated on their performances semiannually while Job Order employees shall be rated quarterly each year.  Records of attendance should be maintained in accordance with Civil Service Rules and Regulations;  Applications for vacation/sick/maternity and other leaves shall be recommended by the immediate supervisor. Absences should be covered by application for leaves. The Accounting must be notified immediately for salary deduction due to exhausted leave credits;  Any notice to the cashier to withhold the incentives of an employee shall be made in writing by the Chief of Hospital; and

116

 Complaints and grievances of employees shall be acted upon in accordance with the grievances procedures.  This section shall maintain the safety, security and confidentiality including updating of personnel records. OTHER RELATED POLICIES  Signature on all hospital documents should always be affixed over printed names of the original copies of the documents. A rubber stamped facsimile of the signature of the official should only be used on duplicate copies.  All personnel on off-duty days are prohibited from roaming around hospital premises unless for justifiable reasons.  Observance of house rules in the various designated official quarters of the Tarlac Provincial Hospital such as the following to wit: 

Prospective occupants must first seek the permission of the Chief of Hospital.



All new occupants of the various designated official quarters of the Hospital are required to register to the Hospital Dormitory Manager;



Cooking, gambling and smoking are prohibited;



Only hospital personnel are allowed to occupy the designated official quarters.



Installation of unnecessary appliances are prohibited; and



Vendors are not allowed to enter these designated official quarters.

RESPONSIBILITIES  Prepares comprehensive manpower development program which includes appointments, promotions, transfer, detail, welfare and benefits, and training of personnel.  Maintains and ensures confidentiality of personnel records.  Acts on personnel actions and transactions in accordance with Civil Service Law and Rules.  Coordinates training and research needs with the other services.  Provides counseling and/or gives advice on referred cases.  Reviews and submits required reports.  Acts as Liaison Officer to the Provincial Human Resource Management Office.

117

STANDARD OPERATING PROCEDURES PREPARATION OF APPOINTMENTS Upon receipt of the approved request for renewal of appointments or upon instruction to prepare appointment papers from the Provincial Human Resource Office:

PROCEDURES a. Requires prospective appointee to properly and completely accomplish the following: - Personal Data Sheet (PDS), - Statement of Assets, Liabilities and Network, - Transcript of Records, - Diploma, - Board Rating, - PRC or certification of appropriate eligibility, - NBI Clearance, - Medical Certificate.

PERSON/S RESPONSIBLE

Administrative Aide IV

b. Submits all of the above documents. c. Prepares the following: - -Appointment paper, - -Position Description Form (PDF), - -Oath of Office, - -Certificate of Assumption to Duty; Administrative Aide IV d. Have the prospective employee sign the Appointment Papers and Position Description Form;

Prospective Employee

e. Forwards the same to the Department or Service Head. f. Signs Position Description Form Department and returns Head / Service Head to Administrative Aide IV g. Forwards all documents to the Administrative Officer h. Reviews all papers and other related documents for their completeness and set initials i. Forwards the Position Description Form and Assumption to Duty to the Chief of Hospital for signature j. Signs Position Description Form, Assumption Chief of Hospital to Duty and certifies photocopies of all documents k. Hands document to Secretary for release to the Liaison Officer. l.Releases documents to Liaison Officer. m. Records in logbook and forwards to the 118

Secretary

Provincial Human Resource Management Liaison Officer Office for processing PROMOTIONS

PROCEDURES

PERSON/S RESPONSIBLE

a. Writes a letter of recommendation to the Chief of Hospital for possible promotion of staff

Head of Service

b. Makes final decision and sends approved papers to the Administrative Aide III for the preparation of indorsement.

Chief of Hospital

c. Prepares indorsement and attaches supporting documents and forwards to the Administrative Officer

Administrative Aide III

d. Reviews all papers and other related documents for their completeness and set initials and forwards to the Chief of Hospital

Administrative Officer

e. Signs indorsement.

Chief of Hospital

f. Releases to the Liaison Officer for submission to the Office of the Governor thru the Provincial Human Resource Office g. Forwards documents to the Office of the Governor thru Provincial Human Resource Office properly receipted on the file copy.

Secretary

Liaison Officer

KEEPING ATTENDANCE AND TIME RECORD POLICIES ON TIMEKEEPING AND ATTENDANCE USING THE BIOMETRIC DEVICE For all TPH employees’ compliance the following policies concerning timekeeping and work arrangements in using the Biometrics device will hereafter be adopted: 1. Service/Sections are required to record their attendance every working day as follows.

119

2. Request for exchange of duties for personnel under various shifts should be submitted three (3) days before the exchange of duty supported by a request letter approved by the immediate supervisor. Non compliance shall not be approved. 3. Offsetting of absences for J.O‘s may be considered on a case to case basis depending on the Call of Duty prior approved of the immediate supervisor. 4. J.O’s can render service on Holidays provided they will not exceed the 22 working days. 5. Personnel on seminar, convention or field work shall present an approved Travel Order, Certificate of Appearance or Exemption Form on the said date as supporting document.

120

6. Previous flexible working hours (flexi-time) prior to the issuance of this Memorandum are considered null and void. 7. Application for vacation/forced leave for permanent and casual employees shall adhere to the CSC policy that it should be filed five (5) days before the said date. Noncompliance shall not be approved. 8. Sick Leave should be applied immediately upon reporting back to duty. A Medical Certificate is required for five (5) days absences and above. Failure to submit appropriate documents, the said leave shall be considered “unauthorized”. 9. Time in and out policy should be strictly followed. Incomplete Time in and out is considered “Half Day”. 10. Monthly schedule of the Department or Section shall be submitted to the Administrative Office at least five (5) days in advance. 11. In case of system failure, the employee shall Log in or out in their respective logbook. 12. Employees rendering overtime work shall also use the biometrics device to record their attendance. 13. Employees who do not go on rotation/shifting, the schedule shall be from 8:00 AM to 5:00 PM with lunch break from 12:00 PM to 1:00 PM. 14. Some employees by nature of their function, that is, ‘On-Call’, are exempted. To wit; - Provincial Health Officer II - Provincial Health Officer I - OIC – Chief of Hospital Operations - Chief of Clinics - Administrative Officer V - Chief Nurse - Contractual and Part-Time Consultants - Resident Doctors*** Subject to re-evaluation TIMEKEEPING PROCEDURE

PROCEDURES a. Registers time of arrival and departure following the policy on Biometrics Device b. Prints out bioscript at the end of the month for Permanent employees and on the 16th and 1st of the month for Casuals and JOs c. Sorts bioscript as to Service and compares from filed leave of all personnel d. Prepares monthly report on the absences of all employees. e. Attaches bioscript on payrolls as supporting document. f. Submits a copy of the bioscripts to the Provincial Human Resource Office and files another copy as reference.

121

PERSON/S RESPONSIBLE Employee

Administrative Aide IV

PAYROLL PREPARATION PROCEDURES

PERSON/S RESPONSIBLE

a. Coordinates with the PHRMO regarding adjustment in payroll. b. Double checks adjustments in payroll, encodes and prints draft payroll, c. Hands draft to the Liaison Officer for submission to the Provincial Human Resource Office d. Prepares final payroll and remittances e. Releases final payroll and remittances to the Liaison Officer f. Receives, reviews, arranges and initials the final payroll and remittances g. Prepares Obligation Request h. Forwards to the Administrative Officer IV for funding and recording i. Funds and records Obligation Request and set initials j. Forwards documents to the Chief of Hospital for signature k. Signs final payrolls and remittances.

Administrative Aide VI

Human Resource Personnel Administrative Aide VI/IV

Administrative Officer IV Chief of Hospital

l. Releases documents to Administrative Aide IV. m. Receives duly signed payrolls and remittances n. Releases to Liaison Officer o. Forwards to Provincial Human Resource Office for processing Liaison Officer

Secretary Administrative Aide IV

LEAVE APPLICATION PROCEDURES

PERSON/S RESPONSIBLE

a. Gets internal use leave form and Civil Service Commission official leave form

Employee

b. Properly fills up and signs both forms c. Forwards to immediate supervisor for approval recommendation d. Signs Recommending Approval Caption and forwards to the Head of Service e. Signs Approval Recommendation Caption and forwards to the Leave Clerk (Administrative Aide VI) 122

Immediate Supervisor

Head of Service

f. Hands to Leave Clerk for recording and typing activities g. Types CSC Leave Form and records in employee’s Leave Cards and forwards to Admin Officer V

Leave Clerk/Administrative Aide VI

h. Reviews, initials and forwards to the Chief of Hospital

Admin Officer V

i. Signs CSC Leave Form and returns to Secretary

Chief of Hospital

j. Records and releases to Liaison Officer

Secretary

k. Submits to PHRMO and requests recipient to sign on the Log Book

Liaison Officer

ISSUANCE OF EMPLOYMENT AND RESIDENCY INTERNSHIP TRAINING CERTIFICATES

PROCEDURES a. Fill up the request form and submit it at the Personnel Unit

PERSON/S RESPONSIBLE Requesting Employee

b. Reviews completeness of information written in the request form. If in doubt, asks the requesting employee about lacking data. c. Instructs requesting party when to come back to get the document. Allots time for verification of the validity of data given and for the signatories to review and sign certification. d. Verifies validity of information given by comparing with existing file e. Prints the certificate and mark it with a control number and logs on record book f. Forwards to the Administrative Officer for review and initial g. Reviews and set initials h. Forwards to the Head of Office and the Chief of Hospital for signature i. Signs certificate j. Attaches dry seal on certificate when necessary k. Releases the certificate to the requesting employee by signing on the record book to avoid duplication of certificate issuance.

Administrative Aide IV/III

Administrative Officer Head of Office/Chief of Hospital

Administrative Aide IV/III

PREPARATION OF SERVICE RECORD 123

PROCEDURES

PERSON/S RESPONSIBLE

a. Request for an updated service record

Employee

b. Prepares a updated service record and forwards to the Administrative Aide VI

Administrative Aide III

c. Reviews and set initials and forwards to the Chief of Hospital d. Signs and forwards to secretary

Administrative Aide VI Chief of Hospital

e. Releases to Administrative Aide III

Secretary

f. Records and releases to employee

Administrative Aide III

124

ASSISTANCE TO PERSONS COMING TO THEOFFICE OF THE CHIEF OF HOSPITAL PROCEDURE

PERSON/S RESPONSIBLE

a. Upon presentation of complaint, problem or query, records in the Log Book and refers to Chief of Hospital b. Studies matters and refers to Administrative Officer using the Referral Slip c. Studies further and refers to the Head Unit concerned for appropriate action d. Studies the matter thoroughly and gives recommendation to Administrative Officer e. Prepares communication needed after consultation with the Unit Head f. Sends communication to Chief of Hospital g. Reviews and signs communication and hands to Secretary h. Records in the logbook, gets file copy and indicates therein the date of release i. If hand-carried, asks recipient to sign on file copy, if mailed, indicates date of release on file copy

Secretary Chief of Hospital

Administrative Officer Unit Head Concerned Administrative Officer Chief of Hospital

Secretary

ASSISTANCE TO HOSPITAL PERSONNEL WITH PROBLEM PROCEDURE

PERSON/S RESPONSIBLE

a. Presents his problem and seeks advice and assistance from immediate supervisor or from section head b. Listens to the problem which may be either personal or official c. Finds solution to the problem within reasonable time d. If the employee is not satisfied with the solution, accompany him/her to the Administrative Officer, especially if the problem is official e. Confers and reaches a solution of theproblem f. If the problem cannot be resolved, consult the Chief of Hospital g. Threshes out difficulties and institutes remedial measures h. If the problem cannot yet be resolved because employee is not satisfied, endorse to the higher authority

125

Employee

Supervisor

Administrative Officer, Employee and Supervisor

Chief of Hospital

APPLICATION, RECRUITMENT AND SELECTION PROCEDURE

PERSON/S RESPONSIBLE

a. Submits application letter addressed to Chief of Hospital, attaches pertinent credentials needed

Applicant

b. Interviews applicant c. Refers to personnel unit through Secretary d. Records in the logbook, the name of the applicant, date of receipt and referral and the position applied for e. Takes application to personnel unit f. Receives application, together with Chief of Hospital instructions g. Prepares and initials endorsement letter to the Office of the Governor h. Forwards to Chief of Hospital for signature i. Signs endorsement and forwards to the Provincial Human Resource Office.

Chief of Hospital Secretary

Personnel Unit

Chief of Hospital

COMMUNICATION PROCEDURES PROCEDURE

PERSON/S RESPONSIBLE

a. Upon receipt of correspondence from various sources either through mails, couriers, hand carried etc. and addressed to the office, records open correspondence in the logbook indicating therein the date of receipt, origin, subject matter and date of correspondence, verifying if stated enclosures are attached and if not put a notation on the face sheet. b. If communications are addressed to employees, hands the same directly to the concerned employee. c. If communications are closed, hands the same to Chief of Hospital just like the open communication. d. Reads communications and returns the same to the secretary with instruction to hand the same to the concerned officials or the Administrative Officer after recording. e. Sends communications to the concerned Official f. Studies and analyzes the contents, 126

Secretary of the Chief of Hospital

Chief of Hospital

Secretary

prepares response/endorsement, initials it and sends to the Chief of Hospital through the Secretary. g. Receives response to incoming communications and hands to the Chief of Hospital h. Reviews and signs communication Chief and of Hospital gives to the Secretary i. Records action taken and sends toSecretary the Concerned Official j. Receives outgoing communications, Concerned if Official to be sent by mail, retains a file copy, if for personal delivery, hands to Liaison Officer k. Delivers communication to theLiaison Officer concerned office, asking recipient to sign the file copy returning the same to the Concerned Official l. Files communication Concerned Official

127

Concerned Official

Secretary

HOSPITAL INFORMATION MANAGEMENT SYSTEM The IT Department is a significant part of the Hospital when it comes to document retrieval since its operation involves acquisition, management and timely retrieval of large volumes of information since it manages the Hospital Information Management System. This system automates all hospital tasks and transactions. Moreover, it is the Department’s duty to direct the operations of computer and related equipment like data networks. It is also involves in the development, maintenance, and use of computer systems, software, and networks for the processing and distribution of Tarlac Provincial Hospital’s data and services. The divisions mandate is to ensure that Technology and Information management is in alignment with the plans and strategies of the government. OBJECTIVES: 

To standardize data that will result in fewer corrections or missing data.



To centralize data storage ensuring data integrity and providing a database for future statistical and management reporting.



To reduce the time spent by staff filling out forms, freeing resources for more critical tasks.



To speed up the billing process by having accurate, timely data resulting in quicker payments and a better cash flow.



To reduce the amount of time spent by administration creating and publishing schedules.



To process claims at the least possible time and maximize revenue collections.



To keep data in secure place and controls who can reach the data in certain circumstances.

FUNCTIONS  Repairs and maintains software, hardware and network connections.  Effectively utilizes hospital facilities and improves inventory control  Provides information required to support patient care  Safeguards data integrity, security and accessibility  Captures and analyses clinical data  Captures the progress of treatment of individuals and gauges the response to treatment and drugs for groups of patients  Makes data collected available for research purposes  Generates MIS reports, which help the management in making policy decisions.  Maintains records necessary for statutory requirements  Assist the administrative offices in better planning, monitoring and control of medical and health services. Benefits of HIMS 128



Easy access to doctors and hospital personnel, data to generate varied records, including classification based on demographic, gender, age, and so on. It is especially beneficial at ambulatory (out-patient) point, hence enhancing continuity of care. As well as, Internet-based access improves the ability to remotely access such data with authorization.



It helps as a decision support system for the hospital authorities for developing comprehensive health care policies.



Efficient and accurate administration of billing, diet of patientand distribution of medical aid. It helps to view a broad picture of hospital growth



Improved monitoring of drug usage, and study of effectiveness. This leads to the reduction of adverse drug interactions while promoting more appropriate pharmaceutical utilization.



Enhances information integrity, reduces transcription errors, and reduces duplication of information entries.



Hospital software is easy to use and eliminates error caused by handwriting. New technology computer systems give perfect performance to pull up information from local server.

HOSPITAL STANDARD OPERATING PROCEDURES PROGRAMMING/CODING MODULES

OF

HOSPITAL FORM

PROCEDURE a. Receives request or report from Department Heads or Officer in charge b. Reviews copy to amend. c. Prepares File for Coding & Programming d. Review and testing of finished program results e. Integration to the system modules f. Forward to Officer in charge for review and corrections g. Deployment of updated Module to Department.

AMENDMENTS

OR

PERSON/S RESPONSIBLE HIMS Staff Programmer Programmer HIMS staff Programmer Programmer HIMS staff

REQUEST FOR ADDITIONAL MODULE ACCOUNT PROCEDURE a. Receives request or report from the person or Officer in Charge b. Verification of the identity/validity of the Hospital employee through HR or Department Head. c. Creation of additional module account to the database

129

PERSON/S RESPONSIBLE HIMS Staff Programmer/ Programmer Assistant

Programmer/ Programmer Assistant

REQUEST FOR CORRECTION/EDITING SYSTEM/DATABASE PROCEDURE a. Receives request or report from the person or Officer in Charge b. Verification of the validity of request c. Reviews system logged d. Once cleared, correct/edit data.

OF

DATA

IN

THE

PERSON/S RESPONSIBLE HIMS Staff Programmer/ Programmer Assistant Programmer/ Programmer Assistant Programmer/ Programmer Assistant

REQUEST FOR SOFTWARE/HARDWARE OR NETWORK REPAIR PROCEDURE Receives request or report from the person or Officer in Charge Attend to the report. Pull out softwares/hardwares for repair Repairing procedures Testing ,monitoring and dispatching

PERSON/S RESPONSIBLE HIMS Staff Technical Support Programmer/ Technical Support Programmer/ Technical Support Programmer/ Technical Support

REQUEST FOR THE ISSUANCE OF TPH IDENTIFICATION CARD (ID) PROCEDURE Receives request or report from the person or Officer in Charge Employee fills up ID Form Processing of ID Distribution of ID

PERSON/S RESPONSIBLE HIMS Staff Technical Support Technical Support Technical Support

REQUEST FOR BIOMETRICS ACCOUNT PROCEDURE Receives request or report from the person or Officer in Charge Verification of the identity/validity of the Hospital employee through HR or Department Head. Creation of additional biometric account to the database.

130

PERSON/S RESPONSIBLE HIMS Staff Programmer/ Technical Support Programmer/ Technical Support

HOSPITAL MAINTENANCE UNIT

POLICIES: 1. Responsible for the provision of optimum physical environment for patient care. 2. Should update manual of policies and procedures to facilitate hospital operations and comply with the numerous local, national, international codes, standardsand regulations on the construction and operation of the hospital facilities and utilities. 3. Shall establish and implement a Comprehensive Preventive Maintenance Program and Disaster Preparedness Plan to avoid uninterrupted service. 4. Shall have proper training for handling and repairs of equipments. 5. Shall maintain good relations with other hospital departments andoutside organizations concerned with regulations and development of the field. 6. Work orders/request for construction, repairs and maintenance service must be processed bythe Maintenance Unit. All work orders shall be recorded and monitored toensure efficient service delivery and reporting. 7. Notices for cleanliness and sanitation shall be posted in conspicuous areas. PROCEDURES: REQUEST FOR REPAIR WORKS PROCEDURES

PERSON/S RESPONSIBLE

a. Presents written request to undertake the repair work. b. Examines and determines the extent of repair works to be done. c. Prepare evaluation report and materials needed in the repair.  If the materials are not available, prepares RIV and forwards to Supply Officer who will start with the procurement process. 131

Requesting Unit Concerned Maintenance Unit

Concerned Maintenance Unit



If the repair service cannot be provided by CMU, prepares recommendation to have it repaired by outside service provider through the Supply Officer.

d. Prepares and forwards the accomplished job order to Administrative Officer.

duly the

e. Reviews and initials job order andforwards to Chief of Hospital. f. Approves job order and returns to concerned maintenance unit for appropriate action. g. Undertakes the repair if the CMU is capable of doing.  If not forwards it to the outside service provider h. After the repair, have the requesting unit acknowledge the completion of repaired service in the job order form i. Acknowledge the repaired item and/or the completion of repair service j. 10. File job orders as a basis for the monthly report for submission to the Administrative Officer

Concerned Maintenance Unit

Administrative Officer

Chief of Hospital Concerned Maintenance Unit

Concerned Maintenance Unit Requesting Unit Concerned Maintenance Unit

MOTOR TRANSPORT UNIT POLICIES:  Travel of hospital vehicles shall be covered by trip tickets and posted for information.  All hospital vehicles shall be regularly inspected for repair and maintenance needs. A logbookon repairs and maintenance conducted shall be maintained and updated. POLICY FOR THE USE OF AMBULANCE  Shall be used in conducting or fetching from Tarlac Provincial Hospital and to other hospitals.  Request for the use of ambulance should be coursed thru the Department Head concerned forproper evaluation of the patient. The prescribed ambulance transfer slip shall be used in makingthe request, subject to the approval of the Chief of Hospital or Senior House.  Shall be used exclusively for patients and shall be on a 24-hour service.  A hospital physician shall accompany the patient, if necessary.  Only two relatives / companions shall be allowed to accompany the patient in the ambulance.  Only indigent patients shall be conducted free-of-charge.  Patients coming from / going home to different municipalities should request the ambulance oftheir municipalities or district hospital in the area. 132

REQUEST FOR THE USE OF AMBULANCE PROCEDURES

PERSON/S RESPONSIBLE

a. Inquire the availability of the ambulance from the Ambulance Custodian.  Fill-up request form and forwards it to the Chief of Hospital/Senior House Officer for approval b. Approve and sign the request form

Requesting Party/NOD

Chief of Hospital c. Present the signed request form to the nurse on duty d. Inform the ambulance driver on duty regarding the request

Requesting Party Nurse on Duty

e. Prepares trip ticket for approval to the Chief of Hospital

Ambulance Custodian

f. Ask the passenger to sign the trip ticket after the travel

Ambulance Custodian

g. Files approved trip ticket for monitoring purposes

Ambulance Custodian

SECURITY SERVICES FUNCTION: Shall protect lives, properties and critical infrastructure from threats, harm and losses within the hospital premises. POLICIES:  Preparation, implementation and monitoring of approved comprehensive security plan shall be done.  A key management system shall be adopted by the hospital and enforced by the security section. SPECIFIC:  Shall establish and maintain maximum degree of security within the hospital.  Responsible for promoting security and peace and order in the hospital.  Shall have a security manual to guide hospital personnel in the performance of their duties and responsibilities.  Shall be adequately manned and armed to perform their duties effectively.  Shall monitor and record traffic of patients, visitors, personnel and vehicles in the hospital. 133

 Issuance of keys shall be limited to responsible officials. A written record of key authorized and issued shall be maintained by the security unit.  Shall maintain an adequate patrol of the hospital premises. A logbook of inspection and patrols conducted shall be maintained. Any accident or incident occurring during the shift shall be reported and investigated.  Shall establish and implement a Hospital Security Program and conduct security education to obtain cooperation from hospital personnel.  Shall maintain an adequate and accurate documentation and inventory of arms and ammunitions.  Shall coordinate with the Housekeeping and Maintenance Units in the preparation of Disaster Preparedness Plan.  Guard on duty shall not leave his post without a reliever.

DEPLOYMENT OF SECURITY GUARDS:

PROCEDURES a.

PERSON/S RESPONSIBLE

Prepares schedule of duty

Head Security

b. Checks posted guards

Head Security

c. Inspects entry/ exit point of employees, patients and public including bags/ luggage.

Posted Security Guard

d. Inspects / records incoming and out going vehicle.

Posted Security Guard

e. Records and submits unusual/ incident reports.

Posted Security Guard

f. Conducts rounds and inspects buildings, facilities and premises to ensure safety of patients and hospital personnel.

Roving Security Guard

g. Makes report and forwards to the Chief of Hospital.

Head Security Guard

CONDUCT OF INVESTIGATION: 134

a.

PROCEDURES

PERSON/S RESPONSIBLE

Receives and reviews incident report.

Head Security

b. Conducts preliminary report of incidents.

investigation

of

Head Security

c. Submits report to the Chief of Hospital.

Head Security

VEHICULAR ACCIDENT WITHIN A PREMISES PROCEDURE

PERSON/S RESPONSIBLE

a. Investigates Accident b. Takes note of time of occurrence. c. Reports accident to Security Head for investigation and take note of the real names of parties concerned and plate numbers of vehicles d. Takes note of damages sustained by both e. Prepares report and submits to the Administrative Officer. f. Forwards report to Chief of Hospital for information

Guard on Duty

Administrative Officer

VIOLATION OF PEACE AND ORDER PROCEDURE

PERSON/S RESPONSIBLE

a. Pacifies erring parties b. If not settled amicable, records the names of both parties, nature of offense committed, and time of occurrence c. Reports to the Security Head d. Prepares affidavits for signature of aggrieved parties e. Prepares report and submits to Administrative Officer f. Forwards report to Chief of Hospital for information LINEN AND LAUNDRY

135

Guard on Duty

Administrative Officer

FUNCTION: Provides laundry services and ensures adequate supply of clean linen for patients and other hospital units.

POLICIES:  Universally accepted infection control, occupational health and safety standards for hospital laundry services shall be strictly observed and implemented.  Availability of clean linens shall be assured at all times to meet the daily and emergency needs of the hospital.  Perpetual inventory of serviceable and condemned linen, supplies and materials shall be enforced.  Safe working area and properly ventilated to prevent the spread of contaminants.  Appropriate personnel protective equipment shall be enforced for the safety and protection of the staff.  Clean linen shall be properly handled and stored to lessen contamination from surface contact or airborne deposits.  Secured storage area for clean linen shall be provided.  Soiled linens shall be segregated and kept from clean linens at all times.

RESPONSIBILITIES:

 Prepares comprehensive plan for laundry and linen services.  Ensures the efficient collection of soiled linen and timely issuance of clean linen to different units of the hospital.  Monitor the implementation and observation of the universally accepted infection control, occupational health and safety standards among the linen and laundry staff.  Makes raw materials into desired linen and repairs or recycles damaged linen.  Undertakes disinfection of soiled linen.

136

ISSUANCE OF CLEAN LINENS:

PROCEDURES

PERSON/S RESPONSIBLE

a. Submits request slip for required linen.

Nursing Attendant

b. Checks availability of linen and issues requested linen.

Linen Staff

c. Records Issuances.

Linen Staff

COLLECTION AND LAUNDRY OF SOILED LINEN: PROCEDURES

PERSON/S RESPONSIBLE

a. Sorts, accounts, lists and returns soiled linen.

Nursing Attendant

b. Verifies and records the returned soiled linen from the wards/ other units.

Linen and Laundry receiving Staff

c. Informs Nursing Attendant on missing linen.

Linen and Laundry receiving Staff

d. Forwards to laundry area.

Linen and Laundry

e. Disinfects and washes soiled linen.

Laundry Staff

137

f. Sorts, records and stores clean linen.

Laundry Staff

INVENTORY OF LINENS:

PROCEDURES

PERSON/S RESPONSIBLE

a. Records and updates stock cards.

Linen and Laundry

b. Conducts physical inventory of linen and identifies linen for condemn or recycling.

Linen and Laundry

c. Prepares and submits reports of inventory.

Linen and laundry

INVENTORY OF LINEN (CLINICAL AREAS):

PROCEDURES

PERSON/S RESPONSIBLE

a. Conducts monthly inventory of linen.

Nurse Staff concerned

b. Reconciles records of linen receipt and returned.

Linen and Laundry Head

c. Reports missing or unaccounted linen to immediate head.

Linen and Laundry Head

PRODUCTION OF LINEN:

PROCEDURES

PERSON/S RESPONSIBLE

a. Determines the linen requirements.

Linen and Laundry Head

b. Prepares purchases request for raw materials and supplies.

Linen and Laundry Head

c. Inspects and accepts deliveries of raw materials and supplies.

Linen and Laundry Head

d. Instructs linen staff for the desired finished product.

Linen and Laundry Head

e. Inspects sewed linen in conformity with specification together with the coding/ marking.

Linen and Laundry Head

138

f. Maintains inventory log book of all hospital linen with corresponding costs.

Linen and Laundry Head

DISPOSAL OF CONDEMNED LINEN: PROCEDURES

PERSON/S RESPONSIBLE

a. Sorts and inspects torn and worn - out linens.

Linen and Laundry

b. Separates torn/ worn-out linen for recycling or condemn.

Linen and laundry

c. Prepares itemized list of linen for condemn and forwards to Property and Supply

Linen and Laundry

HOUSEKEEPING SERVICES Primary Function and Responsibility:    

     

Responsible in cleaning and maintaining of assigned work Coordinates all cleaning activities to immediate superior Reports defective equipment to immediate superior or office for immediate action or repair Report to Hospital Maintenance personnel of any of the following:  Busted bulbs  Water leaks  And other hospital problem issues Wear a smile while performing duty Observe courtesy at all times Clean all equipments, gadgets and tools after use Reports untoward incident to immediate superior or Hospital Maintenance personnel within the areas of responsibility Practice self-discipline and personal hygiene Practice supplies and materials control

Relation to clients:  Be Respectful and Courteous:  Knock at the door before entering the room.  Greet GOOD MORNING, GOOD AFTERNOON, or GOOD EVENING to a person inside  Speak in direct and clear language your purpose in going there. Answer surely and clearly when you are ask a question  Do not wander inside the room, do what is being told you to do, if instruction are not clear, ask for the clarification only once  Leave the room with a permission and a smile  Qualities and Values 139



Honesty * Return things that are not yours; * Do not forge documents; * Admit errors, accept faults, and learn their corrections.



Trustworthy * Do not lie.



Diligent * Give your work the interest, enthusiasm and efficiency it deserves * Do your job professionally, with effectiveness and with commendable results



Punctual * Reports on-time or earlier * Always visible on post

 

Disciplined and God fearing: Refrain the indulging in vices for it destroys your body and mind. It gives bad effect in your works and depletes your income and savings. Be cautious and avoid other things that may obstruct bodily functioning your own good and our company’s goodwill. Follow instruction with accuracy and correctness. Be a Law abider, and above all always fear God. Remember disciplined is an endowment from God. Always obey and follow company rules and regulation In reporting to your place of work, you have to be in the company’s complete uniform. Wearing your uniform together with together with proper identification lets the people around you know who you are and the company you represent.

     

CLEANING PROCEDURE AND METHODS: I.

FLOOR STRIPPING PROCEDURE A. Chemicals Wax Stripper B. Equipment Wet Floor Sign Two Mop Squeezers Floor Machine (Low Speed) Vacuum Cleaner C. Tools & Materials Stripping Pad Putty Knife Soft Broom Dustpan Mop Rags Water Pail D. Procedure

House Keeping Supervisor needed.

-Requisition of Supplies and Materials

Supply Officer

-Issues supplies and materials as requested.

House Keeping Personnel

-request supplies and materials needed. 140

House Keeping Supervisor

-Issues supplies and materials as requested.

Duties and Responsibilities of House Keeping Personnel   

  



   

Assemble your chemical, equipment, materials and tools Remove any free-standing objects from the floor, vacuum or clean walkoff mats and set aside Sweep or dust mop the area. As you are sweeping or dust mopping, take note of any potential problem areas. Remove any gum or debris that may be stuck to the floor. Mix or dilute stripping solution in accordance with the label instructions Post wet floor signs. There should be more than one sign posted, it must indicate which areas are being worked on Liberally apply the diluted stripping solution to the floor. Do not work in an area larger than 10 feet x 10 feet. If you are stripping problem floors like grouted tiles or heavy build up dirt, it is necessary to work in a small section. Allow the stripping solution to stay on the floor for 7 to 10 minutes before scrubbing. Note: Do not allow the stripper to dry on the floor. Scrub the floor with floor machine. If heavy build-up dirt is present, reapply the stripper before scrubbing to increase contact time. Allow it to stay on the floor and then scrub. Pick-up the solution with a wet vacuum or with a mop. Rinse the floor with clean water and a clean mop. Apply liberal amount of water and pick-up with wet vacuum or mop. Repeat this step twice or trice Clean your equipment and return it to appropriate area. Do not remove the wet floor sign until the floor is completely dried.

II.

SEALING / FINISHING PROCEDURE A. Chemicals Sealer B. Equipment Wet Floor Sign Mop Squeezer C. Materials & Tools Mop (clean) Plastic Pail Dust Pan Soft Broom Plastic Trash Liner Trash Bin with color coding

III.

MAINTENANCE PROCEDURE (Dust and Damp Mopping) A. Chemicals Cleanser, Disinfectant B. Equipment Wet Floor Sign Mop Squeezer Vacuum Cleaner C. Materials and Tools Clean Mop Putty Knife Soft Broom Dust Pan D. Procedure  Assemble your chemical, equipment, materials and tools  Remove any free-standing objects. Vacuum walk-off mats and set aside  Sweep or dust mop the entire floor. Remove any gum or other debris that may stick to the floor with putty knife 141

 Post the wet floor signs. It should be more than one sign posted. The signs must indicate the area that is wet.  Mix chemical according to label directions with cool water  Damp mopping – Light Soils: Dip mop head into the cleaning solution and wring-out. Apply the cleaning solution and wring-out. Apply the cleaning solution to the floors, allow drying.  Wet Mopping – Heavy Soils Dip the mop head into the cleaning solution and lightly tamp in mop squeezer. With heavy soils, be sure to get into the corners and along the edge. Change the clean solution when it become heavy soiled.  Allow the cleaning solution to remain on the floor for five (5) minutes, then pick-up with mop head or wet vacuum.  Rinsing well is necessary in heavily soiled areas. Used a clean mop head and clean water. Apply the rinse water and pick-up with a mop or wet vacuum. Change the rinse water as it becomes soiled. Allow the floor to dry.  Thoroughly rinse your mop heads, buckets and wringer. Return them to their appropriate place. IV.

TOILET CLEANING PROCEDURE A. Chemicals Toilet Bowl cleaner Powder soap B. Equipment Mop squeezer C. Materials & Tools Hand brush Push brush Scouring pad Rubber hand gloves Rags Spray gun Stick broom Dust pan Mop D. Procedure  Assemble your chemical, equipment, materials and tools  Remove all trashcans, collect trash liners within the contents from the trashcans. Close liner and place in trash bag for disposal.  Sweep and pick up litter with the dust pan and broom, start from the end going back to the entrance door. Take note of problem areas and remove sums, tar or any substance from the floor with putty knife Note: Do not sweep trash into the corridor or adjourning area.  Post wet floor sign at the entrance of door to indicate the area is being cleaned and serviced. Mix and dilute cleaning solutions in accordance with the label instructions.  Liberally apply bowl cleaner into toilet and urinal bowls, allow the cleaning solution to stand for a while  Going back, scrub the toilet bowl and urinals using oval brush or scouring pad thoroughly from rim to the water line. Flush water twice and repeat using powder soap. Clean and scrub exterior of bowls with powder soap and include the walls and cubicles. Rinse and wipe dry.  Clean and scrub floor tiles, make several passes on the grouts if necessary. Rinse and mop dry before leaving and place back all trash cans with new liners. 142



Take note of any busted bulbs, leaky fixtures and other defective items to report to the supervisor or to Maintenance.

WORK METHODS o There is a basic approach that applies to the cleaning of almost any kind of area in the building. We say “DAILY” to indicate routine, respective service required to restore the cleanliness of any area after a period of use. The normal period of use of any areas varies with the purpose of the area. Such as the following:  In an office – cleaning must be done at the beginning and the end of the working day.  In a certain kind of area which in use of 24 hours a day, everyday of the week, cleaning should be done as often as once per eight-hour shift? It is the cycle of used area that determines the frequency with which the restorative cleaning procedure must be followed. o The best procedure is to perform each of the four groups in the 3 sequence given.

143