The Philcat Certification Self Assessment and Survey Tool Repaired Final

7/16/2019 The PhilCAT Certification Self-Assessment and Survey Tool (Repaired) FinAL
The PhilCAT Certification Self-assessment and Survey Tool
PhilCAT CERTIFICATION STANDARDS

Survey Criterion Evidence of Progress and Achievements DOTS Surveyors' Comments Survey
Item (Completed by TB DOTS Center) Center Team
Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
1. The TB DOTS center is Signages and signs are placed for easy access
easily located and to the center. EA
patients have convenient
and safe access to the
center.
This standard will be achieved when:
1.1. There is appropriate Signages are placed to provide directions for
signage bearing the name easy access to the center. EA
of the TB DOTS center to
assist patients accessing
the center.
1.2. Physical access is The road to the center is spacious for easy
appropriate for the needs access. EA
of patients.
1.3. Entrances and exits are No parking sign is placed.
clearly marked and free of EA
obstruction and other
hazardous conditions.
1.4. There are resources to Daily and hourly schedules as well as the
inform patients of the duration of the treatment are posted to ensure
daily and hourly schedule the quality of the service.
of TB DOTS services, EA
ensure the quality of
patient waiting.
*Rating scale: 1
1. Non Achievement - The requirements of standard / criterion are not met.
2. Low Achievement - The requirements of standard / criterion are scarcely met
3. Moderate Achievement - The requirements of the standard / criterion are generally met in most circumstances.
4. Extensive Achievement - The requirements of the standard / criterion are fully met in the majority of circumstances and have been for some time.
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OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

(To be completed by sur vey team only. T he sur vey team must make comments on it ems where the survey team disagrees or parti all y disagrees with
inf ormation pr ovided by the TB D OTS center.)
Goal: The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
Standard 1: The TB DOTS center is easily located and patients have convenient and safe access to the center.
Rating (please tick appropriate overall rating for this standard)
Non- Low Moderate Extensive

Achievement Achievement Achievement Achievement
*Rating scale: 2

Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients
2. The TB DOTS Center Structural and physical layout of the facility
provides facilities for the ensured the client‘s privacy and c omfort. EA
comfort and privacy of
its patients and staff.
2.1. The TB DOTS center Housekeeping schedule is practiced to
maintains a clean and maintain cleanliness.
wholesome environment EA
within and immediately
outside its premises.
2.2 There are resources and Pamphlet and magazines are provided for
processes to ensure the waiting patients. EA
quality of patient waiting.
2.3 The lighting in each area The room is well ventilated and well lit for
of the center is the patients comfort. EA
appropriate for the
assigned purpose of the
area.
2.4 The privacy of the staff- Curtains are placed to provide privacy.
patient encounter is EA
assured.
*Rating scale: 3

(To be completed by sur vey team only. T he sur vey team must make comments on it ems where the survey team disagrees or part ial ly di sagrees wi th
Standard 2: The TB DOTS center provides for the privacy and comfort of its patients and staff.

*Rating scale: 4

Rating* Rating*
Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients.
3. The TB DOTS center Proper procedures are strictly followed such EA
provides for the safety of as hand washing, proper segregations of
its patients and staff. garbage and proper storage of drugs.
3.1 There is adequate clean Hand washing area is available inside the EA
water for personal hygiene center.
and sanitation purposes.
3.2 The TB DOTS center Hand washing and after care of the EA
maintains appropriate equipments are strictly followed to ensure
levels of cleanliness and quality service.
antisepsis of all physical
areas, equipment and
instruments.
3.3 General waste, sharps, Garbage cans are provided. They are EA
pathological and properly labelled for proper segregations.
infectious waste,
pharmaceutical and
chemical wastes are
appropriately segregated,
safely handled and
disposed of according to
accepted safe disposal
practices.
3.4 TB drugs are securely TB drugs are properly stored in the cabinets. EA
stored under appropriate
storage conditions.
*Rating scale: 5

Rating* Rating*
3.5 Sputum and other body Sputum collection area is provided for the EA
fluids arehygienic
safe and collectedway.
in a patient.
3.6 There are documented, Flyers, pamphlets and posters are available EA
disseminated and for further information about TB.
implemented procedures
to identify and address the
risks of contamination of
staff and patients from
sources of infectious
diseases.
Standard 3: The TB DOTS center provides for the safety of its patients and staff.

*Rating scale: 6

Rating* Rating*
Goal Patients receive adequate and effective diagnostic and therapeutic ser vices at every phase of their management from screening for TB to
rehabilitation.
4. All patients undergo a Proper assessment is done by the physician EA
comprehensive and health education is provided to the
assessment to facilitate patient.
the planning and
delivery of treatment.
4.1 Appropriate professionals Staffs documented the relevant information EA
obtain and document the regarding patient’s health.
relevant history for each
patient.
4.2 A physician completes The patient will undergo assessment by the EA
and documents the physician.
relevant physical
examination for each
patient.
*Rating scale: 7

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

*Rating scale: 8

Rating* Rating*
Goal: Patients receive adequate and effective diagnostic and therapeutic ser vices at every phase of their management from screening for TB to
rehabilitation.
5. All patients have Laboratory with qualified and trained EA
continuous access to microscopists are available for diagnostic
accurate and reliable TB purposes.
diagnostic tests.
5.1 All patients undergo Qualified and trained microscopists are EA
sputum microscopy by a available to examine the sputum collected.
qualified and trained
microscopist.
5.1.1 The TB DOTS Procedures are being followed to ensure EA

center plans and reliable results.
implements policies and
procedures for assuring
the quality of sputum
microscopy results.
5.1.2 If sputum Laboratory is available for the examination EA
microscopy facilities are of the sputum.
not available in the TB
DOTS center, policies
and procedures for
referring patients to
accessible centers are
implemented and
monitored for
effectiveness.
*Rating scale: 9

Rating* Rating*
5.1.3 External providers Laboratory results are being sent to the EA
of sputum microscopy
contracted based on are
policies and procedures
that include accreditation
status and the presence of
quality control systems.
5.2 Policies and procedures Patients for X-ray examination are being EA
for referring patients to referred to accredited X-ray facilities such as
accredited and accessible NOPH. Correct procedures and policies are
X-ray facilities are being followed.
implemented and
monitored for
effectiveness.
5.3 Policies and procedures Proper procedure in referring patients to EA
for referring patients to an accessible TB Diagnostic Committee is being
appropriately constituted observed.
and accessible TB
Diagnostic Committee are
implemented and
monitored for
effectiveness.
*Rating scale: 10

(To be completed by sur vey team only. T he sur vey team must make comments on it ems where the sur vey team disagrees or parti all y disagrees wi th
rehabilitation.
Standard 5: All patients have continuous access to accurate and reliable TB diagnostic tests.

*Rating scale: 11

Rating* Rating*
Goal Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB to
rehabilitation.
6. A care plan is developed Treatment that is being implemented is EA
and followed for all according to the National TB program and
patients. these are documented properly.
6.1 All treatment is consistent National Tuberculosis Program’s treatment is EA
with the National strictly followed.
Tuberculosis Program
guidelines.
6.2 Flow charts of patient Flow chart is being posted in order for the EA
management from entry to patient to be aware of the treatment.
separation are used to
facilitate quality care and
are accessible to patients
and staff.
6.3 DOTS partners are There is an assigned DOTS partner in each EA
selected and assigned TB patient. These DOTS partner ensures that
based on predetermined the patient will follow the treatment regimen.
criteria and procedures
and these are accessible to
patients and staff.
*Rating scale: 12

Rating* Rating*
6.4 Education is provided to Health teachings are provided by the staff to EA
all patients to help them further help the patient enhance his/her
understand their medical knowledge regarding the nature of the
condition and prognosis disease and how it can be cured.
and to encourage their
adherence to the treatment
regimen and health
promotion / illness
prevention activities.
6.5 An appropriately Follow up visits and check ups are being EA
comprehensive evaluation done to evaluate the patient’s progress.
of the patient's clinical Proper documentation is observed.
progress is made and
documented at each visit.
6.6 Policies and procedures Based on the records (TB registry), no EA
for detecting treatment defaulters have been documented.
defaulters and getting
them back into treatment
are implemented and
monitored for
effectiveness.
*Rating scale: 13

rehabilitation.
Standard 6: A care plan is developed and followed for all patients.

*Rating scale: 14

Rating* Rating*
Goal Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB to
rehabilitation.
7 Patients have continuous TB drugs are being monitored and stored EA
access to safe and properly for safety administration.
effective anti-TB
medications throughout
the duration of their
treatment.
7.1 The TB DOTS Center has Inventory report of the TB drugs is EA
developed and documented to assure that there is a
implemented policies and continuous supply.
procedures for assuring a
continuous supply of TB
drugs to all its patients for
the entire six months
duration of therapy.
7.2 The TB DOTS center Buffer stock of anti-TB drugs is always EA
maintains an appropriate monitored to ensure there is always an
buffer stock of anti-TB available stock.
medications.
7.3 The TB DOTS Center has Drugs are properly stored and are being EA
developed and checked for their expiration date.
implemented policies and
procedures for assuring the
quality and safety of its
TB drugs.
*Rating scale: 15

(To be completed by sur vey team only. T he survey team must mak e comments on i tems where the sur vey team disagrees or parti all y disagrees with
rehabilitation.
Standard 7: Patients have continuous access to safe and effective anti-TB medications throughout the duration of their treatment.

*Rating scale: 16

Rating* Rating*
Goal The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB
DOTS center.
8. Policies and procedures Vision, mission, policies and procedures are EA
for providing care to being developed and are followed so that the
patients are developed, staffs will be guided.
disseminated,
implemented and
monitored for
effectiveness.
8.1 The TB DOTS center's Staffs are aware of the vision and mission. EA
policies and procedures These are implemented and being followed.
are consistent with the
organization's goals,
statutory requirements,
accepted standards, and
the TB DOTS center's
community
responsibilities.
8.2 Policies and procedures Proper referral is being implemented. List of EA
for patient referral to other referral centers, addresses and contact
services are implemented persons is available.
and monitored for
effectiveness.
*Rating scale: 17

Survey Survey Item Survey Item Survey Survey Item Survey
Item Item Item
8.3 Patient default rates are No defaulters are being reported yet. But in EA
monitored and
procedures are policies
developedand case there is, it will be documented.
and implemented to
improve default rates. The
policies and procedures
are monitored for
effectiveness.
8.4 Policies and procedures Policies and procedures are observed so t hat EA
for identifying and each external group are aware of their roles
working with external and responsibilities.
groups in providing DOTS
services are developed,
implemented and
monitored for
effectiveness.
*Rating scale: 18

(To be completed by sur vey team only. T he sur vey team must make comments on it ems wher e the sur vey team disagrees or parti all y disagrees wit h
Goal: The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB DOTS
center.
Standard 8: Policies and procedures for providing care to patients are developed, disseminated, im plemented and monitored for effectiveness.

*Rating scale: 19

Rating* Rating*
Goal The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB
DOTS center.
9. Policies and procedures Records and reports were handled properly EA
for managing patient and securely to ensure consistency of t he
information are information.
developed, disseminated,
implemented and
monitored for
effectiveness.
9.1 Each patient is uniquely Each patient has a case number which is EA
identified from entry and being recorded in the TB registry logbook.
throughout the course of The case number is consistent with NTP
management. treatment card and all related documents.
9.2 The TB DOTS center NTP forms are recorded properly, filled up EA
maintains a database of correctly and is being updated with
patient records and related consistency.
registries and enables the
staff to easily access these
databases.
9.3 Policies and procedures Records and reports are handled with EA
for ensuring the security confidentiality and only authorized personnel
and confidentiality of are allowed to access.
patient information are
developed, implemented
and monitored for
effectiveness.
*Rating scale: 20

Rating* Rating*
9.4 The TB DOTS center All the reports are submitted on time. The EA
submits complete and staffs are aware of the deadlines.

accurate reports to all
relevant agencies in a
timely manner.
9.5 The TB DOTS center Staffs conduct meeting to improve and EA
regularly reviews its review center performance.
records to assess and
improve performance.
*Rating scale: 21

(To be completed by sur vey team only. T he sur vey team must make comments on it ems where th e sur vey team disagrees or par tial ly di sagrees wit h
Goal: The management and staff adhere to clear and collaboratively developed policies and procedures for the efficient operation of the TB DOTS
center.
Standard 9: Policies and procedures for m anaging patient information are developed, disseminated, implemented and monitored f or effectiveness.

*Rating scale: 22

Rating*
Rating*
Goal The TB DOTS center staff provide efficient and competent DOTS services.
10. The TB DOTS Center Staffs undergo trainings and seminars to EA
has an adequate number provide quality care to TB patients.
of qualified personnel
skilled in providing
DOTS services.

10.1 An adequate number of The center is equipped of well trained staff EA
qualified and appropriately (physicians, nurse, midwives and
trained personnel provide microscopist).
and are accountable for the
following functions:
10.1.1 Leadership, City Health Officer is available for EA
management and overall leadership management of the center.
responsibility for the
operations, resources and
performance of the TB
DOTS center
10.1.2 Clinical patient care Nurses are capable of providing care to the EA
services patient.
10.1.3 Diagnostic services, Trained medical technologist is capable of EA
including sputum performing diagnostic services.
microscopy
10.1.4 Drug management Staffs instruct patients in drug administration EA
*Rating scale: 23

Rating* Rating*
and DOTS partner as well as in monitoring
patient’s compliance.
10.1.5 Information Staffs observe confidentiality of patient’s EA
management record.
10.1.6 Financial Staffs do have monthly salary for their EA

management services.
10.2 Personnel follow clear job A written job description is being signed by EA
descriptions, each staffs.
responsibilities and
accountabilities.
10.3 All personnel are Staffs are aware and follow procedure in EA
infection control.
responsible for safety in
the workplace and the
quality of the service they
deliver.
10.4 Personnel receive up to Certificates are available as proof of the EA
date training based on training and seminars joined by the staff.
training needs assessment.
*Rating scale: 24

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

*Rating scale: 25

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7/16/2019 The PhilCAT Certiﬁcation Self-Assessment and Survey Tool (Repaired) FinAL

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

5.1.1 The TB DOTS Procedures are being followed to ensure EA

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

The PhilCAT Certification Self-assessment and Survey Tool

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS

PhilCAT CERTIFICATION STANDARDS

submits complete and staffs are aware of the deadlines.

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

Rating (please tick appropriate overall rating for this standard)

Non- Low Moderate Extensive

PhilCAT CERTIFICATION STANDARDS