Dr. Montano G. Ramos Hospital
Dr. Montano G. Ramos Hospital
Dr. Montano G. Ramos Hospital
INFIRMARY
Dr. Montano G. Ramos Hospital
141 Mindanao Ave., Bahay Toro, Proj. 8, Quezon City
FINDINGS:
Submit policy addressing patient’s rights
Proof of discharge plan
Proof of Creation, Membership, and Minutes of Meeting for the following committees:
Committee Creation/Order Policy Minutes of meeting
Credentialing and Privileging / X X
Waste Management / / X
Patient Safety / X X
Infection Control / / X
Emergency and Disaster Preparedness / / X
CQI / / X
Grievance / X X
Selections and Promotions X X X
Proof of Annual accomplishment report
Valid Memorandum of Agreement with Waste Management Service, Ambulance, Security
Presence of annual plan for training activities
Proof of Job descriptions with conforme
Presence of Annual Statistical Reports
Policy of filing and retrieval of charts
Policy to protect records and charts against loss, destruction, tampering and unauthorized used.
Proof of preventive maintenance of equipment, presence of operating manuals of medical equipment
Contract or Appointment of person in charge of security.
Presence of sentinel event reporting system
Certificate of Training (in-house) or MOA of personnel in-charge of maintenance of equipment
Present copy of manuals of equipment
Policy for cleaning, disinfecting, drying, packaging and sterilizing of equipment, instruments, supplies
Presence of policies in reporting of notifiable diseases (reporting for PIDSR policy)
Submit copy of updated sanitary permit
Presence of Quality Improvement Program and proof of implementation
Presence of Customer Satisfaction Survey and analysis
PROGRAMS
Mother-Baby Friendly Accreditation or received copy of letter of intent
Immunization logbook
Designation of HEMS Coordinator
Newborn Screening for Hearing logbook
PERSONNEL
Copy of the following:
- Accountant or accountant clerk – Diploma, certificate of trainings attended, Contract
- Billing/Cashier – Contract, trainings
- Clerk - Contract, trainings
- Supply Officer/Storekeeper - Contract, trainings
- Laundry Worker – contract
- Cook - contract
- Security guard – contract or MOA
- Nurse Supervisor – Diploma, valid PRC license, contract, Master’s Degree in Nursing or at least 9 units.
- NURSES to hire additional 8 nurses– submit contract and PRC ID
Recommendation for physical plant: - required to apply for upgrading in function of the facilities to meet the
minimum requirement governing the new classification of hospitals as per AO 2012-0012
-Secure approved permit to construct prior to all major addition, alteration
and upgrading as an infirmary level from DOH0NCRO before proceeding with its construction.
EQUIPMENT/INSTRUMENT
Submit photo and official receipt of the following: