.

0 PURPOSE:
1.1 To guide and ensure the continuous improvement of quality services provided by ABC Hospital.
1.2 To fix key indicators for the processes, to organize measurement process to assess the
performance index on such key indicators.
1.3 Scheduling of periodical measurement of performance index of key indicators explained above.
1.4 To identify appropriate tools for continual improvement.
2.0 SCOPE:
2.1 Hospital Wide – All Inpatient care areas
2.2 Applicable to all employees of the hospital
3.0 RESPONSIBILTY:
3.1 Consultants / Doctors
3.2 All hospital staff
3.3 Core/Quality Assurance Committee
4.0 ABBREVIATION:
4.1 NABH : National Accreditation Board For Hospitals and Healthcare providers
4.2 CQI : Continuous Quality Improvement
5.0 DEFINITION:
5.1 Quality Indicators: Quality indicators are the means to judge the real performance of certain clinical as well
as managerial parameters selected for monitoring and evaluation.
5.2 Sentinel Events: An unexpected occurrence involving death or serious physical or psychological injury, or
the risk thereof to a patient, visitor, or an employee.
5.3 Quality improvements: It is an ongoing response to quality assessment data about a service in ways that
improve the process by which services are provided to the patients.
5.4 Risk management: Clinical and administrative activities to identify evaluate and reduce the risk of injury.
6.0 REFERENCE:
6.1 NABH: Pre Accreditation Entry Level Standards for Hospitals, First Edition.
7.0 POLICY:
7.1 Organization has designated a person as NABH coordinator to meet the quality standards.
7.2 Quality improvement and patient safety programme shall be implemented by Quality & Safety Team.
7.3 The Hospital management makes available adequate resources required for quality improvement and
patient safety program.
7.4 Sri Lakshmi Medical Centre & Hospital has identified key performance indicators to monitor the clinical
and managerial areas.
7.5 Quality Policy:
7.5.1 We hereby assure quality healthcare to patients through reliable healthcare services, available medicines
and maintainable equipments.
7.5.2 We shall ensure efficiency of operations and effectiveness of treatment through our competent human
resources.
7.5.3 We shall review this policy for continuing suitability, adequacy and effectiveness.
7.5.4 We shall achieve this through the quality objectives and targets set for various departments.
8.0 PROCEDURE:
8.1 Approach To Designing, Measuring, Assessing And Improving Quality:
8.1.1 Planning: Planning for the improvement of patient care and health outcomes includes a hospital-wide
approach.
8.1.2 Designing: Processes, functions or services are designed effectively based on: Mission and vision of Sri
Lakshmi Medical Centre & Hospital needs and expectations of patients, staff, and others.
8.1.3 Measurement: Data is collected for a comprehensive set of Quality measures. Data is collected as a part
of continuing measurement, in addition to data collected for priority issues. Data collection considers measures
of processes and outcomes. Data collection includes at least the following processes or outcomes:
8.1.3.1 Patient assessment
8.1.3.2 Laboratory safety & quality
8.1.3.3 Diagnostic Radiology safety & quality
8.1.3.4 Processes related to medication use
8.1.3.5 Processes related to anesthesia
8.1.3.6 Processes related to the use of blood and blood components
8.1.3.7 Processes related to medical records content, availability and use
8.1.3.8 Risk management activities
8.1.4 Assessment:
8.1.4.1 The assessment process involves the relevant departments to draw conclusions about the need for more
intensive measurement.
8.1.4.2 A systematic process is used to assess collected data in order to determine
whether it is possible to make improvement of existing processes, actions taken to improve the Quality
Improvement processes, and whether changes in the processes resulted in improvement.
8.1.4.3 Collected data is assessed at least annually and findings are documented and are forwarded through the
proper channels.
8.1.4.4 When assessment of data indicates, a variation in Quality, more intensive measurement and analysis
will be conducted and in addition, the department/service or team will reassess its Quality measurement
activities and re-prioritize them as deemed necessary.
8.1.4.5 Internal Communications:
8.1.4.6 The top management has defined and implemented an effective and efficient process for
communicating the Quality Policy, Objectives, Quality management requirements and accomplishments.
8.1.4.7 This helps the hospital to improve the performance and directly involves its people in the achievement
of the Quality Objectives.
8.1.4.8 The Management actively encourages feedback and communication from people in the hospital as a
means of involving them through the following modes:
8.1.4.8.1 Monthly Meetings;
8.1.5 Documentation:
8.1.5.1 Quality Manual: This is an outline of hospital policies of ABC HOSPITAL together with the Mission,
Vision and Values of ABC HOSPITAL Quality
Policy and Patient Safety priorities. Quality Manual also contains the structure and functions of the continuous
quality improvement programme.
8.2 Chairman/Quality Manager/NABH Coordinator at ABC HOSPITAL has the overall authority,
responsibility and commitment to communicate,
implement, control and supervise the compliance of various departments with the accreditation standards. The
roles and responsibility of the NABH Coordinator include:
8.2.1 Establishing and maintaining the Quality Improvement and Patient Safety Program.
8.2.2 Document control.
8.2.3 Schedule and conduct Internal Audits.
8.2.4 Schedule and conduct of Management Review meeting.
8.2.5 Ensuring corrective and preventive action arising from the above
8.3 Document Control:
8.3.1 Documents such as regulations, standards, policies, SOPs, manuals and other normative documents as
well as drawings, software form part of the Hospital Quality Management System.
8.3.2 A copy of each of these controlled documents shall be archived for future reference and the documents
shall be retained in their respective department the documents are maintained in paper or electronic media as
appropriately required.
8.3.3 Documents are identified and established as two levels namely:
8.3.3.1 Quality Manual;
8.3.3.2 Hospital Policies & Procedures;
8.3.4 The Heads of the Departments of the respective departments shall review all documents issued to
personnel as a part of management system annually and they shall approve it for the use. The Head of Quality
issues the finalized document.
8.3.5 The Head of Quality ensures that:
8.3.5.1 Authorized editions of appropriate documents are available at all locations where operations essential
to the effective functioning of the Hospital are performed.
8.3.5.2 Documents are periodically reviewed and revised where necessary to ensure suitability and compliance
with applicable requirements.
8.3.5.3 Invalid or obsolete documents are promptly removed from all prints of issue or use, or otherwise
assured against unintended use.
8.3.5.4 Obsolete documents are retained for either legal and / or knowledge preservation purposes are suitably
marked or destroyed or the record and the record of this maintained in a separate register.
8.3.6 Document Changes:
8.3.6.1 Revision of management systems documents is carried out when necessary by the original author and
updated at least once in two years.
8.3.6.2 When alternate persons are designated for review, they shall first familiarize themselves with pertinent
background information upon which to base their review and approval.
8.3.6.3 Document control system does not follow for the amendments by hand unless there is an extreme
circumstance.
8.3.6.4 These amendments shall be marked, initialed and dated only by the Head of the Department.
8.3.6.5 The amendment shall be brought to the notice of the NABH coordinator and the same shall be reissued
8.4 Preventive Actions:
8.4.1 The NABH Coordinator shall be perpetually vigilant and identify potential sources of non-compliance
and areas that need improvement.
8.4.2 These may include trend analysis of specific markers such as turnaround time, risk analysis, etc.
8.4.3 Where preventive action is required, a plan is prepared and implemented.
8.4.4 All preventive actions must have control mechanisms and monitor for efficacy in reducing any
occurrence of non-compliance or producing opportunities for improvement.
8.5 Corrective Action:
8.5.1 The NABH Coordinator takes all necessary corrective action when any deviation is detected in Quality
Management System.
8.6 Root Cause Analysis: Deviations are detected by:
8.6.1 Patient complaints/feedbacks.
8.6.2 Non-compliance receipt of items/sample.
8.6.3 Non-compliance at Internal/external Quality Audit. Management Reviews.
8.6.4 The NABH coordinator conducts and coordinates the detailed analysis of the nature and root cause of
non-compliance along with the responsible persons from the respective sections.
8.7 Selection and Implementation of Corrective Actions: Potential corrective actions are identified and the one
that is most likely to eliminate the problem is chosen for implementation.Corrective action is taken into
consideration the magnitude and degree of impact of the problem.All changes from corrective action is
documented and implemented.
8.8 Monitoring Of Corrective Actions: The NABH Coordinator shall monitor the outcome parameters to
ensure that corrective actions taken have been effective in eliminating the problem.
8.9 Procedures for Internal Quality Audit:
8.9.1 Internal audit shall be conducted by the internal audit team members once in six months.
8.9.2 Internal audit team members shall be trained on Pre Accreditation Entry Level NABH standards either
internally (a trained person who in turn trains the other members of the team) or externally (training conducted
by Quality Council of India).
8.9.3 Audit starts with the opening meeting. All departmental heads shall be informed about the purpose of
audit, audit timings and duration of audit etc.
8.9.4 All minor correction shall be suggested then and there by the auditor to the departmental staff.
8.9.5 Audit gets over with the closing meeting, over all observations shall be summarized by the chief auditor.
Audit observations shall be handed over to the chairman of the quality assurance committee in a standardized
format.
8.9.6 All the audit reports shall be discussed with the core committee members and the observations noticed
will be presented to the Chairman for improvements.
8.9.7 The Audit reports shall be forwarded to the concerned Departmental Heads.Corrective and preventive
actions will be done by the department staff based on the audit observations. Reports of the corrective and
preventive actions will be submitted to the Quality department by the concerned Head of the department.
8.10 Procedure for collection of data, interpretation and analysis of Quality Indicators:
8.10.1 Collection of Data: Reports of all key indicators as decided by the management will be submitted to the
quality coordinator at the end of every month by the Head of each department. All the data will be collected in
the standardized format.
8.10.2 Analysis of Data: All the data will be assessed in the form of Structure, process and the outcome.
8.10.3 Structure: Structure includes the facilities provided to the staff. Formula used for calculation. Training
or awareness of the set formulas quality improvement programme.
8.10.4 Process: Strict adherence of developed procedures in the daily work routine. In case of deviations same
will be documented in the quality indicator reporting form with proper reasoning.
8.10.5 Out Come: Based on the reports received trend analysis will be done and the same will be reported to
the chairman/ Management.

Quality Improvement Program:

Objective:

1. To achieve good health care/ information processing and to

facilitate the delivery of quality patient care.

2. To see to it that the procedures and practices of the MRS

conforms to the acceptable standards.

3. To provide feedback to facilitate necessary corrective actions.

Scope:

1. Covers the making of initiatives for the improvement of the

delivery of quality patient/client service. That encompasses the
medical record staff, medical staff, administration and nursing
staff.

Details:

1. Formation of Medical Records Committee:

a. Should consist of not less than three members and not more
than six. Which may be a;
 A representative of the doctors from both medicine and
surgery.
 A representative of the nursing administration.
 A representative of hospital administration.
 A representative of allied health staff-physiotherapy;
social work, etc.
b. Terms
 The members of this committee should serve at least two
years.
 The chairman of the committee should be appointed from the
retiring group and serves in an advisory capacity to the
members.

c. Responsibilities
 Ensuring that accurate and complete medical records are kept
and readily available for every patient treated in the
hospital.
 Helping to ensure that medical staff complete all the
medical records of patients under their care by recording a
discharge diagnosis and writing a discharge summary (where
required) for each discharged patient.
 Determining the standards and policies for the medical
record services of the health care facility.
 Recommending action when problems arise in relation to
medical records and the medical record service.
 Controlling new and existing medical record forms used in
the health care facility (all forms should he cleared by the
Medical Record Committee before being put into use).
 Insure that there is proper filing, indexing, storage and
availability of all patients’ records.
 Advise and develop policies with the aid of legal counsel to
guide the medical record staff & administration as far as
matters of privileged communication and release of
information is concerned.

d. Activities:
1. Planned and Systematic Approach - a quality assurance plan
should exist and address the following:
 Scope of the program
 Objective
 Methods to be used
 The individuals to be involved in the program
2. Monitoring- there should be a systematic ongoing process
of collecting information on clinical and non-clinical
performance.
3. Assessment - the periodic analysis and interpretation of
the information collected in order to identify problems in
patient care.
4. Action - at this stage important problems in patient care
 or opportunities to improve care are identified, action/
studies are undertaken.
5. Evaluation - the effectiveness of actions taken is
evaluated to ensure long-term improvement.
6. Feedback- to be effective, results of the activities
should be regularly relayed to the staff or people
involved in the program.

Mandatory Reporting To DOH And Philhealth

Objective:

1. To collate accurate and reliable mandatory report to DOH

and PhilHealth.

Scope:

1. Medical record in-charge in mandatory report and the respective

institution (DOH and PhilHealth).

PhilHealth Mandatory Reporting of the top 10 Leading Causes (Monthly

report)

Details:

1. Collate top leading causes from the final diagnosis of each

patient by encoding it accurately in the system.

a. Predetermine the PhilHealth and Non PhilHealth Census.

b. Number of discharges encompasses PhilHealth and Non

PhilHealth patient and its Total Census

c. Quantitative Data of Quality Assurance Indicator

o Monthly Bed Occupancy Rate (MBOR) as Total of NHIP

Census plus total of Non NHIP Census divided by
Number of Days per month indicated multiplied by the
number of DOH authorized beds and multiplied by 100.
o Monthly NHIP beneficiaries Occupancy Rate (MNHIBOR)
as Total number of NHIP Census divided by Number of
days per month indicated multiplied by the number of
DOH accredited Beds and multiplied by 100.
o Average Length of stay per NHIP Patient as Total
number of NHIP Census divided by Total of NHIP
Discharges.
 d. Indicate the Newborn census in which excluding the newborn
with illness.

e. Identification of top 10 leading causes in classifications

of common causes of confinement, surgical procedures,
surgical sterilization, obstetrical procedures, mortality
diagnosis and most common reasons for referral.

2. Generate hard copy of the report for signature of the Chief of

Hospital and produce three (3) duplicates all original, one (1) for
the Hospital use and two (2) for the PhilHealth utilization.

7. Make the copies received at the PhilHealth Office for the

authentication, and kept hospital copy on file.

Information Officer

Objective:

1. To accommodate and direct clients coming in the hospital for a

various purpose or reasons.

2. To provide clear and precise information for convenience of

clients, patients, watchers, friends and associates.

SCOPE: Pertaining to all hospital staff, patients, watchers,

visitors and associates coming in the hospital for any
health or non health concerns.

DETAILS:

1. Welcomes patients and visitors coming in by greeting

patients and visitors in person and answering inquiries or referring
questions to other staff members.

2. Telephone attendant relaying incoming and interoffice call.

3. Maintains reception area in neat and orderly condition at

all times.

4. Assists patients with insurance papers and billing

questions.

5. Opens and sorts all office mail. Delivers outgoing mail to

post office at end of day.

6. Participates in the medical office emergency routine,

whenever required. Summons ambulance or assists other staff members
as needed.

HOSPITAL TRAFFIC
 1. All inquiries made by in coming clients in the information area
will be catered by the information officer.

2. All emergency cases will be directly addressed by the Emergency

room.

STORAGE

File Rooms/Storage
 OPD & in-patient
 active & inactive
SHELVING & CABINETS
 Closed cabinets
 secured
 less dusty
 Open shelves
 space saving
 ease in filing & retrieval
 Steel Cabinets
 Index card cabinets

ARRANGEMENT OF FILE SHELVINGS

 minimal walking distance from work area
 left – right expansion of files with approved numbering
system
 back2back or wall-mounted; 0.7- 0.8 m depth
 1.8 -2.0 meter high divided into 6 layers
 may provide kick stool or ladders
 preferably steel racks

STORAGE SPACE REQUIRED

= Annual Discharges + New OPD x Retention Period

Records per meter

SAFE KEEPING

SAFETY
 Structural integrity – heavy load
 Vibration free
 Fire high risk
 No Smoking signage
 No volatile and flammable substances
 Of fire retardant building materials
 Smoke detector & alarm system
  Fire extinguisher
 Fire escape
 Emergency light

LIGHTING & VENTILATION

 general illumination – 500 lux; with natural lighting
 ceiling lamps installed between and parallel to shelves
 room temperature and humidity at file room
 air conditioned staff area for comfort
 dust filtration is desirable (screened windows)

MAINTENANCE

 Well-maintained
 building components
 building equipment & devices
 office equipment & tools
 immediate surrounding
 Work area and file room always kept clean and orderly
 Practicing 5S
 Vermin control
 Termite proofing & control

RETENTION
Retention period

1. Emergency room records/blotters and other 25

yrs.
Records of prospective medico-legal significance
2. Birth and death certificates
Permanent
3. In- patient’s chart 15
yrs.
4. Out-patient’s chart 15
yrs.
5. Indexes
Permanent
6. Logbooks
Permanent
7. Daily Census 2
yrs.
8. Statistical notifiable disease 2
yrs.
9. Request forms 2
yrs.
DISPOSAL

1. Check the Record Disposition Schedule for records which has

reached the required retention period.
2. Pull out medical records from the file.
3. Prepare a list of records for disposal.
4. Communicate with the ADMIN office regarding a request to dispose
of medical records addressed to the Chief of Hospital.
5. Actual disposal will be directed by the head of the Medical
Records.
6. A certificate of disposal shall be prepared containing the
following data;
a. Nature of the record
b. Manner of disposal
c. Place of disposal
d. Date of disposal
e. Approximate volume
f. Weight of records

Policy: Safety and Security

Objectives:
The primary purpose of the Safety & Security Policy is to
improve safety. The staffs, employees and health care
workers focus on problems in health care safety and how to
solve them.

To ensure that proper handling of patients are practiced by

all the health care members.
To create an environment free from any risks or hazards to
the patients, clients and hospital staffs.
Scope: Covers all staffs, employees, physicians and clients of this
hospital and its premises.
General provisions:

1. The Medical Mission Group Hospital seeks to provide a safe and

secure environment conducive to the recovery and maintenance of
the health of clients and employees alike. In the event of
unforeseeable circumstances that would arise from uncontrollable
or unexpected events, the patient or significant others are
required to report it immediately to the health care team or the
maintenance crew so that it will be acted upon promptly.

2. Nursing service rendered by this hospital should be rendered in a

manner that is careful and mindful always of the patient’s
welfare. Due care towards patients or clients should be observed
at all times.
3. The hospital maintenance staff checks equipments daily for any
malfunction or breakage to prevent any accidents or injury. The
hospital staff removes the equipments deemed malfunctioning upon
checks and sends it to the maintenance or engineering department
for repairs. In the event of any observed malfunction of
equipment, the patient or watcher shall not use it to avoid
injury and report it immediately to the nurse or maintenance crew
for repairs.

4. Any leaking faucets or pipelines, wet floors should be reported

immediately by the person who sees it first so that the janitor
or maintenance crew will attend to it immediately.

5. Wheelchairs are available on all nursing units, but getting in

and out of them without assistance may be hazardous. The patient
and watchers are instructed to ask for help or assistance from a
member of the health care team.

6. All medical equipment/gadgets related to the care of patient must

be regularly checked by the staff for proper functioning and to
avoid injuries and to protect life.

7. Security guards inside the hospital perform rounds and checks

hospital premises regularly. All the hospital staff seeks to
create a safe and secure hospital environment. Watchers are not
allowed to loiter around corridors especially at night. Bringing
of valuables and jewelries inside the hospital is discouraged.
Patient and watchers are responsible for any loss of their
valuable items. It is encouraged to bring only essential items
such as clothing or objects used for personal hygiene.

8. The hospital’s point of entry and exits are guarded at all times
during the day, fire exits are open but are under the supervision
of the security guard. Hospital rounds are performed by the
security guards throughout day and night. At night starting
11:00pm, the main entrance/exit of the hospital building is
locked, fire exits are secured. The ER will serve as the point
of entry and exit until 5:00am when the main entrance/exit is
opened again. A security guard is assigned at the ER department
at all times.

9. Firearms and deadly weapons are strictly not allowed inside the
hospital. It is required that all firearms and deadly weapons be
declared and deposited to the security guard on duty at the main
entrance upon entry to the hospital.

10. Fire drills are annually exercised and conducted by the Fire
Department of Tagum City. Fire extinguishers are strategically
located throughout the hospital premises. In the event of any
fire, the patients and watchers are requested to remain in their
room and do not become alarmed. The hospital staff will attend to
 and assist the patients in an orderly manner to avoid confusion
and stampede.

11. Patients admitted are properly screened, health history

checked and laboratories/diagnostic procedures requested so that
their illness will be properly diagnosed whether they carry
infectious diseases that warrant isolation or immunodeficiency
that requires reverse isolation. Rooms are labeled isolation or
reverse isolation and the watchers are strictly instructed to
minimize visits especially by children and the elderly.

12. Rooms are well ventilated, spaced and lighted all throughout
the hospital facility in order to provide a safe and therapeutic
environment.

13. This hospital is strictly smoke-free.

A. Environmental Safety / Life Safety Measures

1. If you were injured, take the following steps:

a. Notify the department head immediately.
b. Acquire medical treatment.
c. Inform the Administrative Officer for investigation and
proper action.

2. In cases of fire, remember the word RACE:

R = Rescue (move people out of the room, close the door and
relocate patient beyond fire doors.
A = Alarm. Pull the nearest fire alarm.
C = Confine. (close the doors, cover trash can)
E = Extinguish or evacuate.
* Know the evacuation route, fire alarm pull stations and fire
extinguisher locations in your area.

3. In operating a fire extinguisher, remember the word PASS:

P = Pull the pin near the handle.
A = Aim the nozzle at the base of the fire.
S = Squeeze the handle.
S = Sweep the nozzle over the fire area.

B. X-Ray

1. Understand and apply the cardinal principles of radiation

control, time, and distance shielding.

2. Do not allow familiarity to result in false security.

 3. Never stand in the primary beam.

4. Always wear protective apparel when not behind a protective

barrier.

5. Always wear a personnel-monitoring device and position it

outside the protective lead apron on the collar.

6. Never hold a patient during a radiograph examination. Use

mechanical restraining devices when possible. Otherwise allow
parents or friends of the client to stay with the client to
secure him/her.

7. The person holding the patient must always wear a lead apron
and if possible, lead gloves.

8. Use gonadal shields on all personswithin childbearing age when

such use will not interfere with the examination.

9. Examination of pelvis and lower abdomen of women of

reproductive capacity should be limited to the 10-day interval
following the onset of menstruation. During the known
pregnancy, these examinations, when appropriate, should be
postponed until the conclusion of the pregnancy or at its
latter half.

10. Always collimate to the smallest field’s sizes appropriate

for the examination.

C. Laboratory Universal Safety Precautions

1. Gloves should be worn whenever handling or obtaining specimen

of any kind. They must be worn during disinfecting and
cleaning.

2. Laboratory gowns should be worn. (Mask and eyewear as needed)

3. Wash hands in between patients, after removing gloves, after

performance of tests, before leaving the laboratory as needed.
4. Dispose needles & other sharp objects in punctures resistant
containers. Never manually recap, hand as break a needle.

5. Specimens should be transported in rigid containers, enamel,

tray, racks, etc. Specimen for transport between institutions
(must have referral) should be labeled clearly, double-bagged
 on placed in a 2nd leak proof and puncture resistant
containers.

6. Laboratory work surfaces should be contaminated with an

appropriate chemical disinfectant after a spell, when work is
finished or whenever necessary.

7. All contaminated materials must be decontaminated prior to

disposal or cleaning for re-use using appropriate methods.

8. All contaminated materials & specimens should be placed be

leak proof autoclavable plastic bags for autoclaving.
Biohazard labels and instructions for final disposal should be
clearly indicated.

9. Wastes which are not biological in nature, not contaminated or

not potentially infected should be collected separately &
treated clearly indicated.

10. Never pipette by mouth.

11. Centrifuge specimens tightly capped or never as open tubes.

12. Do not eat, drink, smoke, and apply cosmetics or store food
& personal items in the laboratory working area.

13. Any cut or accidents of exposure to blood & body fluids

should be thoroughly washed with soap & water or an
antiseptic. Encourage bleeding. Such incidents must be
reported immediately to the medical doctor for treatment/s &
counseling should be provided.

14. Educate & train staff in the practice of bio-safety guidance

senior member of the laboratory.

D. Janitorial And Housekeeping Safety

1. When cleaning high areas such as: windows, ceilings,

jalousies, etc., a stepladder or ramps should be used.

2. Janitors should wear thick rubber boots especially when

disposing garbage and cleaning comfort rooms.

3. A qualified electrician should check-up electrical equipments

at least once a month with emphasis on open wires and its safe
operation.

4. A warning sign or marker should be placed when waxing the

floor or cleaning with wet mop. The area being waxed or wet
should be cordoned off.

5. Cellophane used for garbage disposal is considered infected

and, therefore it should not be re-used.
 6. Janitors and Helpers should wear protective apparel at all
times, such as: gloves, boots, and mask.

E. Linen and Laundry

I. Receiving all soiled linens.
1. Receive all soiled linens from all departments to be
classified accordingly by using mask, caps and gloves.

2. Soiled linens with communicable disease such as PTB, burns,

hepatitis B are placed inside a yellow bag.

3. All soiled linens placed in yellow plastic bags are soaked

with Lysol before washing.

4. Non-communicable soiled linens placed in a white sack are

likewise segregated such as patients’ gowns, pillowcases,
linens or bed sheets, nursery smock gowns and others.

II. HAZARD cases such as when sorting linens; blades; surgical

needles and syringes, wet floors, sharp equipment, the
following safety measures are to be observed:
1. Use thick gloves such as leather.

2. Use boots; rough cement/finish is needed for flooring.

3. Regular check-up of equipment’s by the maintenance department.

F. Dietary Department

1. Wear safe, sensible clothes for your work. Wear safe

comfortable shoes, with good soles, Do not wear high-heeled
shoes for work. Ragged or over-long sleeves or ragged clothing
may result injury.

2. If you have to reach for a high objects, use a ladder, not a

chair or table or a makeshift. Never overreach. Be careful
when you have to reach high to fill coffee urns, milk tanks,
etc.

3. Horseplay or practical jokes on the job are forbidden.

4. Keep floors clean and dry. Pick up any loose objects from the
floor immediately to prevent someone from falling and
slipping.

5. Do not overload your trays. Trays should be loaded so as to

give good balance. An improperly loaded tray can become
dangerous.

6. Use potholders and tongs when getting hot foods. Wear apron,
shoes and hairnets mask when cooking and distributing of
foods.
 7. Dispose all broken glass and china immediately.

8. Take sufficient time to serve your patient properly. Haste

makes waste.

9. Remove from service any chair, table or other equipment that

is loose, broken or splintered so as to prevent injury.

G. Maintenance and Repairs

Safety measures of maintenance personnel for electrician, aircon
technician and other equipment technician shall use the following
safety devices while fixing line electrical wires:
1. Wear rubber shoes.

2. Wear insulating gloves.

3. Use safety belts while fixing or installing electrical wiring

especially at the lateral wall of a building;

4. Use step ladder with rubber footing;

5. They shall not fix “live wires” while under the influence of
liquor;

6. They shall be in the presence of mind while doing electrical

works.

7. All electrical equipments shall be fixed with a grounding

wire.

H. Electrical Safety

This section applies to all electrical work(s) in MMGH&HSCT. Those

who direct or perform electrical construction or repair are expected
to be familiar with and follow applicable regulations and codes.
I. General Details

A. Electrical systems and equipment hard-wired to building

electrical systems:

1. All work with electrical systems and equipment hard-wired to

building electrical systems or to the electrical distribution
network must be managed by the Engineering Department.

2. All major medical equipments must be grounded or as directed in

the equipment manual.

B. Repair and fabrication of department-owned electrical equipment:

Repair and fabrication of department-owned electrical equipment must
be conducted by a qualified individual who is authorized to do the
work. Materials and methods must be appropriate for the type of use
and the location.

C. Connections to hospital power sources and use of electrical

equipment:

1. Cord and plug equipment should be plugged directly into a wall

outlet. Exceptions for extension cords and multiple outlet strips
are noted in for ease of use.

2. All equipment, whether personal or hospital-owned, used on

hospital property, including extension cords and multiple outlet
strips, must be certified by the Engineering Department for safe
use.

D. Equipment Safety

1. All electrical components must be assumed energized until

positively proven otherwise.

2. Control circuit devices, such as push buttons, selector switches,

and interlocks, may not be used as the sole means for de-energizing
circuits or equipment.

3. When in doubt of the integrity of the equipment, never plug it in

the electric socket. Call the Engineering Department, inform about
the situation and ask for assistance.

II. Responsibilities

1. Unit Heads

Implement these electrical safety policies and procedures as a part

of the department's comprehensive health and safety programs, in
accordance with electrical safety of the city.

2. Supervisors and principal investigators

a. Assure employees have appropriate electrical safety training.

b. Assure that repair and fabrication of department-owned electrical

equipment is done by a qualified individual who is authorized to do
the work. Environmental and health safety guidelines can provide
assistance with evaluating and monitoring of equipment safety
operations with regards to their electrical operation.
3. Employees

a. Perform electrical work only if qualified and authorized.

b. Use materials and methods appropriate for the type of use and the
location. For example, damp locations may require watertight
fittings, and cords exposed to sunlight should be UV-resistant.

c. Perform work as trained, using appropriate equipment, insulated

tools, and appropriate personal protective equipment (PPE).

4. Engineering Department

Responsible for establishing additional internal policies and

procedures for electrical safety including high voltages (>600
volts).

III. Procedures for Electrical Work and Use of Electrical Equipment

A. Purchase of electrical supplies and equipment

Electrical supplies and equipment must be purchased by departments

on a Purchase Requisition to be checked by the engineering
department for safety and quality compliance and approved by the
management.

B. Appropriate applications for extension cords

Extension cords may be used to supply power to appliances under

limited conditions. These include:

1. Temporary situations such as laboratory experiments lasting no

longer than 90 days.

2. Situations in which permanent wiring is inappropriate because

equipment is moved frequently.

3. Power tools or other portable appliances used on a transient

basis.

C. Proper selection and use of extension cords

1. Must be appropriately sized for the anticipated load, in good

condition, free of splices, repairs, and signs of excessive wear.

2. Must not pass through doors or windows.

3. Must not be stapled or attached to a floor, wall, or ceiling.

4. Must not be connected in series.

5. Must not create a tripping or other safety hazard.

6. Must be protected where exposed to foot or wheel traffic to

minimize tripping hazards and damage to the cords.

D. Use of multiple outlet surge protectors

1. Must be equipped with an automatic circuit breaker. Outlet strips

with fuses or without overcurrent protection are not acceptable.

2. Must have a cord no more than 6 feet long and must be directly
plugged into a wall receptacle.

3. Must be protected where exposed to foot or wheel traffic to

minimize tripping hazards and damage to the cords.

4. Must not be connected in series.

5. Specific equipments require the use of Automatic Voltage

Regulator should only be used with it. Always check for the fuses of
AVR’s if there is any malfunction of the equipment.

E. Equipment in patient care areas

1. Portable equipment for use in patient care or clinical laboratory

areas must have a hospital-grade plug.

2. Personally owned line-powered devices are not allowed in

designated patient care areas, except when deemed safe and as
allowed by management.

F. Fire prevention and combustible materials

Place heat-producing equipment at a safe distance from combustible

materials such as paper, wood, and plants. Combustible containers
shall be properly grounded and transfer containers bonded (connected
by cable) to the storage equipment (i.e. tank, drum).

G. Tripped circuit breakers

Report all problems with tripped electrical circuit breakers to the

Facilities Management at (530) 752-1655. Facilities Management
should be the only department working within electrical panels or
load-rated switchgear. Tripped circuit breakers can indicate a
serious electrical hazard.
H. Damaged equipment, plugs, and cords

Equipment with damaged plugs or cords or other conditions that

constitute an electrical hazard must be removed from service until
repaired.

I. Electrical circuit panels or disconnects

Electrical circuit panels or disconnects should not be blocked. A

minimum three foot clearance shall be maintained in front of panels.

J. Restrictions on use of UL (or equivalent) listed equipment

Use of equipment must be consistent with the restrictions of the

certification. In many cases when equipment is certified by a
testing laboratory such as UL, there are restrictions on the use of
the equipment. The restrictions are listed on the equipment label
adjacent to the UL listing. For example, equipment may be certified
only for home use or only for use when mounted vertically.

For strict compliance of all MMGH&HSCT employees:

1. Electrical equipment shall be free from recognized hazards.

2. Listed or labeled equipment shall be used or installed in

accordance with any instructions included in the listing or
labeling.

3. Sufficient access and working space shall be provided and

maintained around all electric equipment to permit ready and safe
operation and maintenance of such equipment.

4. Ensure that all electrical service near sources of water is

properly grounded.

5. Tag out and remove from service all damaged receptacles and
portable electrical equipment.

6. Repair all damaged receptacles and portable electrical equipment

before placing them back into service.

7. Ensure that employees are trained not to plug or unplug energized

equipment when their hands are wet.

8. Use safeguards for personnel protection and electrical protective

equipment.

9. Select and use appropriate work practices.

10. Follow requirements for electrical hazard guidelines.

11. All personal electrical appliances brought by clients or
watchers shall be inspected by the Maintenance Department.

12. Immediately report any medical equipment failure.

13. Power tools, ladders, welding machines, etc must be used in

accordance with manufacturer specifications.

14. Do not leave electrical equipment(s) in traffic lanes.

Return equipment to its proper location when not in use.

Hospital Electrical Safety Guidelines:

1. An electrical shock is always unpleasant, but it can be

lethal in the intensive care unit.

2. It is extremely important that all hospital personnel be

constantly on the watch for manufacturing defects or wear
and tear of critical parts.

3. Even if equipment is in perfect condition when it arrives

from the manufacturer, it is subject to the normal wear and
tear of daily hospital use. This type of deterioration may
be very severe if the equipment is dragged around, in a
great rush, from one room to another in response to
emergencies.

4. It should he clear to everyone that if any defective

equipment is noted, or if a tingle is sometimes felt when
using a piece of equipment, this is a signal to stop using
the equipment and report it.

5. All electrical equipment with heat producing elements must be

turned off when not in use.

6. All electrical equipment brought into the hospital must be

checked by the maintenance department staff before being used.
Example of such items include hair dryers or electric razors,
etc. Please have all electrical equipment checked before using it
in the hospital; your nurse will be happy to make arrangements
for the electrical safety check for you.

Electrical Equipment Failure Reporting

1. Immediately report all accidents, no matter how minor, to your

Supervisor and fill out a report Equipment Maintenance Logbook.
2. If you can identify the cause of the accident, be sure to note it
in the report included in Equipment Maintenance Logbook so that
corrective action may be taken to prevent another accident of the
same type from occurring.

K. Nursing Service Department Safety

1. Nursing Staff

a. Wearing of gloves, especially during I.V. insertion, caring

for patients with contagious diseases, caring of patients
during emergency and during surgical operation.
b. Goggles are utilized as needed for procedures that may
involve splashing of fluids.
c. Wearing of goggle and mask during surgical operation.
d. Always practice the importance of proper hand washing
techniques.
e. Medication safety practice should be followed from the
Nursing Service Manual Procedures and Medication Policy.
f. All nursing staff should be immunized accordingly.
2. Disposal
a. All collected items are segregated accordingly to color
coding standard of waste management.
b. Disinfects are applied on infectious and pathological waste
before disposal.
c. Used needle and other sharp objects should be placed in
sharp resistant container. Disinfectant is applied to them
before disposal.

L. Hospital Security Personnel

1. Hospital security guards must never disclose any patient

information (like room assignment) especially through
telephones, unless the security guard has verified that the
specific patient or watcher allows information to be given and
that the patient or watcher knows the person is requesting the
information.

2. Security guard assigned in the emergency room must assist ER

personnel and is responsible for recording vehicular plate
numbers that transported the patient in the security logbook.

3. For Medico-legal cases, the security guard assigned in ER must

call or contact the police.
4. The security guard is responsible for collecting, securing and
recording the patient’s valuables, cash, jewelries or cellular
phones if the latter has no accompanying identified relative
or significant others. The security guard will then deposit
the collected cash, jewelries or valuables to the cahsier for
safekeeping.

5. Security personnel are tasked to do rounds within the hospital

premises at regular intervals.

6. Security personnel are responsible for protecting the lives of

personnel and client of the hospital and the hospital
properties.

7. Security personnel must remind patients, hospital clients or

watchers to safeguard their valuables and belongings at all
times.

8. Security personnel should maintain the hospital’s peace and

order. Security personnel must pacify any trouble that may
arise.

9. Security personnel must never release cadavers unless the

requesting party has accomplished all documents, clearances
and signatories required for release. The party who requests
the release of the cadaver must also provide a photocopy of a
valid identification and must be verified by the security
guard before releasing the cadaver.

10. If situations that arise overwhelms the decision making

capacity of security personnel, the security personnel must
refer to the higher officer of the hospital.

11. All persons coming in and out of the hospital building must
be listed, logged in and logged out by the security personnel
in the security logbook at all times, even at night where the
port of entry and exit is only the Emergency Room.

12. Persons coming in and out of the hospital premises must be

observed and checked by the security personnel. Any firearms
or deadly weapon must be deposited at the security guard and
can only be released upon the departure of the owner/carrier
of the firearms or deadly weapon from the hospital premises.