the philcat certification self-assessment and survey tool (repaired) final

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

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The PhilCAT Certification Self-assessment and Survey Tool

*Rating scale:

1. Non Achievement - The requirements of standard / criterion are not met.

2. Low Achievement - The requirements of standard / criterion are scarcely met3. 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.

1

PhilCAT CERTIFICATION STANDARDS

Survey

Item

Criterion Evidence of Progress and Achievements

(Completed by TB DOTS Center)

DOTS

Center Rating*

Surveyors' Comments Survey

TeamRating*

Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients. 1. The TB DOTS center is

easily located and

patients have convenient

and safe access to the

center.

Signages and signs are placed for easy accessto the center. EA

This standard will be achieved when:

1.1. There is appropriate

signage bearing the nameof the TB DOTS center to

assist patients accessing

the center.

Signages are placed to provide directions for

easy access to the center. EA

1.2. Physical access isappropriate for the needs

of patients.

The road to the center is spacious for easyaccess. EA

1.3. Entrances and exits are

clearly marked and free of obstruction and other

hazardous conditions.

No parking sign is placed.EA

1.4. There are resources to

inform patients of the

daily and hourly schedule

of TB DOTS services,ensure the quality of

patient waiting.

Daily and hourly schedules as well as the

duration of the treatment are posted to ensure

the quality of the service.

EA




*Rating scale:




2

OVERALL RATING AND COMMENTS, COMMENDATIONS AND RECOMMENDATIONS BY SURVEY TEAM

(To be completed by survey team only. The sur vey team must make comments on items where the survey team disagrees or parti all y disagrees with

inf ormation pr ovided by the TB DOTS 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-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




3


Survey

Item



DOTS

Center

Rating*


Team

Rating*

Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients

2. The TB DOTS Centerprovides facilities for the

comfort and privacy of

its patients and staff.

Structural and physical layout of the facilityensured the client‘s privacy and comfort. EA


2.1. The TB DOTS center maintains a clean and

wholesome environment

within and immediatelyoutside its premises.

Housekeeping schedule is practiced tomaintain cleanliness.

EA

2.2 There are resources and

processes to ensure thequality of patient waiting.

Pamphlet and magazines are provided for

waiting patients. EA

2.3 The lighting in each area

of the center isappropriate for the

assigned purpose of the

area.

The room is well ventilated and well lit for

the patients comfort. EA

2.4 The privacy of the staff- patient encounter is

assured.

Curtains are placed to provide privacy.

EA




*Rating scale:




4


(To be completed by survey team only. The sur vey team must make comments on items 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.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




5


Survey

Item



DOTS

Center

Rating*


Team

Rating*

Goal The TB DOTS Center provides a safe and effective physical environment to its staff and patients.

3. The TB DOTS centerprovides for the safety of

its patients and staff.

Proper procedures are strictly followed suchas hand washing, proper segregations of garbage and proper storage of drugs.

EA


3.1 There is adequate clean

water for personal hygieneand sanitation purposes.

Hand washing area is available inside the

center.

EA

3.2 The TB DOTS center maintains appropriate

levels of cleanliness and

antisepsis of all physical

areas, equipment andinstruments.

Hand washing and after care of theequipments are strictly followed to ensure

quality service.

EA

3.3 General waste, sharps,

pathological andinfectious waste,

pharmaceutical and

chemical wastes areappropriately segregated,

safely handled and

disposed of according toaccepted safe disposal

practices.

Garbage cans are provided. They are

properly labelled for proper segregations.

EA

3.4 TB drugs are securelystored under appropriatestorage conditions.

TB drugs are properly stored in the cabinets. EA




*Rating scale:




6


Survey

Item



DOTS

Center

Rating*


Team

Rating*

3.5 Sputum and other body

fluids are collected in asafe and hygienic way.

Sputum collection area is provided for the

patient.

EA

3.6 There are documented,

disseminated and

implemented procedures

to identify and address the

risks of contamination of staff and patients from

sources of infectious

diseases.

Flyers, pamphlets and posters are available

for further information about TB.

EA





Standard 3: The TB DOTS center provides for the safety of its patients and staff.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




7


SurveyItem



DOTSCenter

Rating*


Team

Rating*Goal Patients receive adequate and effective diagnostic and therapeutic services at every phase of their management from screening for TB to

rehabilitation.

4. All patients undergo a

comprehensive

assessment to facilitate

the planning and

delivery of treatment.

Proper assessment is done by the physician

and health education is provided to the

patient.

EA


4.1 Appropriate professionals

obtain and document the

relevant history for each patient.

Staffs documented the relevant information

regarding patient’s health.

EA

4.2 A physician completes

and documents the

relevant physicalexamination for each

patient.

The patient will undergo assessment by the

physician.

EA




*Rating scale:




8




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.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




9


Survey

Item



DOTS

Center Rating*


TeamRating*

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

5. All patients have

continuous access to

accurate and reliable TB

diagnostic tests.

Laboratory with qualified and trained

microscopists are available for diagnostic

purposes.

EA


5.1 All patients undergo

sputum microscopy by aqualified and trained

microscopist.

Qualified and trained microscopists are

available to examine the sputum collected.

EA

5.1.1 The TB DOTScenter plans and

implements policies and

procedures for assuring

the quality of sputummicroscopy results.

Procedures are being followed to ensurereliable results.

EA

5.1.2 If sputummicroscopy facilities are

not available in the TBDOTS center, policies

and procedures for

referring patients toaccessible centers are

implemented andmonitored for effectiveness.

Laboratory is available for the examinationof the sputum.

EA




*Rating scale:




10


Survey

Item



DOTS

Center

Rating*


Team

Rating*

5.1.3 External providers

of sputum microscopy arecontracted based on

policies and proceduresthat include accreditation

status and the presence of

quality control systems.

Laboratory results are being sent to the EA

5.2 Policies and proceduresfor referring patients to

accredited and accessible

X-ray facilities areimplemented and

monitored for effectiveness.

Patients for X-ray examination are beingreferred to accredited X-ray facilities such as

NOPH. Correct procedures and policies are

being followed.

EA

5.3 Policies and proceduresfor referring patients to an

appropriately constituted

and accessible TBDiagnostic Committee are

implemented andmonitored for

effectiveness.

Proper procedure in referring patients toaccessible TB Diagnostic Committee is being

observed.

EA




*Rating scale:




11


(To be completed by survey team only. The sur vey team must make comments on items where the survey team disagrees or parti all y disagrees wi th



rehabilitation.

Standard 5: All patients have continuous access to accurate and reliable TB diagnostic tests.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




12


Survey

Item



DOTS

Center

Rating*


Team

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

and followed for all

patients.

Treatment that is being implemented isaccording to the National TB program and

these are documented properly.

EA


6.1 All treatment is consistentwith the National

Tuberculosis Program

guidelines.

National Tuberculosis Program’s treatment isstrictly followed.

EA

6.2 Flow charts of patient

management from entry to

separation are used tofacilitate quality care andare accessible to patients

and staff.

Flow chart is being posted in order for the

patient to be aware of the treatment.

EA

6.3 DOTS partners are

selected and assigned

based on predeterminedcriteria and procedures

and these are accessible to patients and staff.

There is an assigned DOTS partner in each

TB patient. These DOTS partner ensures that

the patient will follow the treatment regimen.

EA




*Rating scale:




13


Survey

Item



DOTS

Center

Rating*


Team

Rating*

6.4 Education is provided to

all patients to help themunderstand their medical

condition and prognosisand to encourage their

adherence to the treatmentregimen and health

promotion / illness

prevention activities.

Health teachings are provided by the staff to

further help the patient enhance his/her knowledge regarding the nature of the

disease and how it can be cured.

EA

6.5 An appropriately

comprehensive evaluationof the patient's clinical

progress is made anddocumented at each visit.

Follow up visits and check ups are being

done to evaluate the patient’s progress.Proper documentation is observed.

EA

6.6 Policies and proceduresfor detecting treatment

defaulters and getting

them back into treatmentare implemented and


Based on the records (TB registry), nodefaulters have been documented.

EA




*Rating scale:




14





rehabilitation.

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


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




15


Survey

Item



DOTS

Center

Rating*


Team

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

access to safe and

effective anti-TB

medications throughout

the duration of their

treatment.

TB drugs are being monitored and stored properly for safety administration.

EA


7.1 The TB DOTS Center hasdeveloped and

implemented policies and

procedures for assuring acontinuous supply of TB

drugs to all its patients for

the entire six months

duration of therapy.

Inventory report of the TB drugs isdocumented to assure that there is a

continuous supply.

EA

7.2 The TB DOTS center

maintains an appropriate

buffer stock of anti-TBmedications.

Buffer stock of anti-TB drugs is always

monitored to ensure there is always an

available stock.

EA

7.3 The TB DOTS Center has

developed and

implemented policies and procedures for assuring the

quality and safety of itsTB drugs.

Drugs are properly stored and are being

checked for their expiration date.

EA




*Rating scale:




16


(To be completed by survey team only. The survey team must make 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.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




17


Survey

Item



DOTS

Center

Rating*


Team

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

for providing care to

patients are developed,

disseminated,

implemented and

monitored for

effectiveness.

Vision, mission, policies and procedures are being developed and are followed so that the

staffs will be guided.

EA


8.1 The TB DOTS center's

policies and procedures

are consistent with theorganization's goals,

statutory requirements,

accepted standards, and

the TB DOTS center's

communityresponsibilities.

Staffs are aware of the vision and mission.

These are implemented and being followed.

EA

8.2 Policies and proceduresfor patient referral to other

services are implemented

and monitored for

effectiveness.

Proper referral is being implemented. List of referral centers, addresses and contact

persons is available.

EA




*Rating scale:




18


Survey

Item

Survey Item Survey Item Survey

Item

Survey Item Survey

Item

8.3 Patient default rates are

monitored and policies and procedures are developedand implemented to

improve default rates. The policies and procedures

are monitored for

effectiveness.

No defaulters are being reported yet. But in

case there is, it will be documented.

EA

8.4 Policies and proceduresfor identifying and

working with external

groups in providing DOTSservices are developed,

implemented and


Policies and procedures are observed so thateach external group are aware of their roles

and responsibilities.

EA




*Rating scale:




19


(To be completed by survey team only. The sur vey team must make comments on items where 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, implemented and monitored for effectiveness.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




20


Survey

Item



DOTS

Center

Rating*


Team

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

for managing patient

information are

developed, disseminated,

implemented and

monitored for

effectiveness.

Records and reports were handled properlyand securely to ensure consistency of the

information.

EA


9.1 Each patient is uniquely

identified from entry and

throughout the course of management.

Each patient has a case number which is

being recorded in the TB registry logbook.

The case number is consistent with NTPtreatment card and all related documents.

EA


maintains a database of

patient records and relatedregistries and enables the

staff to easily access thesedatabases.

NTP forms are recorded properly, filled up

correctly and is being updated with

consistency.

EA

9.3 Policies and proceduresfor ensuring the security

and confidentiality of

patient information are

developed, implemented

and monitored for effectiveness.

Records and reports are handled withconfidentiality and only authorized personnel

are allowed to access.

EA




*Rating scale:




21


Survey

Item



DOTS

Center

Rating*


Team

Rating*


submits complete andaccurate reports to all

relevant agencies in atimely manner.

All the reports are submitted on time. The

staffs are aware of the deadlines.

EA


regularly reviews its

records to assess andimprove performance.

Staffs conduct meeting to improve and

review center performance.

EA




*Rating scale:




22


(To be completed by survey team only. The sur vey team must make comments on it ems where the 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 managing patient information are developed, disseminated, implemented and monitored for effectiveness.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement




*Rating scale:




23


SurveyItem



DOTSCenter

Rating*


Team

Rating*Goal The TB DOTS center staff provide efficient and competent DOTS services.

10. The TB DOTS Center

has an adequate number

of qualified personnel

skilled in providing

DOTS services.

Staffs undergo trainings and seminars to

provide quality care to TB patients.

EA


10.1 An adequate number of

qualified and appropriately

trained personnel provideand are accountable for the

following functions:

The center is equipped of well trained staff

(physicians, nurse, midwives and

microscopist).

EA

10.1.1 Leadership,

management and overallresponsibility for the

operations, resources and performance of the TB

DOTS center

City Health Officer is available for

leadership management of the center.

EA

10.1.2 Clinical patient care

services

Nurses are capable of providing care to the

patient.

EA

10.1.3 Diagnostic services,including sputum

microscopy

Trained medical technologist is capable of performing diagnostic services.

EA

10.1.4 Drug management Staffs instruct patients in drug administration EA




*Rating scale:




24


Survey

Item



DOTS

Center

Rating*


Team

Rating*

and DOTS partner as well as in monitoring patient’s compliance.

10.1.5 Informationmanagement

Staffs observe confidentiality of patient’s record.

EA

10.1.6 Financial

management

Staffs do have monthly salary for their

services.

EA

10.2 Personnel follow clear jobdescriptions,

responsibilities and

accountabilities.

A written job description is being signed byeach staffs.

EA

10.3 All personnel are

responsible for safety inthe workplace and the

quality of the service theydeliver.

Staffs are aware and follow procedure in

infection control.

EA

10.4 Personnel receive up to

date training based ontraining needs assessment.

Certificates are available as proof of the

training and seminars joined by the staff.

EA




*Rating scale:




25




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 in providing DOTS services.


Non-

Achievement

Low

Achievement

Moderate

Achievement

Extensive

Achievement

the philcat certification self-assessment and survey tool (repaired) final

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