Self Assessment Form (SAF)

7/25/2019 Self Assessment Form (SAF)

1/25

The PhilCAT Certification Self-assessment and Survey Tool

PhilCAT CERTIFICATION STANDARDS

SurveyItem

Criterion Evidence of Progress and Achievements

(Completed by TB DTS Center!

DTSCenter

"ating#

Surveyors$ Comments Survey

Team

"ating#

oal The T! DOTS Center "rovides a safe and effective "hysical environment to its staff and "atients#$# The T! DOTS center is

easily located and

"atients have convenient

and safe access to the

center#

This standard %ill &e achieved %hen'

%&%& There is appropriatesignage bearing the name

of the TB DTS center to

assist patients accessing

the center&

%&'& Physical access is

appropriate for the needsof patients&

%&& Entrances and e)its are

clearly mar*ed and free ofobstruction and other

ha+ardous conditions&

%&,& There are resources to

inform patients of the

daily and hourly schedule

of TB DTS services-ensure the .uality of

patient /aiting&

#"ating scale0

%& Non Achievement1 The re.uirements of standard 2 criterion are not met&

'& Low Achievement 1 The re.uirements of standard 2 criterion are scarcely met& Moderate Achievement1 The re.uirements of the standard 2 criterion are generally met in most circumstances&

,& Extensive Achievement1 The re.uirements of the standard 2 criterion are fully met in the ma3ority of circumstances and have been for some time&

%


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O(ERA)) RATIN AND CO**ENTS+ CO**ENDATIONS AND RECO**ENDATIONS !, SR(E, TEA*

(To be completed by survey team only. The survey team must make comments on items where the survey team disagrees or partially disagrees with

information provided by the TB DOTS center.)

oal' The T! DOTS Center "rovides a safe and effective "hysical environment to its staff and "atients#

Standard $' The T! DOTS center is easily located and "atients have convenient and safe access to the center#

Ratin. (please tic* appropriate overall rating for this standard!

Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




'


3/25



Survey

Item



DTS

Center"ating#


Team

"ating#

oal The T! DOTS Center "rovides a safe and effective "hysical environment to its staff and "atients

0# The T! DOTS Center"rovides facilities for the

comfort and "rivacy of

its "atients and staff#


'&%& The TB DTS center

maintains a clean and

/holesome environment/ithin and immediately

outside its premises&

'&' There are resources andprocesses to ensure the

.uality of patient /aiting&

'& The lighting in each area

of the center is

appropriate for the

assigned purpose of thearea&

'&, The privacy of the staff1

patient encounter is

assured&

#"ating scale0





4/25






Standard 0' The T! DOTS center "rovides for the "rivacy and comfort of its "atients and staff#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




,


5/25



Survey

Item



DTS

Center"ating#


Team

"ating#

oal The T! DOTS Center "rovides a safe and effective "hysical environment to its staff and "atients#

1# The T! DOTS center"rovides for the safety of

its "atients and staff#


&% There is ade.uate clean

/ater for personal hygiene

and sanitation purposes&

&' The TB DTS center

maintains appropriate

levels of cleanliness andantisepsis of all physical

areas- e.uipment andinstruments&

& 4eneral /aste- sharps-

pathological and

infectious /aste-pharmaceutical and

chemical /astes are

appropriately segregated-

safely handled anddisposed of according to

accepted safe disposalpractices&

&, TB drugs are securelystored under appropriate

storage conditions&

&5 Sputum and other body

fluids are collected in a

#"ating scale0




5


6/25



Survey

Item



DTS

Center"ating#


Team

"ating#

safe and hygienic /ay&

&6 There are documented-disseminated and

implemented procedures

to identify and address theris*s of contamination of

staff and patients from

sources of infectious

diseases&





Standard 1' The T! DOTS center "rovides for the safety of its "atients and staff#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




6


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Survey

Item



DTS

Center"ating#


Team

"ating#

oal Patients receive ade2uate and effective dia.nostic and thera"eutic services at every "hase of their mana.ement from screenin. for T! to

reha&ilitation#,& All "atients under.o a

com"rehensive

assessment to facilitate

the "lannin. and

delivery of treatment#


,&% Appropriate professionalsobtain and document the

relevant history for each

patient&

,&' A physician completes

and documents the

relevant physicale)amination for each

patient&

#"ating scale0




7


8/25





oal' Patients receive ade2uate and effective dia.nostic and thera"eutic services at every "hase of their mana.ement from screenin. for T! to

reha&ilitation#

Standard 3' Patients receive ade2uate and effective dia.nostic and thera"eutic services at every "hase of their mana.ement from screenin. for T! to

reha&ilitation#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




8


9/25



SurveyItem



DTSCenter

"ating#


Team

"ating#

oal' Patients receive ade2uate and effective dia.nostic and thera"eutic services at every "hase of their mana.ement from screenin. for T! toreha&ilitation#

4# All "atients have

continuous access to

accurate and relia&le T!

dia.nostic tests#


5&% All patients undergo

sputum microscopy by a

.ualified and trained

microscopist&

5&%&% The TB DTScenter plans and

implements policies andprocedures for assuring

the .uality of sputum

microscopy results&

5&%&' If sputummicroscopy facilities are

not available in the TB

DTS center- policies

and procedures for

referring patients toaccessible centers are

implemented and

monitored foreffectiveness&

#"ating scale0




9


10/25



Survey

Item



DTS

Center"ating#


Team

"ating#

5&%& E)ternal providers

of sputum microscopy arecontracted based onpolicies and procedures

that include accreditation

status and the presence of

.uality control systems&

5&' Policies and procedures

for referring patients to

accredited and accessible

:1ray facilities areimplemented and

monitored for

effectiveness&

5& Policies and procedures

for referring patients to an

appropriately constitutedand accessible TB

Diagnostic Committee are

implemented and

monitored foreffectiveness&

#"ating scale0




%;


11/25






reha&ilitation#

Standard 4' All "atients have continuous access to accurate and relia&le T! dia.nostic tests#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




%%


12/25



Survey

Item



DTS

Center"ating#


Team

"ating#


reha&ilitation#5# A care "lan is develo"ed

and follo%ed for all

"atients#


6&% All treatment is consistent

/ith the


13/25



Survey

Item



DTS

Center"ating#


Team

"ating#

6&, Education is provided to

all patients to help themunderstand their medicalcondition and prognosis

and to encourage their

adherence to the treatment

regimen and healthpromotion 2 illness

prevention activities&

6&5 An appropriately

comprehensive evaluationof the patient$s clinical

progress is made and

documented at each visit&

6&6 Policies and procedures

for detecting treatment

defaulters and gettingthem bac* into treatment

are implemented and

monitored for

effectiveness&

#"ating scale0




%


14/25






reha&ilitation#

Standard 5' A care "lan is develo"ed and follo%ed for all "atients#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




%,


15/25



Survey

Item



DTS

Center"ating#


Team

"ating#


reha&ilitation#7 Patients have continuous

access to safe and

effective anti-T!

medications throu.hout

the duration of their

treatment#


7&% The TB DTS Center has

developed and

implemented policies and

procedures for assuring acontinuous supply of TB

drugs to all its patients for

the entire si) months

duration of therapy&

7&' The TB DTS center

maintains an appropriatebuffer stoc* of anti1TB

medications&

7& The TB DTS Center has

developed and

implemented policies andprocedures for assuring the

.uality and safety of its

TB drugs&

#"ating scale0




%5


16/25






reha&ilitation#

Standard 6' Patients have continuous access to safe and effective anti-T! medications throu.hout the duration of their treatment#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




%6


17/25



Survey

Item



DTS

Center"ating#


Team

"ating#

oal The mana.ement and staff adhere to clear and colla&oratively develo"ed "olicies and "rocedures for the efficient o"eration of the T!

DOTS center#8& Policies and "rocedures

for "rovidin. care to

"atients are develo"ed+

disseminated+

im"lemented and

monitored for

effectiveness#


8&% The TB DTS center$s

policies and procedures

are consistent /ith theorgani+ation$s goals-

statutory re.uirements-

accepted standards- and

the TB DTS center$scommunity

responsibilities&

8&' Policies and procedures

for patient referral to other

services are implemented

and monitored foreffectiveness&

#"ating scale0




%7


18/25



Survey

Item

Survey Item Survey Item Survey

Item

Survey Item Survey

Item

8& Patient default rates are

monitored and policies andprocedures are developed

and implemented toimprove default rates& The

policies and procedures

are monitored for

effectiveness&

8&, Policies and procedures

for identifying and

/or*ing /ith e)ternal

groups in providing DTSservices are developed-

implemented and

monitored for

effectiveness&

#"ating scale0




%8


19/25





oal' The mana.ement and staff adhere to clear and colla&oratively develo"ed "olicies and "rocedures for the efficient o"eration of the T! DOTS

center#

Standard 7' Policies and "rocedures for "rovidin. care to "atients are develo"ed+ disseminated+ im"lemented and monitored for effectiveness#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




%9


20/25



Survey

Item



DTS

Center"ating#


Team

"ating#

oal The mana.ement and staff adhere to clear and colla&oratively develo"ed "olicies and "rocedures for the efficient o"eration of the T!

DOTS center#8# Policies and "rocedures

for mana.in. "atient

information are

develo"ed+ disseminated+

im"lemented and

monitored for

effectiveness#


9&% Each patient is uni.uely

identified from entry and

throughout the course ofmanagement&

9&' The TB DTS center

maintains a database of

patient records and relatedregistries and enables the

staff to easily access these

databases&

9& Policies and procedures

for ensuring the security

and confidentiality ofpatient information are

developed- implemented

and monitored for

effectiveness&

#"ating scale0




';


21/25



Survey

Item



DTS

Center"ating#


Team

"ating#

9&, The TB DTS center

submits complete andaccurate reports to allrelevant agencies in a

timely manner&

9&5 The TB DTS center

regularly revie/s itsrecords to assess and

improve performance&

#"ating scale0




'%


22/25





oal' The mana.ement and staff adhere to clear and colla&oratively develo"ed "olicies and "rocedures for the efficient o"eration of the T! DOTS

center#Standard 8' Policies and "rocedures for mana.in. "atient information are develo"ed+ disseminated+ im"lemented and monitored for effectiveness#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




''


23/25



Survey

Item



DTS

Center"ating#


Team

"ating#oal The T! DOTS center staff "rovide efficient and com"etent DOTS services#

$9# The T! DOTS Center

has an ade2uate num&er

of 2ualified "ersonnel

s:illed in "rovidin.

DOTS services#


%;&% An ade.uate number of

.ualified and appropriately

trained personnel provideand are accountable for the

follo/ing functions0

%;&%&% >eadership-

management and overallresponsibility for the

operations- resources and

performance of the TB

DTS center

%;&%&' Clinical patient care

services

%;&%& Diagnostic services-

including sputum

microscopy

%;&%&, Drug management

#"ating scale0




'


24/25



Survey

Item



DTS

Center"ating#


Team

"ating#

%;&%&5 Information

management

%;&%&6 =inancialmanagement

%;&' Personnel follo/ clear 3ob

descriptions-

responsibilities andaccountabilities&

%;& All personnel areresponsible for safety in

the /or*place and the

.uality of the service theydeliver&

%;&, Personnel receive up to

date training based on

training needs assessment&

#"ating scale0




',


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oal' The T! DOTS center staff "rovide efficient and com"etent DOTS services#

Standard $9' The T! DOTS Center has an ade2uate num&er of 2ualified "ersonnel s:illed in "rovidin. DOTS services#


Non-

Achievement

)o%

Achievement

*oderate

Achievement

E/tensive

Achievement

#"ating scale0




'5

Documents

Self Assessment Form (SAF)