Republic of the Philippines

Provincial Health Office

Tarlac Provincial Hospital

Department/Function:

All hospital services

Effective Date:

August 1, 2016
Revision
Date:
July 1, 2016

Tarlac City
(045) 982- 1306
Policy Title:
TARLACPROVINCIALHOSPITAL@yahoo.com
POLICIES AND PROCEDURES ON MEDICAL DEVICES
Benchbook Reference Number:

Policy Number:
2.5.6.f.1
Originator:
Quality Assurance
Committee

Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

POLICIES AND PROCEDURES ON MEDICAL DEVICES

Policy:
To maximize utilization of medical devices and equipment, these should be used, maintained,
stored and disposed of based on technical specifications.
Procedures:

It is the responsibility of the end-user to use, maintain, and store their medical
equipment and devices according to the manufacturers specifications.

The Supplies Department shall maintain records of all medical equipment.

Records of equipment are maintained and updated regularly.

Medical devices and equipments shall be calibrated and checked daily for operating
capacity.

All requests for maintenance or repair should be done through the proper form (JO).

All equipments that are non-functioning or needing repair shall be pulled out from the
service until appropriate actions have been taken.

All non-functioning medical devices shall be surrendered to the Provincial General

Supplies Department for disposal.

There is presence of operations manual of medical equipment.

There is preventive maintenance program that ensures all equipment are checked,
maintained, and/or calibrated to an appropriate standard or specification.

SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO

CHIEF OF HOSPITAL

Republic of the Philippines

Provincial Health Office

Tarlac Provincial Hospital

Department/Function:

All hospital services

Effective Date:

August 1, 2016

Revision Date:

July 1, 2016

Tarlac City
Policy Title:
(045) 982- 1306
TARLACPROVINCIALHOSPITAL@yahoo.com
POLICY ON SAFE PRACTICE AND
ENVIRONMENT(MAINTENANCE PROGRAMS FOR SAFE AND
EFFICIENT USE OF MEDICAL EQUIPMENT)

Policy Number:

Originator:
Quality Assurance
Committee

PHIC Benchbook Reference Number:

2.5.6.1.1; 6.1.1.c.1; 6.1.2.a.2 & 6.1.2.b.1
Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

POLICIES AND PROCEDURES ON SAFE PRACTICE AND ENVIRONMENT

Purpose:
1. To set forth guidelines on maintaining and repairing equipment.
2. To assure equipment is functioning prior to usage.
Guidelines:

The Supplies Department shall maintain records of all medical equipments.

All equipments shall be operated according to manufacturers instructions.
Requests for regular preventive maintenance and equipment repairs shall be
forwarded to the Provincial General Services Department (PGSD).
All repairs or maintenance check done shall be documented.
Equipments shall be checked daily for operating capacity.
All equipments that are non-functioning or needing repair shall be pulled out from
the service until appropriate actions have been taken.
TPH adheres to DOH AO# 2008-002 on the gradual phase out of Mercury. In line
with this, all thermometers and BP measuring devices are now non-Mercurybearing.
There is presence of policies and procedures for safe and efficient use of medical
equipment.
There is proof of the implementation of the policies and procedures for the safe and
efficient use of medical equipment.
There is proof of monitoring of the implementation of the policies/procedures on
quality control diagnostic examination of equipment.

SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO

CHIEF OF HOSPITAL

Republic of the Philippines

Provincial Health Office

Tarlac Provincial Hospital

Department/Function:

All hospital services

Effective Date:
August 1, 2016

Revision Date:
July 1, 2016

Tarlac City
(045) 982- 1306
Policy Title:
TARLACPROVINCIALHOSPITAL@yahoo.com
POLICY ON SAFE PRACTICE AND
ENVIRONMENT
(PREVENTIVE MAINTENANCE OF
EQUIPMENT)

Policy Number:

Originator:
Quality Assurance
Committee

PHIC Benchbook Reference Number:

6.1.1.c.1
Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

POLICIES AND PROCEDURES ON SAFE PRACTICE AND ENVIRONMENT

(PREVENTIVE MAINTENANCE OF EQUIPMENT)

PROCEDURES
1. Buildings
The main concerns with regard to building maintenance are daily cleaning, repairs of damaged
parts, and security in order to ensure building safety and security. Daily cleaning has a favorable
effect on the attitude of those using the building and is important to maintain the necessary level
of cleanliness for the health facilities. It also leads to the discovery of damaged equipment and
its breakdowns and for their subsequent early repair, thus prolonging the life of the building,
equipment and medical equipment.
Repair work mainly consists of the repair or renewal of exterior finishing materials, which protect
the structure of the building. Based on other countrys experience it believed that the remodeling
or partial rebuilding will be required every ten years due to changes in activities and/or staff
increases. The regular inspections and repairs required to prolong building life are outlined
below:

OUTLINE OF REGULAR BUILDING INSPECTIONS

EXTERIOR
Repair or repainting of exterior finishes

- every five (5) years

Inspection or repair of metal roof

- inspection every year

Periodical cleaning of downspouts, drains

and others

- every month

Inspection and repair of ceilings, doors/

windows

- every five (5) years

Periodical inspection and cleaning of

drainage

- every year

INTERIOR
Changes in interior finishes

- as required

Repair and repainting of interior walls

- as required

Repairing of ceiling

- as required

Retightening or changing of fittings

- every year

With regard to security work, access to the building must be checked and security measures
must be taken to prevent the theft of any equipment.
2. Service Equipment
Regular preventive maintenance is essential for building service equipment prior to reaching the
state of repairing breakdowns and replacing parts. While the life of the building service
equipment is determined by the length of operation, it can certainly be prolonged by proper
operation and regular checks, oiling, adjustment, cleaning, repair, etc. Regular checks can
prevent breakdowns and accidents and can also prevent the unnecessary extension of an
accident

During regular checks, expendable parts are replaced and overhauling and cleaning, etc., are
conducted in accordance with maintenance manuals, making it essential that the maintenance
staff fully understand the deigned systems and capacities, etc., to prevent any accident.
Accordingly maintenance technicians for the electrical, air conditioning, water supply and
drainage must be aware and familiar with the facilities, and must be knowledgeable of the
following lives of major building service equipment, to wit:

Lives of Major Building Service Equipment

Electrical Equipment
Generator

15 to 20 years

Panel boards

20 to 30 years

Fluorescent lamps

5,000 to 10,000 hours

Incandescent lamps

1,000 to 1,500 hours

Plumbing Equipment
Pumps

10 to 15 years

Tanks

15 to 20 years

Pipes and valves

10 to 15 years

Plumbing Fixtures

20 years

Sewage treatment Plant

10 years

Air conditioning and Ventilation

Pipes

10 to 15 years

Fans

10 to 15 years

Air Conditioners

10 years

Separate-type air conditioners

5 to 10 years

3. Medical Equipment
The proper maintenance of medical equipment is important to ensure safe and efficient
activities. Some of the hospital equipment uses precision parts/ and/ or electronic circuitry which
are vulnerable to change as such ambient factors as temperature and humidity as well as
vibration and shock.
In general, equipment maintenance mainly comprises daily checking by users, breakdown
checking by expert engineers of which the hospital has none and regular checking which is
conducted once or twice a year. Regular checking to detect problematic areas requiring needing
repair should be undertaken by the Maintenance Unit of the Hospital at least once a year. Major
repair of the hospital medical equipment is referred to the original vendor, making use of
warranties if still in force.

OUTLINE OF REQUIRED EQUIPMENT

Self Check

Repair Establishment

General Equipment

4 times a year

Once a year

Analytical Apparatus

Inspection only

Twice a year

Optical Apparatus

Regularly, twice a year

Once a year

Sterilization Apparatus

Regularly, twice a year

Once a year

* Annual visitation from the DOH-Hospital Maintenance Service for check up and calibration of
hospital equipment
EQUIPMENT PREVENTIVE MAINTENANCE PROGRAM
The Tarlac Provincial Hospital requires the utilization of a wide variety of equipment ranging
from the simplest to the more complicated for diagnostic and therapeutic services. Because
these equipments are used frequently, there is a need for periodic preventive maintenance of
these equipments.
The Maintenance Department is tasked to answer this need 24 hours a day to ensure smooth
operations of the hospital. The Provincial Government of Tarlac assigns one of the provincial
engineers to Tarlac Provincial Hospital for the infrastructure needs and general equipment
maintenance
GENERAL OBJECTIVES OF PREVENTIVE MAINTENANCE
1. To provide continuous maintenance procedures and systematic inspection mechanism to
reduce the incidence of breakdown.
2. To determine the necessity for major and minor repairs to prevent further deterioration or
unscheduled interruption of function of the equipment.
Specific Advantages of Preventive Maintenance
1. Ensure continuous availability of equipment.
2. Increase the life of the equipment.
3. To provide prolonged service.
4. To ensure timely replacement of spares.
5. Time availability.
6. Satisfactorily quality of services.

7. Safety of operation.
8. Savings in the cost of timely repairs.
ORGANIZATION
The maintenance department is headed by a maintenance supervisor who is tasked with
the over-all responsibility of ensuring safe working conditions of all hospital equipments, tools,
machines and other materials relevant to the provision of quality patient care in the different
patient care in the different hospital department. He is also tasked with the supervision and
management of the maintenance shop. He is directly answerable to the administrator and
coordinates with the different department heads and staff answerable to the administrator and
coordinates with the different heads and staffs with regard general repairs and maintenance of
basic hospital equipments.
Under his direct supervision are 4 employees with different specific positions as: A/C
Electronic Technician, Painter/Foreman Build, and Management.
Schedule of Duties of Maintenance Personnel
The maintenance personnel will follow 8-5 scheme.
Proper Uniform/Decorum
1. All maintenance personnel should mark their interaction with all hospital staff with
utmost courtesy AND RESPECT.
2. All telephone calls should be answer with proper telephone courtesy. Always
yourself when you answer the phone.

identify

3. Proper uniform should be worn at all times during duty hours.

4. All maintenance personnel should properly identify themselves before entering a
patients room for any repair. They should wear their hospital ID at all times for
proper identification.
Guidelines in the Maintenance of Equipment
1. Equipment should be checked frequently to ensure it is in good working condition through
periodic inventory and testing.
2. Any personnel using a particular equipment must be properly oriented on the purpose and
care of such equipment after use.
3. The quality and kind of equipment kept in a particular unit should be based on the following
criteria.
3.1 clinical services
3.2 needs of patient

3.3 bed capacity

3.4 The need and demand at any given time due high rate of patient turnover
3.5 frequency of equipment use in emergency situations
4. All hospital departments must follow the system formulated by the hospital in requisitioning
repair and disposal of broken equipments.
4.1 Any equipment that needs to be repaired or replace should carry the proper tag of
Out of Order and submitted to the supply officer. The supply officer submits the said
equipment to the Maintenance Department for possible repair and replacement of
parts if within their technological knowledge otherwise the manufacturer of the
equipment has to be contacted by the supply officer for repairs.
4.2 Any equipment that is beyond repair should be returned back to the supply officer
for proper disposal/storage.
4.3 All hospital personnel are responsible for the proper utilization/unkeep of the
equipments under their care.
Standard Operating Maintenance Procedures for Hospital Equipment

The maintenance department will keep a logbook of all hospital equipments to serve as
inventory and guide for the periodic checking of said equipments.
The logbook should reflect the date of preventive maintenance or repair, the parts to be
replaced/defect observed and what action was done. It should also carry the date when
the equipment was returned back to the hospital department where it came from and the
person to whom it was released.
The date of preventive maintenance should be reflected on one side of the equipment by
a sticker duly signed and dated by the maintenance personnel who did the job.
Monthly maintenance of equipment such as air conditioning units should be done during
the weekend where occupancy rates are generally lower than during weekdays.
In case of brownouts, the maintenance on duty has the primary responsibility to operate
the 2 generators so as not to disrupt service to patients. They should be knowledgeable
and skillful on how to start, operate and maintain said equipments. The generator is tests
weekly to ensure functionality at any given time.
During regular water sampling, which is done every 6 months the maintenance
supervisor is to assist the chief med-tech in securing water samples at the main line.
Chlorination is done daily and chlorination testing at the main water tank is done every 3
days using a chlorine comparison chart by the maintenance supervisor. Results should
be properly documented and reported.
When repairs are requested/requisitioned the department head should fill up the job
order form, which includes the date, room number, ward/unit, and signature of person
requesting the defect, which needs repairs. This is forwarded to the supply officer and
will in turn forward it to the maintenance department after approval by the administrator.
The spare part needed is then purchased by the business office and will notify the

maintenance department when it is available. After repair of the defect reported the staff
on duty will sign the job order form to confirm repair done.
All shop tools should not be lent outside or brought out of the shop without the
permission of the maintenance supervisor.
An inventory of shop tools should be kept on a logbook and endorsed to the incoming
shift at all times. Any tools not properly documented and lost during a particular shift will
be the responsibility/accountability of the said personnel.
All maintenance personnel on duty are responsible for the cleanliness upkeep and
security of the shop.
Only authorized maintenance personnel are allowed to work/stay at the shop. No visitors
are to be entertained in order not to disrupt work during the shift.
Telephones are for official business use only. No personal calls are allowed unless its an
extreme emergency.
All job orders for the day should be entered on the white board provided to give all
personnel on duty a clear idea of what is to be done for the day. Job orders
finished/done should be crossed-out to reflect accomplishment for the shift/day.
All personnel on duty should stay at all times at the shop and be ready to answer any
emergency repair and assistance from the different hospital departments.
No maintenance personnel are allowed to come to work on duty under the influence of
alcohol. Proper decorum should be observed at all times.
There is a proof of training of the staff in charge of the maintenance of equipment.
There is plan in place for essential equipment replacement.
There is presence of operations manual of generators, air conditioning unit, and other
non-medical equipment.
There is COC (Certificate of Compliance) for applicable medical/imaging equipment.

Basic Functions of Maintenance Personnel

1. Troubleshoot, repair, clean and install air conditioning units window and split type once a
month.
2. Troubleshoot and repair other electrical equipments/appliances within their competency and
which has lapsed warranty.

3. Report facility defects and prepare job orders for timely replacement/repair.
4. Perform monthly check up of all hospital equipments and document them properly in the
logbook.
5. Accomplish/act promptly on job order requests from various departments of the hospital.
6. Monitor/assist in maintenance of hospital generators.
7. Perform other tasks assigned from time to time.
8. Perform carpentry/painting jobs as requested and ordered.
9. Be ready to be on call as the need arises.

CHEMICAL STORAGE GUIDELINES

Objective: To ensure that chemicals are stored safely and to ensure appropriate reuse of empty chemical
containers.

Storage Groups
A Compatible Organic Bases, Flammables, and Poisons.
B Pyrophoric and Water Reactive Materials.
C Compatible Inorganic Bases, Oxidizers, and Poisons.
D Compatible Organic Acids, Flammables, and Poisons.
E Compatible Oxidizers, Organic Peroxides, and Acids.
F Inorganic Acids not including Oxidizing or Organic Acids.
G Non-Reactive Materials and Non-Hazardous Materials.
H Flammable or Pyrophoric Compressed Gases.
I Compatible Corrosive and Oxidizing Gases and Inert Gases.
J Poison Compressed Gases.
K Explosive or other unstable material.
L Solvents, Flammables, and Combustible Materials.
X Needs secondary containment separate from ALL groups and from each other individually.
Storage Groups that can be stored on the same shelf, or within the same storage cabinet, if each Group
is segregated by secondary containment:

SHELF

STORAGE GROUP

A, B, D, G, L

C, E, F, G

X [store separately]

E.INCOMPATIBLE CHEMICALS
Violent reactions may occur when the following chemicals from different Storage Groups are mixed:

Corrosives + Flammables = Explosion/Fire

Corrosives + Poisons = Poison Gas

Flammables + Oxidizers = Explosion/Fire

Acids + Bases = Corrosive Fumes/Heat

Hazardous wastes (including pathogenic wastes)

store hazardous wastes in appropriate containers
centralize location when possible
label dont abbreviate, label containers first before storage, yellow if possible
do not store incompatible wastes
allow access of handling equipment and emergency response personnel.
give at least 1 inch allowance from cover to allow expansion
Chemicals
place no smoking signs at entrance to storage areas
do not allow ignition sources (open flames, spark producing equipment, static
electricity)
store compatible chemicals
prevent from flowing out by building secondary containment
construction materials should be compatible with chemicals to be stored
use non-combustible materials for flooring
store flammable and combustible liquids at least 25 feet from oxidizers
review every six months
provide ventilation designed to provide at least 6 air exchanges per hour and
discharge the air at least 50 feet from any air intakes for air handling systems, air
compressors, etc.
provide aisles to allow easy access of handling equipment and emergency response
personnel
prevent fugitive dust from entry
spill kits, fire extinguishers (not more than 10 feet from door)
containers over 30 gallons should not be stored over 1 level high inside rooms or a
room totally enclosed within a building and having no exterior walls
Compressed gases
-

store away from stairways, exits

upright position
keep clear of dry vegetation and other combustible materials (at least 15 feet in all
directions)
storage area should not be above 125 degrees F
store away from incompatible materials (at least 20 feet an all direction

Acids,
inorgani
c

Acids,
oxidizin
g

Acids,
organi
c

Alkalis,
(bases
)

Acids,
inorgani
c

Acids,
oxidizing

Acids,
organic

Alkalis
(bases)

Oxidizer
s

Poisons,
inorgani
c

Poisons
,
organic

Water
reactive
s

Organic
solvent
s

Oxidizer
s

Poisons,
inorgani
c

Poisons,
organic

Water
reactives

Organic
solvents

X do not store with

Republic of the Philippines

Provincial
SHELLEY ANN M. MANGAHAS, MD, MHA,
FPAOHealth Office
CHIEF OF HOSPITAL

Tarlac Provincial Hospital

Tarlac City
(045) 982- 1306
TARLACPROVINCIALHOSPITAL@yahoo.com

Department/Function:
All hospital services

Policy Title:
QUALITY IMPROVEMENT PROGRAM

Effective Date:
August 1, 2016

Policy Number:

Revision Date:
July 1, 2016

Originator:
Quality Assurance
Committee

PHIC Benchbook Reference Number:

7.1.x.1
Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

The Quality Assurance Program of Tarlac Provincial Hospital is established to systematically assess the
quality of medical service and to search for solutions to correct any deviations that are observed. To
continue carrying out the program, the functions of the following Standing Committees are hereby stated
and the compositions designated:

POLICY:
Tarlac Provincial Hospital established a Quality Assurance Program to systematically assess the quality of
medical services and to search for solutions to correct any deviations that are observed. To carry out the
program, the functions of the following Standing Committees and functions are hereby stated:

QUALITY IMPROVEMENT COMMITTEE

Functions:
1. Develop a written comprehensive performance improvement plan, and submit the report annually
to the Clinical Board for review and approval.
2. Proceed with an ongoing collection and evaluation of patient care data for the purpose of
identifying opportunities to improve care and clinical performance.
3. Work with clinical services, administrative personnel, and committees to coordinate and integrate
performance improvement efforts between departments to ensure compliance with the standards
mandated by the DOH other regulatory bodies.
4. Prepares list of accepted drugs for use in the hospital (Hospital Formulary).
5. Review requests for inclusion or exclusion of drugs in the Hospital Formulary.
6. Recommend drug selection, procurement, stocking and utilization policies.

QUALITYASSURANCECOMMITTEE
Functions:

1. Develop a written comprehensive performance improvement plan annually for review and
approval by the Hospital Director.
2. Proceed with an ongoing collection and evaluation of patient case data for the purpose of
identifying opportunities to improve care and clinical performance.
3. Work with clinical services, administrative personnel, and committees to coordinate and integrate
performance improvement efforts between departments to ensure compliance with the standards
mandated by the DOH, PHIC, and other regulatory bodies.
4. Review the results of Patients Exit Surveys and Comments dropped in Suggestion Boxes and
make recommendations in response to pertinent findings regarding the quality of hospital service.
5. Meet with the Heads of the various Hospital Committees on regular basis to discuss issues and
concerns of quality in service delivery, function and performance throughout the hospital.

THERAPEUTICS COMMITTEE
Functions:
1. Establish and maintain a Hospital Drug Formulary, and therefore review and approve additions to
and deletions from the formulary.
2. Implement a Drug Utilization Evaluation program.
3. Implement prior approval guidelines for medical utilization.
4. Oversee drug utilization.
5. Submit a monthly Drug Utilization Report.
6. Review and monitor all significant Drug Adverse Reactions.
7. Ensure compliance with the standards mandated by the DOH and other regulatory bodies.

INFECTION CONTROL COMMITTEE

Functions:
1. Monitor the Infection Control Program.
2. Perform surveillance of inadvertent hospital infection potential and cases and promote preventive
and corrective program designed to minimize these.
3. Recommend corrective action based on records of infection and infection potentials.
4. Ensure compliance with the standards mandated by the DOH and other regulatory bodies.

SAFETY COMMITTEE
Functions:

1. To formulate policies and procedures to ensure the safeness of the hospital patients, personnel,
properties and visiting policy.
2. To develop, improve and maintain safety environment for patients and personnel.
3. Establish / organize and regularly implement safety program such as fire and earthquake drills.
4. Coordinate with the heads of services and encourage them to establish and maintain their own
safety policies.
5. Conduct personnel education and patients / watchers enlightenment to obtain their cooperation.
6. Regular monitor compliance with safety measures as establish.

SAFETY COMMITTEE
(Fire and Disaster Preparedness)
Functions:
1. Formulate policies and procedures to ensure the safety of hospital patients, personnel, properties
and visiting public against fire incidence.
2. To develop, improve and maintain an earthquake and fire safe environment in the hospital in
accordance with the Fire Code of the Philippines (PD 1185).
3. To establish / organize and regular implement Earthquake and Fire Safety Program such as
Earthquake Drills and Fire Drills following the prepared Evacuation Plan.
4. To conduct personnel education and patients / watchers enlightenment on fire safety measures,
prevention of and protection from earthquake and fire.
5. To coordinate with heads of services and encourage them to establish and maintain their own
earthquake and fire safety policies.
6. To secure the annual Inspection Certificate.

SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO

CHIEF OF HOSPITAL

Republic of the Philippines

Provincial Health Office

Tarlac Provincial Hospital

Tarlac City
(045) 982- 1306
TARLACPROVINCIALHOSPITAL@yahoo.com

Department/Function:

All hospital services

Effective Date:
August 1, 2016

Policy Number:

Revision Date:
July 1, 2016

Originator:
Quality Assurance
Office

Policy Title:

Policies and Procedures on Ensuring

Patient Satisfaction
PHIC Benchbook Reference Number:
1.4.a.1
Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

Policies and Procedures on Ensuring Patient Satisfaction

Purpose:
To assure that patients are satisfied with the service they are receiving from Tarlac Provincial
Hospital.
Policy:
TPH routinely determines the level of patient satisfaction through ongoing surveys and uses
the results to improve the quality of service delivery.
Procedures:
1. As part of the Admitting Process, all patients are given copies of their rights and
responsibilities.
2. All hospital staff should be made aware of the rights and responsibilities of patients
through orientations given to them upon entry into TPH and through reviews and
updates conducted at least once a year.
3. The Quality Assurance Committee solicits patient feedback through exit surveys and the
data gathered is analyzed to identify areas where service can be improved.
4. Suggestion Boxes are set up in strategic areas in the hospital to allow patients and the
public to air complaints and grievances about hospital personnel or services. The Head
Nurse collates these complaints and forwards them to the Ethics Committee for final
disposition.
5. The PRDO (Provincial Research and Development Office) conducts regular patient
feedback surveys and submits the results to the TPH QA Committee for analysis.
6. The PRDO likewise conducts Time and Motion Studies at the Emergency Room and the
Out Patient Department to monitor waiting times and determine ways to remove sources
of delays in service delivery.

SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO

CHIEF OF HOSPITAL

Republic of the Philippines

Provincial Health Office

Tarlac Provincial Hospital

Department/Function:

All hospital services

Tarlac City Policy Title:

(045) 982- 1306
TARLACPROVINCIALHOSPITAL@yahoo.com
The hospital provides safe blood and blood
products

Effective Date:
August 1, 2016

Policy Number:

Revision Date:
July 1, 2016

Originator:
Quality Assurance
Committee

PHIC Benchbook Reference Number:

Approval:
SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO
Chief of Hospital

Procedures:
1. The hospital ensures that its supply of blood and blood products is safe.
2. The hospital has the appropriate blood service facility.
3. The hospital obtains blood and blood products only from blood service facilities
license/authorized by the DOH. (R.A. 7719, otherwise known as National Blood Service
Act)
4. The hospital obtains blood and blood products collected from healthy voluntary blood
donors only. (R.A. 7719, otherwise known as National Blood Service Act)

SHELLEY ANN M. MANGAHAS, MD, MHA, FPAO

CHIEF OF HOSPITAL