| HOSPITAL SCORECARD | ||||
| YES | NO | |||
| III. SERVICE DELIVERY | ||||
| A. Medical Surgical Services and Outcomes | ||||
| 10. Clinical Departments/Services | ||||
| a. Major departments/services | ||||
| Internal medicine | ||||
| Pediatrics | ||||
| Surgery | ||||
| Obstetrics and gynecology | ||||
| b. Other services/subspecialties | ||||
| Anatomical and clinical pathology | ||||
| Anesthesia | ||||
| Cardiology | ||||
| Dental medicine | ||||
| Dermatology | ||||
| Emergency Medicine | ||||
| Endocrinology | ||||
| ENT-HNS | ||||
| Family medicine | ||||
| Hematology | ||||
| Gastroenterology | ||||
| Geriatrics | ||||
| Immunology | ||||
| Nephrology | ||||
| Neonatology/Perinatology | ||||
| Neurology (Neuroscience) | ||||
| Neurosurgery | ||||
| Nuclear medicine | ||||
| Oncology | ||||
| Ophthalmology | ||||
| Orthopedics | ||||
| Pediatric surgery | ||||
| Plastic and reconstructive surgery | ||||
| Pulmonary medicine | ||||
| Psychiatry | ||||
| Radiology and other imaging services | ||||
| Radiotherapy | ||||
| Rehabilitative and occupational medicine | ||||
| Rheumatology | ||||
| Toxicology/Detoxification | ||||
| Tropical and infectious diseases medicine | ||||
| Urology | ||||
| 11. Occupancy Rate | ||||
| a. Based on authorized bed capacity | ||||
| b. Based on implementing bed capacity | ||||
| 12. Average Length of Stay* | ||||
| *excluding psychiatric/custodial cases | ||||
| 13. Percent (%) Discharged, Improved, and Recovered Patients | ||||
| number of discharged, improved, and recovered/total discharges* x 100 *total discharges refers to all discharges regardless of outcome | ||||
| 14. Death Rates: | ||||
| a. Gross death rate Gross death rate = all deaths/total discharges x 100 | ||||
| b. Net death rate (1 point) Net death rate = all deaths > 48 hrs/total discharges - (deaths < 48 hrs) x 100 | ||||
| c. Maternal death rate (0.5 pt) Maternal death rate = maternal death rate*/total obstetrics discharges x 100 *includes deaths during pregnancy and within 42 days after delivery *includes deaths during pregnancy and within 42 days after delivery | ||||
| d. Infant death rate (0.5 pt) (deaths up to 1 year of age) | ||||
| Formula 1: Infant death rate = all deaths of infants*/total discharges x 100 | ||||
| Formula 2: Infant death rate = all deaths of infants*/total infant discharges x 100 | ||||
| e. Neonatal death rate (deaths up to 28 days) | ||||
| Formula 1: Neonatal death rate = all deaths up to 28 days/total discharges x 100 | ||||
| Formula 2: Neonatal death rate = all deaths up to 28 days/total neonatal discharges x 100 | ||||
| B. ANCILLARY SERVICES | ||||
| 15. Pharmacy Service | ||||
| a. Pharmacy management | ||||
| Generics Act and Cheaper Medicines Act implementation | ||||
| Licensed pharmacist(s) available 24/7 | ||||
| Proper medicine storage (air conditioned, no direct sunlight) | ||||
| Annual review and update of in-house formulary | ||||
| No expired medicines | ||||
| b. Pharmacy counter throughout | ||||
| Formula 1: total number of filled prescriptions/number of pharmacy personnel x 365 | ||||
| Formula 2: average number of daily prescriptions/number of pharmacy personnel | ||||
| c. Unfilled prescriptions | ||||
| total filled prescriptions/total prescriptions x 100 | ||||
| 16. Diagnostic and Other Ancillary Services: | ||||
| a. Radiologic sciences and other diagnostic imaging | ||||
| X-ray | ||||
| Fluoroscopy | ||||
| Ultrasound | ||||
| CT scan | ||||
| Magnetic resonance imaging (in-house and outsourced services) | ||||
| b. Laboratory service capability | ||||
| Tertiary level clinical laboratory | ||||
| Direct Observation Treatment Short Course center | ||||
| Drug-testing unit | ||||
| Routine histopathology | ||||
| Needle aspiration biopsy service | ||||
| Frozen section biopsy service | ||||
| Immunochemistry (in-house or outsourced) | ||||
| Autopsy service (in-house or outsourced) | ||||
| c. Laboratory daily throughout | ||||
| total number of procedures*/total number of laboratorial staff**/day *Total number of procedures = anatomic + clinical pathology procedures **Includes pathologists, lab aides, morticians; excludes clerical staff | ||||
| d. External quality assurance program (EQAS)* | ||||
| Bacteriology | ||||
| Chemistry | ||||
| Hematology | ||||
| *If not done annually, use the latest EQAS in a particular section | ||||
| 17. Blood Bank Service | ||||
| a. Blood bank capability | ||||
| EQAS most recent rating: excellent, very good, or passed | ||||
| Rational Blood Use Act implemented | ||||
| Mass blood donation monthly (MBD) | ||||
| Blood center | ||||
| b. Voluntary blood donation | ||||
| % Voluntary donors = number of voluntary donors/total number of donors* x 100 *Directed and nondirected pre-transfusion and replacement donors | ||||
| c. Blood utilization | ||||
| % Blood utilization = No. of units of red blood cells (RBC) served/number of blood units collected x 100 | ||||
| d. Packed red cell: White blood (WB) ratio (0.3 pt) | ||||
| Pack red cell: WB ratio = No. of units of packed red blood cells (PRBC) served/No. of units of WB served | ||||
| 18. Social Service | ||||
| a. Percentage of classified patients within 24 hours | ||||
| number of patients classified within 24 hours/total inpatients x 100 | ||||
| b. Percentage of patients counseled* | ||||
| number of counseled patients/total inpatients x 100 * patients requiring psychosocial counseling and follow-up | ||||
| c. Percentage of patients provided financial assistance | ||||
| number of patients provided financial assistance/total patients classified x 100 | ||||