Health Care Facility: Standard Assessment Tool/Checklist
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Rename: HCWM Assessment Checklist Monitoring Tool_NAME OF FACILITY
@doh.gov.ph
Health Care Waste Management Program Self-Monitoring Assessment Tool
Name of Health Care Facility: ALEOSAN DISTRICT HOSPITAL Date:
Type of HCF: Hospital Ownership: Government
Classification (General / Specialty): General
Service Capability: Trauma Receiving
Licensed Authorized Bed Capacity (ABC): 100 Beds Implementing Bed Capacity (IBC):
Location of HCF: Brgy. Bancal Alimodian, Iloilo
General Information
Chief of Health Care Facility: Cherubim C. Estrellanes
Contact No.: 09392796775 Email Address: [email protected]
Pollution Control Officer (PCO): Maricel A. Amita
Certificate of Accreditation (COA) No.:
Contact No.: 09774503025 Email Address:
[email protected]Number of Employees / Workers:
Clinical Staff: Non-clinical Staff:
Medical Doctor/s 16 Administrative Personnel/s
Staff Nurse/s 68 Janitorial and Security Personnel/s
Allied Health Personnel/s 59 Other/s:
Other/s
Bed Occupancy Rate:
Health Care Waste Management
What are the wastes generated daily at in the HCF? (Please "Shade / Fill" the selected areas)
General or non-infectious wastes Chemical wastes Radioactive waste
Sharps wastes Pathological wastes Other/s (If any):
Pharmaceutical wastes Anatomical wastes
How much is generated per type of waste in the HCF?
Hazardous Waste
Non-Hazardous Waste (General) (Infectious/pathological/sharps) Wastewater
(kilogram) (kilogram) cubic meter
Month 2022 2023 2022 2023 2022 2023
January
February
March
April
May
June
July
August
September
October
November
December
TOTAL
waste collection fee
General or non-infectious wastes (PhP) Radioactive waste
Sharps wastes Pathological wastes Other/s (If any):
Pharmaceutical wastes Anatomical wastes
Is the HCF practicing segregation at point of generation?
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are there functional waste collection containers in close proximity to all waste generation points for non-infectious wastes, infectious waste, and sharp
waste?
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
How and where it the facility's health care waste stored before collection?
General or non-infectious wastes
Sharps wastes
Pharmaceutical wastes
Chemical wastes
Pathological wastes
Anatomical wastes
Radioactive waste
Other/s:
Are the wastes stored separately? (Please provide photo evidence)
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are all the infectious wastes stored in a protected area before treatment for no longer than the default and safe time?
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
How is the hazardous liquid waste handled? (Please "Shade / Fill" the selected areas if applicable)
Specify for:
Chemical Waste
Cytotoxic Waste
Reagents
Used x-ray film processing liquids
Other/s (If any):
1
2
If the liquid waste is discharged in the sanitation system, where does the latter discharged, and how much is the value?
______________________________________________________________________________________ Capacity:
______________________________________________________________________________________
______________________________________________________________________________________ _____________________
HCWM Treatment and Disposal
What acceptable treatment technology (if any) are done to the wastes before disposal? What type of wastes?
Where is the health care waste disposed of? At the HCF Off-site
If the wastes are disposed at the facility:
Are concrete vaults used for the disposal of sharp wastes? (If Yes, please provide photo evidence)
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are placentas disinfected prior to disposal to placenta pit? (If Yes, please provide photo evidence)
Yes No
If yes, what method of disinfection is used? If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Are treated infectious wastes, sharps, chemical, and pharmaceutical waste encapsulated/inertisized and disposed through safe burial? (If Yes,
please provide photo evidence)
Yes No
If not, please provide explanation/s:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
If any waste is taken off-site, are the wastes transported for treatment by a DENR-accredited transporter?
Yes No
Transporter Name:
Address
Contact No.: Accreditation No.:
Type of Waste Transported: Quantity (Kg):
How is the waste packed? (Kindly provide photo evidence)
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
What types of vehicles are used to transport the wastes?
1
2
Is any of the waste taken to a engineered or sanitary landfill?
Yes No
If not, what happens to the waste at this facility?
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Is the HCW buried immediately after arriving at the dump or landfill site?
Yes No
Is it burned on the site?
Yes No
Is it left unattended at any time after being unloaded?
Yes No
Do waste pickers, children, or others have access to the dump or landfill site?
Yes No
Wastewater Management
What are the uses of water (potable, non-potable, and wasterwater) in the facility?
4
5
What departments in the HCF generate wastewater? (Provide estimated volume generated)
1 Department Name Volume generated
2 Department Name Volume generated
3 Department Name Volume generated
4 Department Name Volume generated
5 Department Name Volume generated
Is the wastewater treated on-site or off-site treated in a centralized wastewater treatment facility?
Operations Management
Is there a trained person responsible for the management of the health care wastes in the HCF? If Yes, provide the name of personnel
Yes No
1 Name of Personnel Position Years of Service
2 Name of Personnel Position Years of Service
3 Name of Personnel Position Years of Service
4 Name of Personnel Position Years of Service
5 Name of Personnel Position Years of Service
How many people are involved in waste collection and are special skills required by the HCF? No. of Personnel:
1 Name of Personnel Skills/Training acquired Years of Service
2 Name of Personnel Skills/Training acquired Years of Service
3 Name of Personnel Skills/Training acquired Years of Service
4 Name of Personnel Skills/Training acquired Years of Service
5 Name of Personnel Skills/Training acquired Years of Service
What sort of worker safety measures are in place?
1
2
3
4
5
What are the current operational standards for HCW and what are the applicable national, regional, and local policies?
1
2
3
4
5
Are there any written standard operating procedures for the segregation, storage, treatment, and disposal of the HCW?
1
2
3
4
5
Are appropriate personal protective equipment (PPE) provided to all staff in charge of the waste management?
Yes No
What personal protective equipment (PPE) are provided to the staff? (Please specify)
1
2
3
4
5
Is procurement of new health care materials reviewed to reduce the waste stream and to avoid potential treatment problems?
Yes No
What are the daily waste collection routines, including waste packaging?
1
2
3
4
5
How much does HCW operational cost in the HCF?
Does the budget provision cover these costs?
Yes No
Risks of the Current Waste Management System
Does the management of the HCF have concerns about the facility's current HCW practices?
Yes No
If so, what problems do they identify?
Does the assessment above indicate that the facility's current waste management practices pose any health risks to patients, nurses or doctors, other staff,
or visitors?
Yes No
If yes, what kind of risks?
Does the waste presented pose any risk to waste collectors?
Yes No
If yes, what kind of risks?
DOH HFDB Assessment Form 2
HCWM Self-Assessment Tool
Revision 0, March 18, 2022
ent Program Self-Monitoring Assessment Tool
Government
General Information
[email protected]
[email protected]
h Care Waste Management
e / Fill" the selected areas)
Radioactive waste
Other/s (If any):
Radioactive waste
Other/s (If any):
No
_________________________________________________________
_________________________________________________________
_________________________________________________________
y to all waste generation points for non-infectious wastes, infectious waste, and sharp
No
_________________________________________________________
_________________________________________________________
_________________________________________________________
lection?
)
No
_________________________________________________________
_________________________________________________________
_________________________________________________________
atment for no longer than the default and safe time?
No
_________________________________________________________
_________________________________________________________
_________________________________________________________
the selected areas if applicable)
es the latter discharged, and how much is the value?
Capacity:
_____________________
M Treatment and Disposal
stes before disposal? What type of wastes?
Off-site
? (If Yes, please provide photo evidence)
No
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
? (If Yes, please provide photo evidence)
No
provide explanation/s:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
maceutical waste encapsulated/inertisized and disposed through safe burial? (If Yes,
No
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
ment by a DENR-accredited transporter?
No
Accreditation No.:
Quantity (Kg):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
No
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
or landfill site?
No
No
No
ump or landfill site?
No
astewater Management
er) in the facility?
mated volume generated)
d wastewater treatment facility?
perations Management
ealth care wastes in the HCF? If Yes, provide the name of personnel
No
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
Years of Service
the applicable national, regional, and local policies?
gation, storage, treatment, and disposal of the HCW?
all staff in charge of the waste management?
No
o the staff? (Please specify)
he waste stream and to avoid potential treatment problems?
No
aging?
No
urrent Waste Management System
's current HCW practices?
No
te management practices pose any health risks to patients, nurses or doctors, other staff,
No
No
Health Care Waste Management Program Self-Monitoring Tool
Department / Area of the Hospital:
Date of Inspection:
Monitoring Rating:
Score
Indicators Remarks
References Actual
A. Waste Minimization Practices 20%
1 Re-uses/recycles used containers, articles, papers, and % of recyclable wastes that were recycled
etc. 10 multiplied to 0.10
2 Use of only environment friendly products and materials No styrofoam (polystyrene) and palstic (PVC)
= 5 otherwise, the score is 0; and
10 No mercury containing devices used = 5,
otherwise, the score is 0
B. Waste Segregation 25%
1 No mixed wastes seen at all times = 5,
Waste properly segregated in correct plastic liners otherwise, the score is 0
• Black/Clear: Non-Biodegradable General Waste 5
• Green: Biodegradable General Waste
• Yellow: Infectious Waste
2 Color-coded plastic liners with proper tagging and Color coding and proper tagging and labeling
labeling 4 strictly followed at all times = 4, otherwise,
the score Is 0
3 Use puncture-resistant and leak-proof sharps container Only puncture-resistant and leak-proof
for sharps 4 sharps container used for sharps waste = 4,
otherwise, the score is 0
4 Waste bins strategically placed in designated area Waste bins are placed in strategically
4 designated areas = 4, otherwise, the score is
0
5 Proper segregation of recyclable items Proper segregation practices at all times = 4,
4 otherwise, the score is 0
6 Empty vials brought to the pharmacy section by the Proper management of empty vials practiced
nursing attendant/personnel-in-charge for proper 4 at all times = 4, otherwise, the score is 0
recording and crushing (logbook available)
C. Waste On-Site Collection, Transport, and Storage 20%
1 On-site collection scheduled strictly followed Strict adherence to on-site collection
2 schedule = 2, otherwise, the score is 0
2 Janitorial service uses standard trolley with enclosure in Standard trolley is used to collect waste on-
collecting waste 3 site = 3, otherwise, the score is 0
3 Janitorial service directly transports waste collected to Waste is directly transpored to Central
Central Storage Area 3 Storage Area = 3, otherwise, the score is 0
4 No presence of spillage during collection and transport No occurrence of spillage during collection
3 and transport = 3, otherwise, the score is 0
5 Waste bins thoroughly cleaned, washed, and disinfected Waste bins thoroughly cleaned and
by janitors 3 disinfected at all times = 3, otherwise, the
score is 0
6 Waste transportation route being followed Waste transportation route strictly followed
3 at all times = 3, otherwise, the score is 0
7 Final disposal of waste in approved DENR facility Final disposal of waste in accrediated DENR
3 facility = 3, otherwise, the score is 0
D. Waste Treatment On-Site (If Applicable) 10%
1 Treatment of highly infectious waste conducted 4 Highly infectious waste treated at all times =
2 In case of chemical disinfection, used only allowed 4, otherwise,
Only the chemicals
the allowed score is 0 are used for
chemicals such as Sodium Hypochlorite, Chlorine Dioxide 3 chemical disinfection = 3, otherwise, the
and Hydrogen Peroxide score is 0
3 In case of the use of microwave or autoclave, the 3 Equipment has passed the validation test =
equipmentManagement
E. Wastewater has passed the validation test
(Personnel-in-Charge) 15% 3, otherwise, the score is 0
1 Regular testing of effluents 5 Effluents tested regularly = 5, otherwise, the
2 Preventive maintenance schedule for Sewage Treatment 10 score is 0
Strict adherence to STP maintenance
Plant (STP) followed
F. Administrative 10% schedule = 10, otherwise, the score is 0
1 Staff with formal training and education on proper health Staff had undergone formal training and
care waste management (HCWM) 2 education on proper HCWM = 2, otherwise,
the score is 0
2 Infection control protocol observed and practiced Strict adherence to infection control
4 protocols at all time = 4, otherwise, the score
is 0
3 Posters and other IEC materials available on-site On-site presence and visibility of posters and
2 other IEC materials = 2, otherwise, the score
is 0
4 Accident/incident reports submitted if any Prompt submission of complete accident/
2 incident reports, if any = 2, otherwise, the
score is 0
Total Percentage 100% 0
Monitoring Team: ________________________________________________________
Signature of Area Supervisor: _______________________________________________
Date:
Monitoring Rating
Grade/Actual Score/Interpretation
100% Excellent with full compliance
91%-99% Highly satisfactory with highly adequate compliance
81%-90% Satisfactory with adequate compliance
75%-80% Fair with compliance
74% and below Poor with low compliance
DOH HFDB Assessment Form 3
HCWM Assessment Tool
Revision 0, March 18, 2022
