Quyết định 3088/QD-BYT

MINISTRY OF HEALTH
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SOCIALIST REPUBLIC OF VIETNAM
Independence - Freedom - Happiness
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No. 3088/QD-BYT

Hanoi, July 16, 2020

Chapter & Criterion

CONTENT

Page

CHAPTER 1

ESTABLISHMENT OF STEERING COMMITTEE AND FORMULATION OF PREVENTION PLAN

Criterion 1.1

Establishment and strengthening of steering committee for epidemic prevention and control and work teams of hospital

Criterion 1.2

Nosocomial outbreak response planning

Criterion 1.3

Sufficient planning for response to epidemic scenarios upon epidemic declaration

Criterion 1.4

Procurement and stockpile of equipment for epidemic prevention and control

Criterion 1.5

Preparation of isolation area for healthcare workers

CHAPTER 2

TRAINING

Criterion 2.1

Provision of training in epidemic prevention and control procedures for each work position to all workers

Criterion 2.2

Training of additional workers mobilized in case of main workforce shortage due to epidemic

CHAPTER 3

GENERAL PRECAUTIONS

Criterion 3.1

Regulations on use of face masks in hospital

Criterion 3.2

Level of compliance with regulations on use of face masks

Criterion 3.3

Hand hygiene in hospital

CHAPTER 4

SCREENING AND STREAMLINING

Criterion 4.1

Screening and streamlining signage

Criterion 4.2

Reception and classification table

Criterion 4.3

Method for temperature checking for patient streamlining purpose

Criterion 4.4

Patient streamlining system

Criterion 4.5

Screening room

Criterion 4.6

Isolation rooms for suspected cases

CHAPTER 5

INFECTION PREVENTION FOR SOME CROWDED AREAS

Criterion 5.1

Application of information technology in organization of medical examination and treatment

Criterion 5.2

Waiting area, queue area

Criterion 5.3

Sample collection

Criterion 5.4

Medical imaging department

Criterion 5.5

Functional testing department

Criterion 5.6

Pharmacy

Criterion 5.7

Vendor booth

Criterion 5.8

Cafeteria

Criterion 5.9

Hospital bill payment counter

CHAPTER 6

MANAGEMENT OF SAFETY OF PATIENTS AND PATIENT FAMILIES

Criterion 6.1

Regulations on family presence restriction

Criterion 6.2

Preparation of isolation area for patients from affected areas

Criterion 6.3

Intrahospital patient transport

Criterion 6.4

Preparation of inpatient rooms in hospital departments

Criterion 6.5

Admitted patient care

Criterion 6.6

Admitted patient management

Criterion 6.7

Enhancement of remote medical examination, treatment and consultation

CHAPTER 7

HEALTHCARE WORKER SAFETY MANAGEMENT

Criterion 7.1

Interdepartmental consultations, interdepartmental meetings and hospital briefings

Criterion 7.2

Health monitoring for healthcare workers

Criterion 7.3

Management of risk from outsourced workers

CHAPTER 8

HOSPITAL HYGIENE

Criterion 8.1

Restroom management

Criterion 8.2

Cleaning of frequently touched surfaces

GUIDELINES ON IMPLEMENTATION AND ASSESSMENT METHOD

Chapter & Criterion

CONTENT

Maximum score

Self-assessment score

CHAPTER 1

ESTABLISHMENT OF STEERING COMMITTEE AND FORMULATION OF PREVENTION PLAN

Criterion 1.1

Establishment and strengthening of steering committee for epidemic prevention and control and work teams of hospital (5 points)*

Have established a steering committee for epidemic prevention and control immediate upon epidemic occurrence

1

Have established a steering committee and appointed the following positions:

- The hospital director as head of the steering committee

- A hospital deputy director for professional operations as head of the professional team

1

Have established a steering committee and appointed the leaders of the following work teams:

- Professional team (in charge of treatment, infection control, etc.)

- Epidemiological investigation team

- Communications team

- Finance - Logistics team

- Supervision team

1

Have established a steering committee with full regulation of operations and assigned tasks to work teams and members thereof

1

Work teams and members thereof perform the tasks assigned by the steering committee adequately

1

Criterion 1.2

Nosocomial outbreak response planning (5 points)*

Have a nosocomial outbreak response plan

1

The plan elaborates on task assignment, task timeline, procedures, funding estimate and supervision of task performance

1

Have a shift schedule, work team assignment and a referral plan

1

Have a detailed plan for maintenance of treatment for patients with chronic diseases and hemodialysis patients

1

Have a detailed plan for online meetings, briefings and consultations

1

Criterion 1.3

Sufficient planning for response to epidemic scenarios upon epidemic declaration (7 points) *

Have epidemic response scenarios

1

Have a scenario for each epidemic level

1

Have a scenario where a unit is isolated (essential and non-essential units)

1

Have a scenario where a nosocomial outbreak occurs and multiple units are isolated (essential and non-essential units)

1

Have a scenario where a nosocomial outbreak occurs and the whole hospital is isolated

1

Have practiced drills for scenarios for which practice drills are possible

1

Have gained experience and revised the scenarios after drills practice

1

Criterion 1.4

Procurement and stockpile of equipment for epidemic prevention and control (3 points)*

Have calculated budget for procurement of equipment for epidemic prevention and control and procured such equipment

1

Have sufficiently stockpiled essential personal protective equipment according to Decisions 1259 and 1460 (or applicable decisions)

1

Have sufficiently stockpiled essential drugs, consumables and equipment according to Decisions 941 and 1533 (or applicable decisions)

1

Criterion 1.5

Preparation of isolation area for healthcare workers (4 points) *

Have prepared an area for isolation of healthcare workers upon an epidemic

1

Have equipped the isolation area for healthcare workers with protective equipment

1

Have provided healthcare workers with regulations on operation of the isolation area

1

Have prepared a logistics plan for the isolation area for healthcare workers

1

CHAPTER 2

TRAINING

Criterion 2.1

Provision of training in epidemic prevention and control procedures for each work position to all workers (3 points)*

Have provided training in the guidelines of the Ministry of Health on screening, diagnosis and treatment of COVID-19 or epidemics of other acute respiratory infections

1

Have provided training in infection control and use of personal protective equipment

1

Have provided training in cardiopulmonary resuscitation in patients with respiratory diseases

1

Criterion 2.2

Training of additional workers mobilized in case of main workforce shortage due to epidemic (3 points)

Have an additional worker mobilization plan, including list of additional workers

1

Have an additional worker training plan

1

Have provided additional workers with training in tasks requiring their participation (ventilator use, sample collection and sample transport).

1

CHAPTER 3

GENERAL PRECAUTIONS

Criterion 3.1

Regulations on use of face masks in hospital (3 points) *

Have provided instructions on use of facemasks in the hospital through different forms of communications such as posters, bandrolls and television.

1

Have assigned personnel for control and supervision of use of facemasks in the hospital.

1

All workers are responsible for reminding patients and patient's families not wearing facemasks to wear facemasks.

1

Criterion 3.2

Level of compliance with regulations on use of face masks (5 points) *

 (give score based on result of compliance assessment: 1 point if 90% of patients comply, 1 more point if the remaining 10% comply; 1+1 = 2 points if 100% comply)

100% of workers in areas having contact with patients

1

≥ 90% of patients visiting the hospital for examination.

1

100% of patients visiting the hospital for examination.

1

≥ 90% of patient’s families and visitors.

1

100% of patient’s families and visitors.

1

Criterion 3.3

Hand hygiene in hospital (5 points) *

Handwashing stations with water always have soap.

1

Handwashing stations with water have disposable hand towels.

1

Crowded areas (lobby, etc.) and areas with many passersby (gates, entrances, staircases, hallways, etc.) are all equipped with hand sanitizer dispensers.

1

Have assigned personnel to regularly check hand sanitizer dispensers to ensure that hand sanitizer is sufficiently and regularly supplied.

1

Areas with many passersby such as front entrances and gates are equipped with automatic hand sanitizer dispensers.

1

CHAPTER 4

SCREENING AND STREAMLINING

Criterion 4.1

Screening and streamlining signage (4 points) *

Have screening and streamlining signage.

1

Content of the signage is conformable to the requirements in Official Dispatch No. 1385/CV-BCDQG dated 19/3/2020.

1

Signage is sufficiently placed at locations needing screening and streamlining instructions.

1

Have reflective or light box signage.

1

Criterion 4.2

Reception and classification table (6 points) *

Have a reception and classification table.

1

Give instructions on electronic health declaration to visitors and inspect declaration made by visitors

1

The reception and classification table is located no further than 10m away from the gate (if the table is otherwise located due to infrastructure limitations, there is a separate path to the table, which does not go through a building and is marked using ropes.

1

The reception and classification table must meet ventilation requirements (has open door and fan or located at a well-ventilated place).

1

The table is equipped with a hand sanitizer dispenser and waste bag/container, and is regularly manned by assigned personnel.

1

Give out (or sell) face masks to patients visiting the hospital for examination without a facemask.

1

Criterion 4.3

Method for temperature checking for patient streamlining purpose (maximum 3 points) *

By digital thermometer (handheld thermometer, temperature scanner, etc.)

1

By temperature scanner (ordinary scanner or visual recording scanner).

1

By visual recording scanner.

1

Criterion 4.4

Patient streamlining system (4 points) *

Do streamline patients visiting for examination.

1

There are separate gate and way for those with suspicious symptoms.

1

The separate way for those with suspicious symptoms does not go through a crowded building or run along the corridor of a crowded building.

1

The separate way is marked using ropes or barriers and is one way.

1

Criterion 4.5

Screening room (5 points) *

There is a screening room.

1

The screening room is completely separated from the inpatient department or crowded areas, and is well ventilated.

1

The screening room is readily equipped with personal protective equipment.

1

The screening room has an anteroom, a handwashing basin and a bathroom.

1

The screening room is connected with the sample collecting area and medical imaging area or samples are collected and imaging procedures are performed in the screening room.

1

Criterion 4.6

Isolation rooms for suspected cases (3 points) *

The isolation rooms are well ventilated and not connected to the central air conditioning system.

1

The isolation rooms are well ventilated and completely separated from the inpatient department or crowded areas.

1

The isolation rooms are well ventilated and each has an anteroom, a handwashing basin and a bathroom.

1

CHAPTER 5

INFECTION PREVENTION FOR SOME CROWDED AREAS

Criterion 5.1

Application of information technology in organization of medical examination and treatment (2 points)

Have assigned staff to schedule appointments over the phone.

1

Take appointments online.

1

Criterion 5.2

Waiting area, queue area (3 points) *

Have notifications and instructions advising patient’s family against accompanying the patient to the hospital.

1

Have solutions for increasing ventilation in the waiting area (opening more windows to utilize natural ventilation, installing ventilation fans, etc.).

1

Waiting chairs are arranged sparsely; waiting chairs are arranged as appropriate to epidemic situation.

1

Criterion 5.3

Sample collection (5 points) *

The sample collecting room is well ventilated and has its surfaces sanitized with a suitable disinfectant solution on a daily basis.

1

Social distancing requirements are complied with during the sample collecting process as appropriate to epidemic situation.

1

Different types of samples are collected in different areas.

1

Sample collectors wash their hands (and change used gloves) immediately after collecting samples from a patient.

1

Healthcare workers coming into direct contact with persons suspected of having a respiratory disease to collect their samples are fully equipped with personal protective equipment.

1

Criterion 5.4

Medical imaging (4 points) *

The rooms where imaging procedures are performed are well ventilated and have their surfaces sanitized with a suitable disinfectant solution on a daily basis.

1

Instructions are provided and only 1 patient is allowed to enter the X-Ray, CT scan, MRI or ultrasound room at a time.

1

There are separate X-Ray, CT scan, MRI and ultrasound rooms for persons suspected of having an acute respiratory infection. If these persons share an X-Ray, CT scan, MRI or ultrasound room with other patients, the room surfaces are disinfected between patients according to regulations.

1

Healthcare workers coming into direct contact with persons suspected of having an acute respiratory infection to perform an imaging procedure are fully equipped with personal protective equipment.

1

Criterion 5.5

Functional testing (4 points) *

The functional testing rooms are well ventilated and have their surfaces sanitized with a suitable disinfectant solution on a daily basis.

1

Instructions are provided and only 1 patient is allowed to enter a functional testing room at a time.

1

Healthcare workers coming into direct contact with persons suspected of having an acute respiratory infection to perform a function test or an aerosol generating procedure are fully equipped with personal protective equipment according to regulations.

1

Having prepared separate areas for non-invasive functional testing, invasive functional testing and aerosol generating procedures.

1

Criterion 5.6

Pharmacy (4 points) *

The pharmacy area is naturally or mechanically ventilated (fans, etc.) in a proper manner.

1

Hand sanitizer is provided for customers.

1

Shields are installed to separate pharmacy staff and customers.

1

There is an ultraviolet disinfection cabinet for cash or cashless payment method is employed.

1

Criterion 5.7

Vendor booth (3 points - not applicable to hospitals without vendor booth)

The vendor area is naturally or mechanically ventilated (fans, etc.) in a proper manner.

1

Hand sanitizer is provided for customers.

1

There is an ultraviolet disinfection cabinet for cash or cashless payment method is employed.

1

Criterion 5.8

Cafeteria (5 points - not applicable to hospitals without cafeteria)

There is a handwashing station outside or inside of the cafeteria with soap or hand sanitizer.

1

Takeaway is available.

1

Tables and chairs are arranged sparsely as appropriate to epidemic situation; the cafeteria is naturally or mechanically ventilated (fans).

1

Cafeteria surfaces are wiped clean with a disinfectant solution on a daily basis.

1

Shields (made of glass, plastic, etc.) are installed between tables.

1

Criterion 5.9

Hospital bill payment counter (4 points) *

The area where the hospital bill payment counter is located is naturally or mechanically ventilated in a proper manner.

1

Hand sanitizer is provided for payers.

1

Shields are installed to separate the staff at the counter and payers.

1

There is an ultraviolet disinfection cabinet for cash or cashless payment method is employed.

1

CHAPTER 6

MANAGEMENT OF SAFETY OF PATIENTS AND PATIENT FAMILIES

Criterion 6.1

Regulations on family presence restriction

There are regulations restricting presence of patient’s family members (each patient is accompanied by one family member).

1

Regulations on family presence restriction have been disseminated to hospital personnel for implementation and supervision purposes.

1

Regulations on family presence restriction have been publicly posted for patients and patient’s families to comply.

1

Criterion 6.2

Preparation of isolation area for patients from affected areas (3 points) *

More than 80% of clinical departments have each prepared at least 1 temporary isolation room according to regulations.

1

All clinical departments have each prepared at least 1 temporary isolation room according to regulations.

1

The hospital has prepared a separate isolation area or  treatment unit for suspected COVID-19 cases or epidemics of other acute respiratory infections, which is closed to all unauthorized persons.

1

Criterion 6.3

Intrahospital patient transport (5 points) *

Provide at least 1 wheelchair for suspected or confirmed cases of acute respiratory infections, which has been given a distinguishing mark.

1

Provide at least 1 gurney for suspected or confirmed cases of acute respiratory infections, which has been given a distinguishing mark.

1

The wheelchair(s) and gurney(s) are stored in a separate area where a “Storage area of transport equipment for suspected cases of acute respiratory infection" sign is placed. The wheelchair(s) is/are not used for other persons.

1

There are procedures for disinfecting the transport equipment after use. The transport equipment is disinfected immediately after use following these procedures before it is used for the next patient.

1

Healthcare workers involved in patient transport are fully equipped with personal protective equipment; and can present and follow the procedures for disinfecting the transport equipment.

1

Criterion 6.4

Preparation of inpatient rooms in hospital departments (6 points) *

Ventilation in the inpatient rooms are enhanced (natural ventilation such as opening the windows but not windows opening to a corridor, mechanical ventilation such as fans, etc.).

2

At least 1 hand sanitizer spray bottle is installed in each room, which is always filled with hand sanitizer.

1

Patient beds are placed at least 1 meter apart with only one patient on each bed; the beds are placed at least 2 meters apart if the epidemic worsens.

2

The beds in every room are divided by waterproof curtains.

1

Criterion 6.5

Admitted patient care (5 points) *

Healthcare workers are provided with sufficient and suitable personal protective equipment when treating and caring for suspected cases of COVID-19 or other acute respiratory infections.

1

Patients with respiratory diseases are placed in separate rooms; the room of a patient with a respiratory disease has no more than one additional patient.

1

Patients are given comprehensive care at least in the intensive care unit and the respiratory department to minimize the involvement of the patients’ families.

1

Patients requiring first level of care of all departments are given comprehensive care.

1

All patients of the hospital are given comprehensive care.

1

Criterion 6.6

Admitted patient management (4 points) *

Patients are requested to notify the hospital immediately upon development of a respiratory infection symptom.

1

Patients are requested to notify the hospital immediately when their families are diagnosed with COVID-19 or another acute respiratory infection.

1

Have ensured that patients of all departments are properly managed and there is no patient with an acute respiratory infection walking freely inside and outside of the hospital.

1

Meals are fully provided for admitted patients with acute respiratory infections.

1

Criterion 6.7

Enhancement of remote medical examination, treatment and consultation (5 points) *

Have formulated and promulgated the regulations of operation of the hotline for COVID-19 and epidemics of other acute respiratory infections.

1

Have made plans for online periodic consultations with other hospitals and held such consultations.

1

Have ensured that all patient referrals/receipts are discussed and notified in advance through the phone or an information technology application to the receiving/referring establishment.

1

Have made plans for remote medical examination and treatment and established a unit in charge of remote medical examination and treatment.

1

The unit in charge of remote medical examination and treatment serves at least 2 types of patients (e.g., patients with chronic diseases currently managed by the hospital) on a regular basis.

1

CHAPTER 7

HEALTHCARE WORKER SAFETY MANAGEMENT

Criterion 7.1

Interdepartmental consultations, interdepartmental meetings and hospital briefings (4 points) *

There are procedures for interdepartmental consultations, interdepartmental meetings and hospital briefings during the COVID-19 pandemic and in the event of epidemics of other acute respiratory infections.

1

There are regulations stipulating online briefings, consultations and meetings during the COVID-19 and in the event of epidemics of other acute respiratory infections.

1

There is sufficient visual, audio, connection, etc. equipment for online briefings, consultations and meetings in relevant departments. The equipment can operate properly and is ready for activation.

1

Hospital personnel hold interdepartmental consultations, interdepartmental meetings and hospital briefings according to the procedures approved by the hospital, which stipulate online communications in the event of an epidemic.

1

Criterion 7.2

Health monitoring for healthcare workers (4 points) *

There are regulations requiring healthcare workers to monitor health condition of themselves and their families and symptoms of respiratory diseases. Upon development of an acute respiratory infection symptom, healthcare workers report it to their direct supervisors immediately.

1

There is a system for monitoring and managing reports on acute respiratory infections made by healthcare workers throughout the hospital (including reports by security guards, cafeteria staff, etc.).

1

There is an electronic management system used to record reports on respiratory infections made by healthcare workers.

1

Healthcare workers having acute respiratory infection symptoms are screened for COVID-19 or other acute respiratory infections.

1

Criterion 7.3

Management of risk from outsourced workers (3 points) *

All outsourced workers have received training in epidemiological factors, risk of infectious diseases, infection control and use of personal protective equipment.

1

All outsourced workers are fully equipped with personal protective equipment appropriate to their jobs (e.g., security guards are equipped with facemasks).

1

Management and monitoring of outsourced workers’ compliance with infection control requirements have been assigned to specific unit(s) and individual(s).

1

CHAPTER 8

HOSPITAL HYGIENE

Criterion 8.1

Restroom management (3 points) *

Have regulations requiring that restroom surfaces be cleaned with a disinfectant solution on a daily basis at a fixed time.

1

Staffs comply with regulations requiring that restroom surfaces be cleaned with a disinfectant solution on a daily basis. Waste on restroom surfaces is removed within 15 minutes.

1

Restroom cleaners wear medical masks and use personal protective equipment such as rubber gloves and boots.

1

Criterion 8.2

Cleaning of frequently touched surfaces (3 points) *

Disinfectant solution is adequately provided at locations frequently touched by patients, patient’s families and healthcare workers (doorknobs, elevators, etc.)

1

Have regulations stipulating surface cleaning using a suitable measure or cleaning of frequently touched surfaces by spraying disinfectant solution (at least 1 time/part of the day during epidemic and at least 1 time/day when there is no epidemic).

1

Regulations on surface cleaning or cleaning of frequently touched surfaces by spraying disinfectant solution are adhered to.

1

TOTAL

150