CB(2) 557/98-99(02)

For Discussion
on 9 November 1998

LegCo Panel on Health Services
Licensing and Monitoring of Private Hospitals

This paper provides the Panel with additional information on monitoring of private hospitals, further to the Panel's discussion on 14 September 1998.


The Department of Health took over the licensing of private hospitals in December 1991. At present, 12 private hospitals are registered under the Hospitals, Nursing Homes and Maternity Homes Registration Ordinance (Chapter 165).

Licensing and Inspection of Private Hospitals

2. The licence of each hospital expires on 31 December of each calendar year. For the purpose of licence renewal, the hospital administration is required to file an annual return on the operation of the hospital in the form of a questionnaire, which is drawn up on the basis of the Guide to Hospital Standards (the Guide) which was endorsed by the Medical Development Advisory Committee in 1990. Over the years, the questionnaire has been revised regularly to bring it up-to-date.

3. The information required from the private hospitals as set out in the most recent version of the questionnaire includes -

  1. Organisation of the hospital

  2. Number of beds

  3. Staffing, facilities, equipment of all service units

  4. Policies and procedures

  5. Fees and charges

  6. Staff development, training and education

  7. Patients' rights

  8. Evaluation of staff performance and service

  9. Practices pertaining to drug labelling

  10. Handling of clinical and chemical wastes

  11. Complaints procedures

  12. Handling of medical gases
An updated Guide and sample questionnaire are attached at Appendix I and II.

4. Since the Department of Health took over the licensing of private hospitals, inspections are conducted to these hospitals prior to their first registration or annual renewal of licence. An inspection team, consisting of a doctor, a nurse and a hospital administrator, will make at least one visit to each private hospital annually to inspect the actual operation of all the services and seek clarification of information provided by the hospital management in the questionnaire. The team will discuss with the hospital management on areas that need rectification or improvement. Follow-up visits will be conducted to ensure that areas of concern have been addressed before the licence for that particular hospital is renewed. Unannounced visits will also be conducted to keep a close monitor on the standard of the hospitals. Verbal or written advice or warnings will be issued where necessary.

Liaison with and Monitoring of private hospitals

5. Since the taking over of the licensing of private hospitals in 1991, the Department of Health has maintained close liaison with private hospitals. Over 30 sets of guidelines, advice and medical alerts were issued to the private hospitals in the past three years. Examples of these guidelines are handling of dead bodies, management of needlestick injury, Y2K compliance for medical equipment, blood products associated with donor with Creutzfeldt-Jakob Disease, etc.

6. The Department of Health also undertakes investigation into complaints received from clients of the private hospitals. Private hospitals are required to furnish reports to the Director of Health on incidents of public health concern or matters pertaining to patient care. Incidents such as wrong labelling of medical gases and the recent incident involving dialysis patients have been reported at the first instance to the Department of Health.

Advice Sought

7. Members are invited to note the contents of this paper.

Department of Health
26 October 1998

A Guide to Hospital Standards

This Guide describes standard hospital practices which are considered essential for hospitals to ensure quality care to their patients. It aims to provide a basis for hospitals to develop and evaluate their own services and activities in every clinical and non-clinical department or unit. It also aims to provide the basis for hospitals and professional bodies to develop standards for individual services. The Guide would be revised and updated regularly to reflect the current consensus on acceptable and achievable hospital standards.

The Standards

A. Organisation and Administration

1. There is a statement of philosophy and objectives which describes the nature and purpose of the hospital's work and development as well as the major philosophical premises under which it will operate.

2. There is an organisational structure which includes all categories of personnel employed in the hospital and delineates the channels of communication as well as the lines of authority and responsibility.

3. There is a governing body/committee/person responsible for :-

  1. the development and application of the objectives statement, making sure that all major decision-makers within the hospital operate according to the statement of direction;

  2. the overall coordination and evaluation of activities within the hospital;

  3. the development of policies and procedures for the whole hospital in order to facilitate its operation and to achieve its stated philosophy and objectives;

  4. overseeing the financial management of the hospital; and

  5. ensuring the hospital's adherence to relevant Ordinances in the Laws of Hong Kong no less than those listed in Annex I.
B. Staffing

1. The number and quality of staff employed is appropriate to the nature and scope of services provided.

    1.1 Each service is directed by a person who is appropriately qualified by education, training and/or experience.

    1.2 Trainees, assistants and other helpers should only work under the direction and supervision of qualified professional staff at all times.

    1.3 There is a mechanism to monitor and review the staffing situation to ensure that the quality and quantity of staff can satisfy the service needs and objectives.

2. There is a mechanism for determining appointments and clinical privileges/responsibilities of professional staff, especially visiting doctors, based on evidences of professional competence, level of training and/or experience, which is uniformly applied to all applicants.

3. Statements of duties or job descriptions are available for all categories of staff to guide their performance and are reviewed and updated on a regular basis.

4. There is a documented staff appraisal system for all staff, based on job descriptions and work objectives, which facilitates the identification of strengths in performance and areas for improvement.

5. The hospital keeps accurate, complete and updated personnel records.

C. Facilities and Equipment

1. The hospital has adequate and appropriate space, facilities and equipment to provide services to the patients in accordance with its objectives.

2. The hospital environment is safe, hygienic and comfortable to the occupants.

    2.1 Lighting, temperature, humidity and noise level are comfortable to the staff and patients.

    2.2 Hazardous materials are handled in accordance with Government regulations and relevant codes of practice.

    2.3 Facilities are clean and regularly maintained.

3. The compatibility between activities and physical design of facilities in the hospital is reviewed as necessary to ensure efficient and effective operation throughout the hospital.

4. The hospital management is responsible for a planned on-going maintenance programme to ensure that facilities and equipment are up to performance standard, safe to the staff and patients, and comply with international/Government codes and standards.

    4.1 Staff are appropriately trained to operate various equipment.

    4.2 Equipment is serviced and tested in accordance with manufacturers' advice.

    4.3 All maintenance and repairs are documented.

    4.4 Life span of each equipment is registered.

    4.5 Facilities are serviced and inspected regularly.

D. Policies and Procedures

1. The hospital management, in collaboration with the head of each department/unit, is responsible for developing policies and procedures for the whole hospital and its services.

2. Policies are :

  1. clearly articulated in understandable language;

  2. documented in a policy manual which is readily accessible by staff for reference;

  3. determined on the basis of adequate information and consultation with relevant fields;

  4. capable of being implemented; and

  5. not in conflict with relevant regulations and by-laws.

3. The policies provide clear directives as to the scope and limitations of the responsibilities and activities of staff.

    3.1 There is evidence that staff are informed of current policies and procedures and follow them in all activities.

    3.2 Guidelines are developed to ensure patient and staff safety.

4. Policies and procedures are reviewed periodically and revised as necessary in order to reflect the current scientific knowledge and principles of services. All relevant procedures should be circulated to staff concerned at a regular interval.

5. Policies and procedures on infection control are developed to minimize hospital infection and to ensure a safe environment for staff and patients.

6. Guidelines/Codes/Regulations/Standards from professional bodies and Government are followed where appropriate. Examples of guidelines are listed in Annex II

E. Patients' Rights

1. There are written policies and procedures to protect the following rights of the patients :

  1. the right to obtain information on one's own diagnosis, treatment and progress;

  2. the right to obtain information necessary to give informed consent to any procedures;

  3. the right to refuse treatment;

  4. the right to confidentiality in all communications and records related to one's own care;

  5. the right to refuse experimentation or participation in teaching programmes;

  6. the right to examine and receive explanation of one's hospital bill.

2. There is a mechanism to register and investigate patient complaints and to ensure fair and reasonable response to the results of investigation.

3. There are appropriate facilities to ensure privacy and to meet the special needs of patients and their visitors.

F. Staff Development and Education

1. There is a job orientation programme to introduce new staff to relevant aspects of the service and aims to prepare them for their role and responsibilities.

    1.1 It includes information about the philosophy and objectives of the hospital and of each department/unit.

    1.2 It includes information about the relationship between each department/unit and the total organisation of the hospitals.

    1.3 It explains the particular duties and functions, lines of authority, areas of responsibility and methods of obtaining appropriate resource materials.

    1.4 It explains the methods that will be used to evaluate the service as well as the staff member's performance.

2. Special orientation programmes are conducted for services which demand special awareness of technology or safety, such as operating theatre service, intensive care and radiology services.

3. Opportunities are provided for staff to receive on-the-job training, in-service education and continuing education where appropriate.

G. Evaluation

1. There are mechanisms to collect and monitor clinical, management and financial information.

2. The hospital management is responsible to submit the following information at regular intervals to the Government:

  1. utilisation rate of hospital facilities and services;

  2. births, deaths and disease classification of in-patients treated;

  3. staffing situation;

  4. audited financial report; and

  5. any other information required by the Government.

3. There is a medical record system which allows clinical evaluation. Each patient's record should contain the information as listed in Annex III where applicable.

Department of Health

Annex I


Antibiotics Ordinance (Chapter 137)
Births and Deaths Registration Ordinance (Chapter 174)
Coroners Ordinance (Chapter 504)
Dangerous Drugs Ordinance (Chapter 134)
Dangerous Goods Ordinance (Chapter 295)
Dentists Registration Ordinance (Chapter 156)
Disposal of Uncollected Goods Ordinance (Chapter 294)
Employees' Compensation Ordinance (Chapter 282)
Employment Ordinance (Chapter 57)
Hospitals, Nursing Homes & Maternity Homes Registration Ordinance (Chapter 165)
Human Organ Transplant Ordinance (Chapter 465)
Medical Clinics Ordinance (Chapter 343)
Medical (Therapy, Education and Research) Ordinance (Chapter 278)
Medical Registration Ordinance (Chapter 161)
Mental Health Ordinance (Chapter 136)
Midwives Registration Ordinance (Chapter 162)
Nurses Registration Ordinance (Chapter 164)
Occupational Safety and Health Ordinance (Chapter 509)
Offences Against the Person Ordinance (Chapter 212)
Personal Data (Privacy) Ordinance (Chapter 486)
Pharmacy and Poisons Ordinance (Chapter 138)
Prevention of Bribery Ordinance (Chapter 201)
Public Health & Municipal Services Ordinance (Chapter 132)
Quarantine and Prevention of Disease Ordinance (Chapter 141)
Radiation Ordinance (Chapter 303)
Smoking (Public Health) Ordinance (Chapter 371)
Supplementary Medical Professions Ordinance (Chapter 359)
Undesirable Medical Advertisements Ordinance (Chapter 231)
Waste Disposal Ordinance (Chapter 354)
Watchman Ordinance (Chapter 299)

Annex II

Examples of Guidelines issued by Department of Health

  1. Recommended Strategies on Hepatitis A Vaccination in Hong Kong

  2. Ensuring Year 2000 Compliance

  3. Guidance to Physicians on Assessment of Medical Fitness to use Respiratory Protection in Conditions of High Roadside Air Pollution Index

  4. Revised Immunisation Programme

  5. Handling of dead bodies

  6. Prevention of Hepatitis B in Health Care Settings

  7. Management after Needlestick Injury or Mucosal Contacts of Blood and Blood Fluids

  8. Guidelines on the Supply and Use of Medical Gases in Hospitals and Clinics

Annex III

Information to be contained in patients' medical records

  1. notes of all doctors in the institution who have attended to the patient;

  2. nursing notes;

  3. patient observation charts;

  4. fluid balance charts;

  5. laboratory, radiological and all other investigation/test reports;

  6. patient consent forms;

  7. anaesthetic records;

  8. operating records;

  9. drug charts;

  10. referral letters;

  11. any other information that are considered basic, essential and relevant to the patient's medical condition.