9 September Nurse 2
9 September Nurse 2
9 September Nurse 2
C'epartrnent of Health
ON L()CSIN MONTELIBANO
IONAL HOS
eR (o9.) 7o3-r 3Eo ro aa : a31-6ao I ro 13 f,l cr66r'r.dorr,eov.ph
To : Medknl Division
: Nursing Division
: Finance Division
: Hospital Operations and Petient Support Services (HOPSS) Division
: Ofrices Dircctly Unde/ha1ltledical Center Chief (MCC)
t'
./'
In line with the recent requirement ofthe Department of Health regarding the updates on the
Manatement Review for the 1st Quarter of 2019, all organizational groups are hercby directed
to submlt a status of the identifled action plans durlng the latest Management Review
conducted last January 1G11, 201!r.
Attached to this memorandum is a copy of the Minutes of the Management Review and the list
of action plans for your reference.
This requirement MUST be submitted to the QMS Office on or before 12NN of May 2, 2019.
3 oIAPR 2o1s
TTIAIIASEMEHT *N'EW
Minutes of the Meeting
{ lanuary 10-11" 2019 }
lnAtbdnm.
*. Julirn M. $Iilqrr. llsdod Csr*€r Cfrid ll
e. Jorg€ ltslsr L Tadigfli - Adity Mnegsn€rt Reprssartdive
Dr. t{gtlta B. Drr aguit - IQA Chdrgao*r
AMS Ss*rid
Ur{tQMR, UnitDC
lQAAufitcs
Dep*tmqtl |f€ads
Ms. ffaiad Vdm- l$O0onsdtilt
Agertds
l. srmls or t$tsrs r*tfirr Fmr pmfiot s trlr{rcatgtr rerflBfns
The stahrc of actions tahn to address conoarnt and hrucs from the disnrssion lrorn prwlous rnan*gernent
rwi* has been presented ald revianed,
fl. C}IAITGIII $IlHf Ef,IERNATAilD II$ENilAtISSUES RETFVAIITTO n|E QUAI.ITV MATTAGIIIE'ITSYSTEIiI
(afst.
Relevant lnternal and External lseues, and their status that affecl oBeretional actlvitlas was pre$€nted and
dixussed bV each organizationalgroup. Fls see resp€ctive presentation fordetails). Some of thes€ changes
Indude:
- N€* servi€es: diabetes center, drugdependencytestin& malasldt center
- Date Prfuacy 461 ssrnpliance, with sorne chalhnges, hrt wlth action plans being implenrented;
considering gstting consultent specific for thls need
r MGdical Resldency Ratation Stateg,y rnandated by DOH wfth some challengesto be addressed and
handled by CMETRU
- Transferlopenlng of new dietary area
- Started implernentetlon of IHOMIS & eCtaims
m. IITSORiiANOil OI{ IHE PERFORMAI{CE AIID EFTECNV TESS Of THE QUAUW MAHA€EMEI{TSYSTBI
{amsl.
Fage I of l0
LOCS o
zas-rcno to ltt a31'tiot t$ tl *lqt'F6rtr'rloh{eY'Ir r
Stne.} ;
Almost 9 cut of 10 clients of CIMMRH ghrts a posrurc feedback to our staff and institution.. There is a very big
and s[nificant difference on the prqportion of posltirre and negative feedbackr. A small percentage of the
inteMewed clientr had a negative feedback.
The blggest source of the fsedbacls are fmm th€ Administrative Sorvicer at afmctt 879x and folbwed bv the
OPD scrvkes. lt can also bo imptied that mo:t of the positfye feedbacts are from the Administrative Senrkes
Based on the data, rmst of the negathrc feedbacks ard suggestbns are hom the OPD services of O$MRH'
Most of the walk-ln mmplaints of the hospital are from the Medical Divisiofr while the least of the complaints
are frorn the Finance Dtvldon. tt is folbnred bV the Nursing Dlvision at 37 and the HOPSSD at 2096' PIAD
reccives an average cf 7 cornptahts per month. A total of 15 comphints w€rs lo&ed through the 8888
Conplaints Hdllna
Changes and reviions of Risk and opportunity assessments w€rc done, with some cfiang* in the methodology
used, New and/or revised obledhes yrere gsnereted as a resuh of the nfl ascessmsnt done, es refected in
respectlve unifs actbn plannlngwoflsheeB and nranagement revhw reports.
Geileral QOP Resutts uar presented W the OIt/tR. Each organizational group pfissentd detailsd QOP targets
and raq.rlts.
fvto* departments in Medtcal Division met their QOP targets with 9496 achierremen! and there are three
obrecthlea that were not consistently m€t from HlM, fior chart omdetion; and tFM fur preEntlt€
maintenance and calibratlrn.
Delays in subrnisdon of QOP results and Actbn Phnoing Worlsheet to QMS offtce by a few oryanlzational
groups ls stitl not€d. fhe QI\{S have lmplemcnt€d a contrul m€ssunE to avoid delays in the suhmlssbn of
required documents.
Oharr$ont*Iffinfhnr nrryonc&#Unft
to lsgte a rnemo for comments on the Mandatory QOPs to bs
QI\,iS cMPS/qMS
implemented
Includa ln status of issues {in each organizational group } the things being All organizational GrouPs
done to address tham. This will serve as basis for rnonitoring forthe net*
report.
Page 2 of 10
Ftepubllc of ttro Frhlllppin€tr
Ilopartrnsrrt of Hesltlr
$uggested to have new QOP target for completion of drart to 8[Fl within 24 hours frorn dischaqe of
pfltient. lt war also iugge$€d to hava 2 leyel targFts one from Initial grbmirsion to HfM and 2d for
re-submission afier HIM qA
Flmr2
- Wfrh noted decreasa In adnrlsslon from 2017 to 2O18; but dischargcs are digbtlv hbher in 2O18
posclbly duc to imprornd intsrd€partfilentel coordinatkrn and collaboration
- Stressed the need fur speclrl erea for prucedure and place fortools stonge.
Pedia Ward
- Whh 6 cases of fall and 4 needle stick injury
OBWard
- U/fth 22 nurses reslgnrtioo, but only 7 were repfaced to date
- Accreditatlon for mother baby friendly hospital completed
- Oecrease in admlssion form 2017 to 2018; and with 7% decrease in dischergss
c!{rrRU
- Totalof19trainingsconducted
- Completed ttc new ernphyec orientatlon manual
- R*$bmttted dorumentt for CPD provilcr appficaticn, awaiting feedback from PflC; with target
completlon whhin this year.
.
Housakeeping
- Wlth noted decrease in quanttty of uraste generated
- Lessencd cats and rats slght@s slnce lrplenrentatlon of no bringing of outsHe food
Page 3 of 10
Reputrltc ot tlr€ PhlllPPlnes
Clspertmsnt of l-lealth
fmnrfDtctdl
r{un$fi6twsflc$l
Completeness of Chart will have 2 targets ilursing Service Ofiice
a. &)?5 complete upon ilbmission to HIM
b. 10tr6 cornpbte afterQQA by HIM
To ldentlfi flew actbfl planr br unmefi trryett not thosc ttat are ongoln3 Floor 2
implermnted.
Status of issues must say what ls currently being done to address thern Flmr 1
To include the FOU$ in the lntereft€d Parties in the prevention of fall Pedia Ward
Internal Mediclne
- Onlyone resldent appllcant
- lssue with the medkal rotation strategy mandated by DOH
- Increase admission
General Surgery
- All targ€ts were met, otcept 1; with 2 resident rcsignations
- Granted 5 year full accrsditatbn for recidency training durirrg the recent accraditatbn visit
- Wfth noted 95.&196 passing rete for in-service exam
- With slfht increase in admisrion and about 506 increase in performed procedurcs
Pedlatric tlepartment
- with less than 1% Hrdl
- Custorner S:tisfaction rating of 99}6'
- All Pedia doctors are now accredited to Data Prl,racy Commission
- Increased passlng of resklents in speciafi board exarn to 87%
- With significant increase In ER cons{rlt, from 9574 to 17681
Stone Center
- Wlt 1386 increase in patients catered
- All QOPs were rnet
DDIRS
- Wnh avemge 6698 monthly x-ray done
- Significant increasa in ultrasound procedures were noted from July to Decernber; mammogtam
Increased by 156%
- Still with issue on CD boarded patients and with noted increase in admission, as well as number of
absconded patients
Page 4 of 10
LIBAI\|O
tlterl ?&$-tsso t' ga ; {.|1-!t8sl iir 1s S clmmrtr-dah.Qov }'lt
- ll€ed equipment to be $hto pnrv{de npre servlces esttsnst€d at 35M. tt.was sugested to shxty the
need and priorftire those that ar€ neesary and plan or* prrchase for the naxt 3 Wan
- Wilh good srppfier for bask implants but with rme chalhqes in wfth crilical irnplents spplier
- !{er diplomate and ncw fellow h the departrnant
- FqqtSrint for Day tuqeryalresdy ldentifid
Department of fuiedhesia
- Wtth chrllengcs in completlng index cases, but uor*ing on n Ouitng Oepartm$t m€etingt
- Grfit€d rearcreditatlon for 3 prrs last October il118
- Averaglng 730 casas per month; Stl6 of *'trldl are OB cases
OB€ync Departrnent
- tssues on oornpletbn of drart withln 24 hours, but wfth dependencies with nureing servke
- Atso with chalbnges in cornpkting nsearch requirements of reddfpts
- Residency accr€dilatbn valH unt$ 2020
CMFTRU
- Started lmplamentatio*l of conpttrngy bared rsseesment an unlfied,adtnission crftefa rnd proc*cs
for residency pmgnrm applicants
- Total of 1tl4 reridcntq wi*r $96 pacsk€ rate In speclatty board exars
Paee 5 of 10
Ftst'ulttlc of th€
tr}Gllsnrf,r€nt of Heslttt
''hlllppln6a
c
AL
tg'lFr3dtro.o ldt i allr-llttoi 6 lg tf,N crrlrsrtr'r*orr'oo* ptt
$fogaf
FflV/AtdsCoraTeam
gffflsffis&{odotPhrr
s1lgT-w1$3ggg9'':
consider uenttfoing a addftlonal actbn plan s{nce infrastructure soh.ttion may Emergency Medicine
take a long tinre to be implernented
Sr. Residents to man triage, wlth tha revision of tnl*ing rnanual
Peti€rltr wlll noi-naet b€ t€quhed to get a copy of the e & tracing from heart
station as supplemental to the findings.
Resldentsshould getthe official rearlts ofthe EC€ tracing instead of asking
patienti to retrieve the same.
Coordinate wilh IHOMP to advertise :ervices at CIJvIMRH website
Pap 6 of 10
Ftepulrllc of tkre PhlliPPlnee
I)spsrtmant {}{ Health
StrFnr&hlrrrrt
To set rne€ting wlth nursing and CMPS to dlscuss issue on chart completbn. To Obstetrks and GynecologY
include Flnance and Accounting as requested b,y Mr Ester
Asountlng Scction to asrist Operating Room for changngthe list of Operott ng nomt Cornplul
ipstrumenti incfuded In ofi pacls Accoadng Secttan
To lnlffie o chonge mamgemerrt pan fur tfic statiltsfin c nt ol the Multi Medtcsl SxiolWork
Dtsciptlrpry Uatt to ccrdilwte wfth Dr Anots&
To request fur 10 more unkt of ventilaton to efficlently ssrve all patieilts in Pulmonary Unlt
need
To fncfude Radlologlc Technlclans and fi4edtech5 In the training pr4ram and sit CM€TRU
down with PET to discuss howto improrc Involrrernent of other medical
department in CMETRU activities and pfirnranu
To incorporate DOH prognms In the rislng number of Persons livkts with lllv ( HIV end AIOS Core Team
PU{|V }
To lntroduce the Nerrr dlagnostic algorhhm In HIV HIV and A|DSCore Team/
Pathobgy
Should include Ophthalrnlogy in all ON cases in the their report Operatln g Roorn Complex
Check / rerriew list of instruments / ltems per OR packs - (li* of instruments Operating Room Complex
reguired in pack) per procedures (last bview 2016 maybe); coordinate with
accountint
To set a meetinS urith concerned unitsbefore start of rcnorration of OR at EFM
Heritage BuiHing. All rnanagers must be informed and inrolved.
MaterLls ilianagement
- Reported"issue on poscible non{haEingof egulpmort us.ger flb Infuslon purnp, etc.
- llew equlpment deliversd - cranbtomy ddf[ MRl, gastro scope, stc-
- Pleimr sterlltrer alrsedy rnhnd in Manlla alaltlrg delirrery to Cl
EFMD
' Scheduhd to mest with cootractorto regadiry pnsumatictubetnansfer and tnnsier of CSSD
cqubment, wlth taryet complation bV 3d wcet of January
Flsrudrrue&lilonplans Aagrllr&&'thtfit
Hospltal Oreratlon and Patjent Snpport Serv*ces
To meEt wlth concern teams to dlscuss issue on $erillrer and issue retateo io MM5
pneumdlc tube renovation fTentatiw meeting date: Jan. 211
Concemed unit to dlllgently chect usage and charglng of equipment and get Concerned Nuning Service
copy of the infusion pump charglng from MMS fior refereflce. Wads
Mr. Dante Bicas {HlM} to provHe standard deflnition of terms used for HIM
transfer in and tnnsfar out of patlentr
To come up with a percentile/more detailed report on the compliance of HIM
99*9S $lg$glgpott pryyq9d is fi st generat.
To lncrease th€ @P target fiom l0days to 15 dafs for comple*eness of charts HIM
To €stablish a guuellne in awfdingthe ov€rpavment and underpaynEnt of HBMO
personnel.
Upyadlng of 230V Flectrical Fower Supply System €FM
for recalling in recalling back fogged job orden
To establish a system EFM
Page 7 of 1O
|'f th6 |*hllltrplnstB
crf lteulth
ffii&dt
Transfur of Centnl fup$y Roort to thc Ncw Bulldlng Materials Management
Section
ET
- 3prdanbg.r|Gtd phntobcfinalhcudthfnthcJarurary
- 1?9E tralniryl cornpbted br Xl18
AMS
- Totaloft$hospltdtralh€d
- DHooeconrmunfi u.rtrwchatbCsrlot
fFc
.2296 llAl rate
Overall complianco from 93.3 to 68,25 for ZOlE
stkk tnirry from 103 to ?1 inddent for 2018
T**
8AC
wf,h 37 faffsd bHs fior 2018 with tntefested bidders
fiff,ontetc t&tft
coordlnote *ith IHoMF to ghn access to rsgusiting units allowlng them to rae 8AC
status of tglr requast
Co$aboration wtth lltOMP to propose farthe proJect rnanagem*nt data ba.re Reseereh Conrnittee
jg tttg$Fq$g status of researches conducted.
Finance
' Top rnaintenrme snd opeftlting erp€naas ere medlcal dental and laboliEtory s{rpplb
- Wth 59( increa$e to elponsecfor Z01f
'- CaCrbanitbndg*lngto$sdmlg
- Additbnal.btd[Ft neqded for iob Ordcr payrolls to corrply with DSM-Csc Joint clrcstar
*ryln$faUnlt
Page 8 of 1O
ftre P
rnt ot
Contact Number
ecthre orStnhatirnal unfts rcportcd on Hentified non-confonr{tlcs and tssued tncklent Reports. There
' also lFsthat wcre bnrandcd b q$S end CARF mre lssucd ad rnonltored.
of the lsstsd frrrcctlvr Actlon Requc*l (CAlr| unrt rlnrdy clorcd. Ort of the 116 Clf,s that m still
r rnnltorlrg 11 nerepn r.ccently bsucd.
u obrcrvtd thtt tharG ls an incrsrsed nur&qr qf Con€cthrs Actlon Requeeta tCARsl in lanuary June and
tst 2018 $ncc mqlortty ofthc unttg rudfted h thc*r rnonths wem from ctnkaUservics.reai In additlon,
anu$r! 2m8, crftlcal rre*e rrerp rudtedrthose ulth hbh nurbq o{ CARIi hou€d ld ,,
2017.
.
- Forms and ro* In$ructionr ata the mo6t oorflnoolv crastad/rwtssd. Conunon isrs inchrde
rnatlort dls$rrnltradoo for submltted srd apprsrnd QtrlS docurnents
,light revlrlon on the QlrrlS Oigital Tracking System. Taryst depkryment dste is
n February20l9
tup.n se€ Admlni$trath,e OfRc€r of the Mabrtah Manlpnrnt gcctloo prescntd the top perbnning
ths bottotn perlormkrg atppllen bascd on the crlterla sct on the supplhr walrrtinn, Deinand Lgttars
r conelrtently bclilg $nt to xpplhn who f*llto perfurm thdr d*lhnry obl[atons.
raYfr, Ptppar pmloctlqil of ucaln of xpplb wcs cnmrmgpd to avold rs*or$ng to ahcrnatfrn rnethodr of
urcrrent and caur dcleyln thr prwlsbn of crpdle,
urAcroFEsouncE3
'calth odbctlons sre now conslst:tlt ard thc bryc awnqnt sf collcctiblcs prwburly de|r1pd ha now bagft
rurcd dotxn Confirruour Oout ndng nilnsrrq3 to lnlp the nntrlnabllfry of thc hrpftal operstlons *ilt
g done.
PorTrrnmEsFffmrnowmHT
:h unlt prcsentcd rtspccth,c inprorernent phns wldr spcctfic ectbn planr Thcsc lrrcMes the bsorring;
Pap 9 of10
+*
f,tcrrl ro-rrto ro aa : a5t aao't to ri lfD.l@'rt dch |,dv.Ph
Page 10 of 10