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1. Q0000000000000000000000000000000000000000000000000 DO 00000000000000000000000000000000000000 00 0 19850000 uua 13 00 0 Dugan DEEL 00 0000000 nne noon une ue nne ooo0 e une nonne oooomoe uuuun9 uuuununnun uumunune gt gt 0 0 0
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61. OOOOUOO00000000000000000000 Oooogac National Indicator Program ccreditation DO 000 UUDDUUDUDBDDUDUDIDDUUDBDBDDUDDUDULHL Quality Hospital Policy 0 0 000 99 UUIDDUDUDUDUGUDUUDUDDUDUDBDBDUDUGUDUDUDUDUDBUDUDUDUDUDUDUDUUDUUDuDLDL 000 0A0D 0 USA Sweden Malaysia Indonesia T hailand Japan Accreditation Accredit Med Audit 0 Accredit 0 Accredit Q AccreditQ Accredit CQI CQI CQI Yes No QA CQI Yes No Value Compass QA QI QC Circle No Yes TQM Yes Yes Yes TOMO 0 Yes Clinical Path Yes Yes TOM Yes No No Yes EBM Yes Yes TOM No No Yes No Yes No HTA Yes Yes Yes Yes No Yes Yes No ISO 9000 No Yes No Yes No No Yes No MB Award Yes Yes No No No No TQM Yes No Yes Yes No Yes No Yes No OOOO00000 OAG O 2005 TQM QCC EPQI KAIZEN OOOO EFOM CQI QA OOOOOO0 EBM 0000 Patient Safety 000000 Accreditation 000000 20050 JLI 1 1 1 1 1 1 TQM Oo L JL JL QCC
62. Li 0 Work Plan for 2040 000000000000000 No SRL OSDOO3I 0 00 0 0 0 Global Expected Result No 644 1 D 1 LU uu 0 0 0 0 0 0 OO000 107 251000 37 00 0 National Quality Assurance Program NQAP Main Objective Providing responsiveness health service to the people Objectives Introduce an institutional monitoring mechanism to Teaching Hospitals Provincial Hospitals and selected District hospitals Q Strengthen the middle level managers to develop managerial skills for the QA program Introduce Quality related data collection in T ertiary Care hospital eg Patients accidents and incidents Re admissions Complications management Customer care Human Resource Development Activities and Methodology Conduct workshop on developing Monitoring Mechanism in each institution Develop a core group at Quality Secretariat Quality management Units to function as facilitator G Developing education materia
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112. 15 Status of Sentrong Sigla Certification and PhilHealth Accreditation Programs for Rural Health Units and Health Centers HCs September 2005 Total Number of RHUs HCs 2835 Total Number of SS Certified RHUs HCs 1375 Total Number of Non SS Certified RHUs HCs 1 010 Total Number of PHIC Accredited RHUs HCs 841 SS Certified Facilities with PHIC Accreditation 660 SS Non certified F acilities with PHIC Accreditation 181 OO 0 DOH 2005 70 OU 0 0 0 UU DUU OU PHICO Benchboog 00000 0 5654 OU OOOOGOOOOOOOOOOOOOCOOCOOOOOOBOCOOCOOOOOOO OU DUUDDDDUDUDUDUDDUDUDUDBDDBDGUDUDUDUDUDUDUDUDUDUDUDUDBDU uDUL OU 0 8 0 0 0 OOOOGOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOO
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122. 8 00 0 Approach Classification Gontnuous Approach Project Program Approach 0 Tap E Down Conventional i Approach amp 7 Type Project qoem F Participatory Bottom 8 Un Planning Approach PRA PLA OOO LFAQ Logical Frame Approach PCM Project Cycle Management dt PlanDoSee PRA Participatory Rural Appraisal PLAQ Participatory Learning and Action uda UUUDUDUUDUUUDDDUDDUDDUDDUDDUDDUDUDUUDUDUUDUUUDUUDUUDUUDUUDUUUUDU Operation Research ORD 0 0 0 0 Root Cause Analysis RCA 111 01 0
123. Statistics Quality Control 596 6 Quality Contro UIDDDUDUDUDUDDUDDDUDUDBDDUDGUDUDDUDUDUDUDUDUDUDUDUDBDUUDUGuDUGUDUUDU OU UIDDUDDUDUDUDUDDBDUUDUDDUDUDDUDUDUDUDUDUDUDBUDDUUDUGUDUDUUUUDU DU OOO00TQCQ Total Quality Contro OOOOOOOOOOOOOOOOOOO OU OOOOOOOOOOOOCOOOOOOOOOOOOOCOOOOOOOOOOGO D OOOO D 0 D 0 OO 0 LU 0 OU oS eS 11111 mw 111 11111 1111 1 11 1111 1 11 1111 1 0 0 ITO Information a TechnologylOOOOOOOOOOOOOO I1 E40 Eg OOOOGOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOOOGA
124. eo ECHTE B OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOGO 5 10000 0800 0800008000000008005000000000000 9 OOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOCOOCOOOOOOOGO 0 0 um 69 DUUDDUDDUDUDUDUUDUDUDBDUDBDUUDGUDUDUDUDUDUDBUDDUUDUDUDUDUDBU uDULDLU DUUIDDDUDDUDUDUDUUDUDUDBDUDBDDUDUDUDUDUDUDUDUDUDDUDUDUDUDUDBBUuDULDLU OOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOOO 000l 42
125. 0 OOOOOOOOCOOOOOOOOOOOOOOOOOOOOOOG 0 9 0 0 5 1 E E 7 oO 1 0 1 DU Uu DU Uu 1 0 91 9 9 L3 Lr r L1 JJ 1 du Oo 5 1 Ez Tip ES ey ES Ez EE ESI ey SE l E ET E E L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Kotler 1998 p 4 22
126. 11 010900 0 0 0 0 O0 Bumble Adulate Hospital O TQM 70 Primary Care Unit UIUDUDUUDUUDUDUUDDUDUDUDDUDDDUDUDUDUDUDUUDUUUDUUUDUUDUUUDUU 0 0 0 0 800 0 000000700000000 99 1 111111 10100 0 Excellent Service Behavior ESBS B E D LU LU Hdd dE BEE Frontline 10 00 0 OU 20020 0 0 000 1111 1111 1111 111 111 11111111111 111 11111 111111111 11111 0 9 00
127. 111111 108 100 Human Resource Plang L EEELEEBE a DELETE DIEI EI EDIT ECCE ELE ELT EEET EEETBILBE DEL 9 0 0 OOOOOCOOCOOOOOOOOOOOOOBOOOOOOOOGO OU OU OU 1 1 1 0 0 20 O 180 0 0 20050 Center for Human Servicd 2001 USAID www qaproject org pubs PDF s zambbook2 1 pdf 109 3 Providing Quality Health Care in the Philippines Basis and Lessons Leizel P Lagrada 3 1 Introduction Quality in health care became a major focus in the health sector more than two decades ago and experts have struggled to define it in a concise generalizable and interpretable manner Different perspectives were considered from the providers of care to health care plans and i
128. 85 0 0 UDDDUDBDDUDUBDUDUDUBUDUDUTQM 45068 8 86 MT OM 8 86 anne ane 87 ease ees RE 89 93 TB illa A Uu ew 0 00 TS 97 98 ABT BHAA DBM MT UU wasa wa 103 0 Providing Quality Health Care in the Philippines Basis and Lessons Me P eee 110 O Quality Assurance and Clinical Governance in Bangladesh Hasan A minul 126 xl M LE 139 F733 Pe ij 1 ES Es 54 E ES EE LESE ESI EJ I E ES Es 5 4 I 0 0 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 0 0 0 0 0 0 O 0 0 0 0 0 0 0 0 0 0 10 0 12 0 13 BABB NOM T EMIT 6 A pbroach ClassifiCotierfiu Pre 8 11111 RE E EEN Oa ccc 9 Dom B l uuu a tance cadences Rodi a ru Se ERES ud Eus 12 EUR E E E GG ua aaa laqya com 13 EVE EE S ET eee eee Pe a a o eiae ca odd uide 14 EE ET BEL mo EN Es BN BN BE ee a D UAM ORUM EUE 16 EX Wh BEC BBE ED ED PPB D a al seva ieu vatum pta und e oce 19 pa DO ae ere ee 21 WE BNE SE RE RE ENE ENB EN ARE Bs ee 22 BB BABS SE DMO O BE a man boa rb
129. 0 0 0 0 0 0 000000 00260 0002006 0 111111111 11 1111111 a a 1 UUDDUDDUDGUDUDUUDUDDUDUDBDDUDUGUDUDUUGUDUGUuDUDUDUDUDUDUBUBDUDU uDnLDU 1111111111111111111 11 1111 11 1111111111111 11111 1 11111111111111111111 1111111 UBOTOUOOAOBOOOOOOAOOGUTOOOOEBDUUOUOTUEOLOUDED 83 E EJ iE 0 E Ji I ed E ed 121 OH SES E E N l 53 EE 11111 UU D Uu 00 OOOOOOOOOCOOCOOOOOOOOOOCOOCOOOOOOOOO 4 D D TOM n L1 0 0 00000000000 0 TOMO 0 0
130. 001500 2 361 OO EE D Uu cae 8 CAID 0 ooooooooooooooooooooooooooool
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132. EJ EJ Ed Ed Ed Ed 1988 gt Population OOOO E OLE E SEES sy 9 5 9 0 9 11 0 0 0 111111 11111 11111 111111111111 11111 1111111 111111111111111111111111 E E E 0 0 0 0 000000 1980 6 H KAIZENIIITI 000 19870 0000000000000 1990 0000000000000000 0001990 0 PAHOg wHO 0 Accreditationg 0 000000 0 Patol 1990 0
133. ELM Ey 2 SERT p Tl EE 2 2 1 EH E r py EET EXE FH E EST TESI E E DJ E E L E Ee p I p E pg E VET as Ez 1 11 L E 53 RE EIE EIE EE 5 1 E E 3 El 4 EJ 1 L1 1 L3 Ca Del 5 5 Ca 1 C ee 1 L3 E 3 s E L1 I E E EJ 1 Em E 1 L1 L1 Ed Oo Ez Ez 1 ETE TE ET
134. UUDDDDUUDDDBDUDUDDUDBDUDUGuDUDUUDUDBDUuDDUDBDUDUDUDUunUDULDLU 9 0 1 0 0 1 1000080 80 00 080 00 9009000000 10000000 00 0 00 00 00 Mutual Participation Model 0 0 L1 nu Clinical Indicatori I HN DL HD D D 00000000000000000 0000000000000000 9 Indicator I 0 1111010000 0 D 0 o L3 C3 C3 17 E 1 DUUDUutl 00000000000 000000000000000000 H H EOD 9111141111 1111111111 1191111
135. 1 0 8 0 80 00 00 009001000000 0 1 9 DU 6 00 10 mans me 5 zm GEN AVI LE Ques in taba EL 82 61 e psc X six iB CP rae TOM Bs LES SAME PIL 8 SM GF ABC 000 EBM Evidence Based 6086 000000000 cP Clinica Path DPC Diagnosis Procedure Combination DO SM Safety Management 00 000 BSC Balanced Score Card HOO TQM T otal Quality Management B S Balance Sheet OO LQ Profit and Loss Statement 0 C F Cash Flow Statement 0 000 ABC Actively based Costing A nalysi e co oao a oa aoa 30 TQ Oo oO 3 ts L dE it E Ey l EE Eas ee ee E
136. 1990 10 6 1 T E 31 OU OU OU OU 0 0 0 0 0 0 0 0 0 0 0 0 utt 1101111011 399811 Quality and 1 1 1 1 1111 11111 1 1011 Health Service Standard Constitutional Law OOD 000000001990 00000000000 Health System Research Institute HSRIQOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Q Public Sector Standard 44 EE 00 0 1985 1989 1990 1995 1998 1999 2000 2002 2003 2004 2005 2006 Health Service Provider A ct Standard for Medical Staff Minimum Requirement Improvement F rontling Environment Beginning TQM Health Service Stand
137. 8 11111111111111111111111 1111111111 11 1 1011011 111 1 11 1 110111111 DO0000CO0O0000O00000000000000000000000000000 000 0 11111111111111 11111111111111111111 111 11111 11 1 1 111111111 1 1 111 1 111 11 1 IEEE LEER DE 1 11 1111 1 1 1111111111 0 OO00000000000000000000000000000000000000000000000 1 1 1 1 1
138. E EF nm ET E EJ 0 0 0 0 E LT 1 E REGEL EE r3 E ppp E ESI Eu E TES CE 3D ESI TESTA EST ESI ESSE EET ESTER E TEST E E E E23 1 EST EI E 217221 2E EJ EJ CEST Ee E TERMS 3 EE EIE LESE EST p IH E E El 0 9 EE E E EGET RI SE ES FI EH ESTEE L E E EST ET E p SES p E El E E E r E UUDDUDUDDBDUDUDUDUDUDUDUDBDBDUDUDUDGUUDDBUDGUDUDUDUDUDUUDLUL LIE POCO DOO eo ODEO EV Ee Ey EZ 111 BERE BE BEI B EE DBUOBDBOBDUEH D dul 1 1000000000 P pap EISE 0 0 0 0 111111111111111 111 111 1 111 B 0 0 0 L1 L1 EJ L1 E Ez L1 L1 L1 L1 L1 L1 L1 L1 L1 Q O i 7 EO es Es E EST Ez LESE p L E EJ CEST E E l EI Fe ya E po E ES End L Ey E E ELE N
139. E EIE 6 EE Ey ESSE p s L1 r3 Ji E FE n 1 19807 0 D lU D UU UD EBM 121 0o edical Technology ssessment 0 0 0 E E 8oooc 5 1 5 ES L3 L3 1 C3 r3 J L1 r3 Fa E EJ 3 0 0 0 0 0 0 OU OU OU OU UU OU 0 DU Uu 0 Uu 0 DOG 0 OOO 0 Uu M 1 N ooog LJ oOo E3 ES inm L3 3 14 r3 H m EJ zg LE Go OHH Exp EST EIE es EJ Eel ee EJ E3 E3 ET co 000000000 000 0 2007 18
140. 130 4 Consumer Value Intent Clinical services will meet and manage consumer expectations and perception of value Elements of Performance Intent Process Consumer participation Ensure Involvement by Consumer A dvisory Council understanding A ccess equity needs and Patient charter input and institute change expectations roles and responsibilities Consumer advocates Consumer value Perception of value Patient performance reporting Patient satisfaction surveys Patient complaints Patient compliments Trained customer service staff Customer friendly culture Customer service feed back Staff recognition awards 4 2 3 Reporting Framework To ensure a framework of assurance and review is established accountability lines need to be developed within organizations and in alignment with Guiding Principles of Clinical Governance Processes for accountability need to be transparent and auditable and will include Roles and responsibilities need to be defined to ensure accountability Documentation at unit or department level of process measurement and agreed targets for the elements within each Performance Area Documentation of investigations reviews feed back and improvements at unit or departmental level Generation of report to organizational Clinical Governance or Quality Committee The report should contain evidence of measurement against targets for the elements within ea
141. Rg EDAD ADFT 47 00 0 HNQA Network Quality Management Training Program Periodic Quality Network Service Internal Specification Service Provision Standard a Basic skill review 00 0 HNQA Network Quality Standard Network Round Audit 48 nm UIDDUDUDUDBDDUDUDUDUDUDUDUDBDBDUDUDUDUDUDUDGuDUUDUDUDUDUDLDL UUDDUDDDUUDDDBDUDUDUDBUDUDUDUUUDUDUDUDDUDUDUGUDBDUDUDUDUuUD UUDUDUDUDUDBDDUDUDUDUDUDUDUDBDBDUDUDUUDUDDBUDGUDUDUDUDUDUDuUL 1100 0 0000000000 D 0 LD Clinical Pathway OOOO Patients Department of Medicine 1 11110010100000000000000
142. 6 0 OU nm OOOOOOOOOOOOOOOOOOOOOOOOOOOOCOOOOOOOOO 01 11 1011111 01 0111 0111 011110111109 1101091111101111111111 9111 111111 0 0 Quality Assurance and Policy Development Group QARPDCO 11111 1111111111 Uu 8 OU Uu OOOOOOOOGO 1 100100 OOOOOOOOOO 11 1000 8 8 0 000000 000000 63 110 01 90 0 0
143. ASEAN 8 0 00000 ASEAN Workshop 1995 D 00011001000 D 1999 00 QCC Workshop 000 00000000 01000000100 0000000 0000 n 90 u00 00000000000000 onp 7 000000000 199 000000000 are 000000000 00000000 0000000000 uality Improvement of District k Health Services 000000 000 00000 0000000000 1000000000 00000000000 au 000000000 uality Improvemen istri 0 D leno my Heath sevice 0000000 ood rly uality Improvemen istri Health Service 0000000 000 DngnnJCA DH 20000000100 Quality Improvement istrict Health Services 0000000 OOO oogggsica 0 Wor Current Initiatives on 20040 0 0 0 0 EPQI in Participants Countries Du 0000 UL L 18 Workshop on EPQI for Health 2008 Regional Workshop Evidence JICA SISCA 000000000 2004 0 0 28 based Participatory Quality 00000 MSPA 5 University 000 20000 m Improvement EPQI in UD 0003100000 Local Health Services 101 l Ej o o og oo ooo ao oo ono ooo ao oo A og oo ooo ao oo ono AA ooo ao oO
144. C3 T E3 7 051 87 1 5 E l J 3 r 4 34 4 0 4 4 54 1 4 p g 2 52 EJ O Ed Ed Ed Ed Ld Ed Ed Ed Ed Ed EJ H L3 F3 E3 O 1 1 3 E qq L3 p 2 oog EST ESI 11 ea E as oo oo oo og oo EXE 23 5 On On Ono On og og On og On On Om On Oa Oa On On ag ag ag ag og og Og og Og Og Oy 1 Oy OQ OD OD 79 PCAHOQ 1999 0 5 OOO OOO WS PS 1111 1111 1 1 11 1 5 1 0
145. D Pel ZP E ETT E l 51 0 E E ees SE GOES 0 0 0000 6 Heath Center 0 0 0 BEBE Oe Oo ELE eo 1181810818 111111 1 0 800008 000008 0000 8 0 0000000 0 EFETEE EE HE EE EFE EEEE EE EE GE ET EE EE BOE 74 L3 L3 Lr r3 r3 oo OO L3 r3 Lr r3 D Uu 0 0 OOUUU D uuu nm D Uu tu DU uuu U
146. 0 19920 OOOOGOOOOOOOOOOOOOCOOCOOOOOOOCOOOOOOOOG OOOOGOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 0 Autonomous OOOOOOOOOOOOOOOOOOOOOOOOOOOO 10 1900 OOOOGOOOOOOOOOOOOOOOOCOOOOOOBOCOOOOOOOOO 00000000 Quality DUDUDDUDDUDDDBDUDUDDUUDUGUDUUDUUDGuUDUDBDGDUDUDUDBDUDUDUDUDUUUUDU 0 55 r3 rH g E LE E EI TMO Chec ETE EISE oo
147. ATCA X ER EJS BDP B su URBS 2 2 427 0 68 TQM Fz c kK 5 8 381 5 AORN TT HH SO 88 83880 0 5 03 SG e jica eA moh MERISSA SNEH 185 6 8 8 RT fT A BE Js JR E 1 2 2 5 OT 5 FH 05 21 AR ALES SEE ISBN4 902715 79 1 O0170 0 1 11 1 11 1 111 1 HOU Hu LU D 180 61 1111111111 11 1 1 Uu URL http wwwjicagojp 1 5 8433 162 FAX 03 3269 2185 E mail iictae jica gojp
148. E I E EJ Er E t E E EE HESS EET p eas ES ET E EI sLDA OOOOOOOOOOOOOCOOOOOOOCOOOOOOOOOOOGO 9 1101111011 LEER BE 01111111111111 0111111141 11111 111 0 0 0 0 1111 11 1111 11 gg DE EIL 8 0 0 0 0 Oo udgggudgtdzttdzatutitt Asian Productivity Organization APO 0 FF ET EJ ESTE E 0 0 0 0 0 Ea OOOOOOOOOOOOOOOOOOOOOOOCOOOOOOOOOO E EJ p4 1 2 p4 FJ F3 F3 FH F3 O EJ 00000 TQM 0 0 90 0
149. ESI EH ESSE 1 1 pp EST ES ES SEI EET E EST EZ ET L3 1 21 EH EH E IE ES EE Loa Ek TEES AEST p CEST ESI ESE 6 1 E 1 1 1 SS NS Ese eer ESI Sey oo oO 38980 Uu 111111111001 0101111191411 111111 1 014101 gd 0111 Ugg OOOOGOOOOOOOOOOOOOCOOCOOOOOBOCOOOOOOOOO TOMOO0000000000000000000000000000000000 OU OU OU OU OU OU OU OU OU 51 E EE SE EI 0 0 0 0 0 0 0 0 FJ Ja p EZ TET EE EI EJ ips 53 pz E EST as E a EJ EST pu E SESS E En u ES Fri E El Es og mesa se DN rs rea Ei E EET asa rs EE EI rss es E aan Ende es ESTE E DESEE IE 1 1 1 0000 oo0000007 0000000 O0 1 noo
150. 0 E 3 11 4 HO 9 3 1 4 E EIE ES EJ SESS E 3 ET ei 5 D uu OOO Uu Uu J g 4o 1 19950 6 0 90000000000000 8 0 n nm 34 34 1 LE ASEAN Workshop Seminar on Quality Management of Health Services J an donesia 3 E LE E Bt L1 5 1 Ul r3 1 1 EJ 1 HO i EJ m nm 98 UUIDDUDDUDUDUDUUDUDDUDUDBDBDUDUUDUDUDUDUDUUDUDUDUDUDUDUUDUUDuDLDLU GG ww eg 110 1 00000000000000000 0000
151. 000 0 x 000000 Evidence DOOOOOD00 0000000000 33 0000000000088 00008000880080888088 Ou 0000000 000000 909000000088888888 00000000808000000003 unnuuu 000000000000000000 000000000008 00008 00 00000000 19 0 000000000000000080000000 00 0000000 1 0 oO00 O OOCOOO O COCOOCOOCO O OOOO OC OOOOO0OC000 24000000000 DUUIDDUDDDUDUDBDDBDUGUDDBDDBDUGUDUDDUDUDUDUDUDDUUDDUDBDUUDUuDUUDUUUDU OOO 00000000 200300000000000 00g 2000000000000000 OOOOOOOOOCOOCOOOOOOOCOOOOOOOOOOOOOOOOOOOOA OOOOGOOOOOOOOOOOOOOGO ooozomoolooooolooolooooooooooolcooooooooooag OOOOOOOOOCOOOOOOOOOOCOOOOOOOOOOCOOOOOOOOOO
152. 6 L9 00 14 Summary of the Different Institutions Organizations that Contribute to the Quality Improvement Efforts in the Philippines training and TA DOH BHFS PHIC SSM PHASE 2 DOH NCHFD PSQua PCAHO T ype of quality Licensing A ccreditation Certification Accreditation assurance Some accreditation Certification improvement instrument Nature of quality Mandatory Voluntary Voluntary Voluntary Voluntary Voluntary assurance improvement program Legal policy Basis RA 4226 RA 9165 RA 7875 AO 17 B s2003 AO 17260 3 Authorization most recent AO 0029 s2005 from DOH amendment Purpose of QA QI Ensure safety Participation to NHIP Prerequisite for PHIC Quality Quality Requirement instrument Permit to operate Quality improvement accreditation Improvement Improvement for DOH Quality improvement Quality Improvement accreditation Quality improvement Target facilities Licensing Hospitals and other health Hospitals out patient Rural health units DOH hospitals Tertiary Confirmatory facilities excluding medical and dental clinics including hospitals drug testing clinics rural health units and Barangay ambulatory surgical laboratories Health Stations clinic dialysis clinic OFW and Accreditation drug testing laboratory maternity clinic anti Seafarer confirmatory drug testing laboratory T B DOT S centers medical hospitals conducting kidney rural health units clinics transp
153. Certification Figure A3 1 shows the Quality Framework under the QIHP Also in 2001 the DOH through the National Center for Health Facilities Development formulated the Department Order numbers 310 J s 2001 and 172 C s2003 which provided for the creation of the DOH Steering Committee and Technical Working Group for the establishment of CQI Program for health regulation cluster and DOH hospitals The intent of these department orders was to promote continuous improvement on the quality of health care provided by the DOH hospitals Figure A3 2 shows the chronological development of policies and establishment of programs and PCAHO 2005 DOH 2003a 113 Figure A3 1 Quality Framework of Quality in Health Program RESEARCH and TRAINING Hospitals Laboratories Outpatie Suppliers Traditional and Clinics to Healers amp Diagnostic Clinics Providers Other Professional JL 41 Providers Licensing to ensure basic safety Accreditation to stimulate continuous quality improvement Initial Phase Externally enforced regulations and standards with periodic evaluation of compliance Later Phases self regulation and self determination
154. EPQI KAIZEN OOOO EFQM CQI QA 000 EBM 0000 0000 Patient Safety 0000000000 0 2031 TI 100 OOOO LLL 1 1 1 1 1 Inter American Development 00000000000000000808000000000000000008 6 8 EPQI 19960 19950 111111 11 11 111 111111 01 1 0 1 1 11 1 1111111111 11 11 11 11 1 1 11 111 111 1111 111 1 1 1 1 11 1 11 1 111111 111 1 0 01 1 1 11 1 1 000003 UH NO 000 0 DOOD U
155. ETE Eg Ea os ET EJ 1 EJ DG ET E GL 0 0 0 0 s lt ti Disciplinaryg ODO OOO Ee EE SE EE Er E E L1 L1 0 0 0 0 0 0 0 0 0 0 E ES E pr E ESSE L1 L1 El L1 L1 L1 LE D 5 1 5 1 4 21 E E OO000000000000000000 8 OOOOOOOOOOOOOOOOOOOOCOOOOOOOOBOCOOOOOOOOOOGO OOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOOOOGA 2051 2004 D T 0 0 D Routine to Research OOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOCOOOOOOOOOO
156. Health and Population Sector Programme HPSP 19982003 0 0 0 0 QAP UUDUUDUDDUUDUUDBDUDUDUuDHUDDUDQuaity Assurance Cell 6 OOOO000 Health Nutrition and Population Sector Programme HNPSP 20032003 O2000000 UUUUDDDUDUUDUDUDUDUUDUDUUDUDUDUDDUDUDUDUDUUDUUUDUDUDUDUUDUDUDUDUUDUDBU 1 1 20050 0 00000000000 Project Appraisal Document PADD 0000000000
157. UUIDDUDDUDUDUDUUDUDDUDUDBDBDUDUGUDUDUDUDUDUDUDUDUDUDUDUDUDUDUUDuDLDLU hoQ 1111 1111 111 1111 1111 11 1 11 11111111 1 1111101111111111 111111 111 1 1 1111 1111111111 a BL 106 0 0 0 0 0 0s00000 Quality Assurance 111111 0 0 0 UOOOOOOOOOOOOOOOOOOOCOOOOOOOOOCOOOOOOOOOOOOOO UUIDDUDDUDUDUDBDUDDUDUGUDBDDUDUDUUDDBDUDUDUUDUUUDUDUUJIJDDUDUDDUDUL 0 0 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOGA D uu 0 0 DD OOOOOCOOOOOOCOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
158. ooo 3 E 12 00 0 00000000N C me D C EREMO m 8 18 GR T3111 oooo0e OOO00 poooo00e 6 00000 000 C 098 ATAT uuu 03000000 UIDUDDUDDUDUDUDDDUDUDGUUDDUUDUUDGUUDDUUUDUUuDUDUuD uDuBnunuu UIDDDUDDUDUDUDDUDUDDDUDUDGUUDUDUUUDUuDUDBDUDUUUDUDUDUDUUDUUDDUUDUuD 0 00 O4000000000000000
159. p ESSE U Uu Iz 145101 E E p 0 0 OU OU E E hg E EE Te SEE s ESSI 0 0 0 FR E Anuwat 00 OGOOOOOOOOOOOOOOCOOCOOOOOOOOOOOGO 0 0 0 0 0 0 OOOO DU utu OOOO OU 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1110001000 Improvement Organization 0000 1100 UU rem 1 9 oriented 1 10000000900
160. policy job expectations Performance management Competency assessment Clinical supervision Peer review College alignment Research and Professional Ensure Teaching development professional and Education ongoing learning Education and guidelines for new procedures and techniques Research applications ethics committee Professional management Ensure Professional practice growth professional Staff satisfaction satisfaction Staff retention Professional satisfaction Development and education Safe staff ratio and skill mix Ongoing learning 3 Clinical Risk Management Intent To minimize risk and identify improvement opportunities through measurement and review to ensure safety Elements of Performance Intent Process Adverse events Measure incidents Incident monitoring Examples drug error patient incidents falls IV and pressure ulcer surveys Hospital acquired infection monitoring Audit reporting Self reporting Risk profile Monitoring trends Audit for potential risks Review Clinical decision support tools automatic flagging of high risk interventions O H and S Medicolegal FOI Coronial enquiries Autopsy results Staff orientation Clinical audit Pressure ulcer surgical Ongoing education dentify high risk patients Patient clinical risk profile Consumer monitoring own care Matching clinical responsibility with clinical ability
161. standards remain on contractual or consultant position while those who are permanent employees of PHIC still require capacity building both on quality tools and processes and on social marketing of the quality assurance program Moreover PHIC sees a need for a training institution that will provide training on quality to their accredited facilities The DOH on the other hand needs to mobilize and orient its representatives to the local government health boards in order to provide assistance to LGUs in implementing the quality improvement program at the primary health care facilities Harmonization of quality policies and processes The respondents noted that one of the strengths of the quality improvement programs in the Philippines is the formulation of appropriate policies However harmonization between licensing and accreditation must be done and streamlining of these processes must be achieved For example the content of the accreditation policy of PHIC must not conflict with the licensing policies of DOH Moreover the certification awarded by SS and PCAHO must complement and not duplicate the one given by PHIC At present DOH and PHIC have separate standards for RHU HCs and bother these institutions issue certification and accreditation separately At Table A3 3 shows the discrepancy between SS certified and PHIC accredited health centers PHIC Circular number 30 series of 2001 however identifies SS certification as a requirement for PHIC accredit
162. 0 0 0 0 0 808 ooooooomocooooolooolcooooooolooooocooooooonl oMOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 0 6 Black Green BatOOOOOOOOOOOOOOOOOOOOOOOO 0 8 0 0 0 Betti 000000000 000 0 80000 0000 0000000000000 0 0
163. 0000 8 10 0000800008 0008 080 0 0000 0000000000 00 0000000000 MAIDO 31 MQII I LI 1111111111 1111111111111411 11111111 1 0 11 1000 8 0 0 0 1987 1 1901000100 19910 Bie BE 011141 8111111111 8 11 111 111 1141 oO OU OU OU oes E ES L3 00000 00 00 00000 D 00000 000 301 0 0 D DU n 000 L 0 321 0 000 D 001300 D DU 1400 00
164. 1 1 Quality Secretariat 1111111 1 1 O 2005 2010 IDA WB Health Services Project 2005 2010 Sri Lanka Health Sector Development Project 4 0 Subcomponent 2 4 Improving Hospital Efficiency amp Quality 11 1 1 Output product 4 1 CQI amp TQM Initiation in Hospital in Uva amp Southern Provinces in Sri Lanka T 60009 000 80000 Quality Secretariat QQ 73600 0 J O 203700000000 200 0 000 2521 0000 Quality Secretaria O0 00000000 caig Quality Secretariat
165. 1 D 1910 0 0 0 OOOOOOOOOCOOOOOOOOOOCOOOOOOOOOOCOOOOOOOGO OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOGO UU Ms caondOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO ME E73 EE 0 0 Dr Mercado OO SSMI b Dr Dayrit 0 0 0 OO 0 Quirino Memorial Medical Center QM MC I Dr Arandiaq C D 69 PSQuag PCAHOD 1 D Dr Marambal OOOO Oo ERE Oo Co L1 nm BenchboogOOOOOOOOOOOOOOOOOOOOO 6 0 5 0 0 584 13710 4541 660 sMOOOOOOOOOOOOOOO
166. 111 111 00 0 0000 00000000 00000 0000000 00000000 0 0000000 00 1 0 0 5 00000 D OOO000d000g 00000 00000000 00000 UD 19921 OOOO 0 1997 00000 000000 000 0 300 HNQA J 0000000000000 00 00000 USAIDO 0000000 00000 00000000 00 111 1 1 0 1 00000 00000 OOOO 77 6 1 11 111 11 111 1 111 1111111 111 1 11111111011111111111111 111 111111 1 0 00 00 0 19901 1 1 10 1 0 00000000900000000039 001 00 0
167. Considering that they have similar constraints in providing quality health care experiences and innovations when shared prove to be an invaluable resource for them Thus it is important to document the experience of each country in designing and implementing its own quality improvement program Traditionally the quality of heath services in the Philippines is ensured through the licensing procedures both for the providers and the facilities However the requirements are often input based and they lack the process and outcome dimensions of quality In the last few years however ensuring quality health services had gone beyond the regulatory arena Like other developing countries the Philippine journey pursuing quality in health services is characterized by challenges and lessons that are worth sharing This study describes the development of the quality improvement program for the health sector in the Philippines including identifying the event that triggered its development identifies the factors that affect the successful implementation of the Philippine quality improvement program for health highlights the Blumenthal 1996 Brown et al Reerink et al 1996 Berwick 2004 PHIC 20043 110 quality improvement program implemented in one public hospital and enumerates the lessons from implementing quality improvement in the Philippines 1 Methodology Information and data were gathered from the following so
168. Global Review WHO Geneva 2005 Strengthening Management in Low Income Countries WHO Health Evidence Network T 2003 What are the Best Strategies for Ensuring Quality in Hospitals WHO Europe WHO ILO 1998 Guidance on Regulatory Assessment of HA CCP WHO Geneva TOME Weg 20050 00000000000000 D TOM I 0000000 C www ndpjapan org 0 http www useor p prize iryou_1html OQ www tqm health gr jp 29081 r0 UU D http www dh gov uk PolicyA ndGuidance HealthA ndSocialCareT opics ClinicalGovernan ce fs en http7 www jqac cony www pfizer zaidan j p fo business pdf forum 6 fo06 148 pdf OOOO 206228 unaixin 000 Bl D Clinical GovernancdTTI 20081 000000 medwave2nikkeibp coj p wcs leaf CI D onair medwave mdps 423367 dgudttnwww nerima hosp or j p Duae Wikipedian 0 TOGM D 20081 0000000 90 http7 ja wikipedia org wiki T QM Business e Coach by 1000ventures com and T en3 Logo http7 www 1000venture
169. L Morrell C and Scrivener RI 2003 Clinical Governance an RCN Resource Guide Royal College of Nurse U K http www rcn org uk publications pdf ClinicalGovernance2003 pdf 89 Department of Health DOH T 2005 Sentrong Sigla Program Updates Bureau of Local Health Development A ugust 2005 unpublished Philippine Hary M 2000 Six Sigma 1 dn t 2000000000 Kaplan R and Norton 31 2001 The Strategy Focused Organization Harvard Business School Press 0 0 01110 Kotler P 1996 Marketing Management 7th edition 9600000000 Link N and Scott J 1 2001 Economic Evaluation of the Baldrige National Quality Programi Planning Report 01 3 NIST Quirino Memorial Medical Center QMMC T 2004 Annual Accomplishment Report 2004 O unpublished Philippine Relman S 1988 000000000000 Starey N 20030 What is clinical governance Evidence based medicine V ol 1 No 12 Hayward Medical Communications WHO 2002 A Framework to Assist Countries in the Development and Strengthening of National and District Health Plans and Programs in Reproductive Health Suggestion for Program Manager WHO Geneva 2003 Quality and Accreditation in Health Care Services a
170. its risks The degree of quality is therefore the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits Avedis Donabedian 1982 The most comprehensive and perhaps the simplest definition of quality is that used by advocates of total quality management W Edwards Deming 1982 Doing the right thing right right away Experts generally recognize several distinct dimensions of quality that vary in importance depending on the context in which a QA effort takes place The following nine dimensions of quality have been developed from the technical literature on quality and synthesize ideas from various QA experts Together they provide a useful framework that helps health teams to define analyze and measure the extent to which they are meeting program standards for clinical care and for management services that support service delivery While all of these dimensions are relevant to developing country settings not all nine deserve equal weight in every program Each should be defined according to the local context and specific programs Technical performance The degree to which the tasks carried out by health workers and facilities meet expectations of technical quality 1 6 adhere to standards Access to services The degree to which healthcare services are unrestricted by geographic economic social organizational or linguistic barriers Effectiveness of care The degree to which desir
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172. mechanism for driving the QA process and at least some of the team members should have managerial responsibility to take decisions that can directly influence service quality However for long term sustainability QA must be integrated into the existing roles and responsibilities of all staff QA must be driven from both the bottom and top of the health system if it is become an integral part of the health delivery system Resource people are required at national regional and district level to support the QA process External technical assistance can act as a catalyst for getting things started especially if there is limited country expertise The role of National level is to advocate the importance of quality improvements strategies and facilitate them locally by providing resources co ordinating training co ordinating standards of care A national QA committee would be an appropriate body to have this responsibility The committee could also support district development by requiring quality of care to be included in the training curriculum of all health service workers so that a culture of quality is fostered in the health service community both public and private At Regional level a quality strategy group should monitor quality and provide supportive supervision to districts A regional training programme should reflect the national strategy with quality indicators and standards based on regional priorities At District level a
173. quality steering team should support facility level quality improvements To support consistent goals for quality across the district this quality steering team should facilitate effective communications between primary and secondary level facilities At Facility level an interdisciplinary QA team should be responsible for continuously monitoring assessing and improving quality Each facility should have targets for its services in line with regional standards Teams should be able to re allocate resources according to priorities and planned interventions 135 Chapter 2 Clinical Governance Introduction Clinical Governance is a systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes Guiding Principles Clinical Governance has been adopted to assure delivery of optimal patient outcomes Principles encompassing fundamental values have been developed to guide and direct the adoption of Clinical Governance A unified response to these principles are demonstrated through improved performance Patient Outcome based Clinical Leadership and Involvement Information and Data Based Sustainable System wide Approach Learning Culture Partnerships Patient Outcome Based Patient consumer outcomes need to be the primary focus in health service delivery decision making Ensure patient rights are valued
174. showed that the factors that promote the development of the quality improvement efforts ranged from the effects of devolution to felt need by health care professionals for quality improvement program and mandate provided by specific legislation Review of documents revealed that there was one accreditation policy that was formulated as a result of adverse medical event The following are the identified triggers for the development of quality improvement programs and other initiatives in the Philippines Devolution The devolution of health services to the LGUs in 1992 was one of the identified trigger factors for the development of quality improvement program particularly for primary health facilities Several studies report that after the health services were transferred to LGUs there was disintegration of preventive and curative health services thereby disrupting the referral chain Moreover the quality of health services deteriorated because of under funding of health programs particularly preventive care low morale of health workers chronic lack of equipment and low quality and unsteady supply of drugs at the local level This was the situation of the public health sector when the DOH sought technical assistance from the USAID to develop the QAP which later became known as SSM Sentrong Sigla became the main quality improvement program that outlined the requirements that will ensure the quality of health services provided by the local health fac
175. the majority of 150 medical clinics that examine Overseas Filipino Workers OFW as mandated by the DOH In addition the DOH also authorized PCAHO to certify the QSS of the Confirmatory Drug Testing PHIC PHIC 2004a PSQua 2004 Interview with Dr Beauty palong Palong 112 Table A3 1 Sentrong Sigla Certified Facilities 1999 2004 F acility T otal Number T otal Certified Accomplishment Rural Health Units Health Centers 2 385 1375 58 Barangay Health Stations 13 540 390 3 Devolved Hospitals 631 97 15 Source DOH 2005 Laboratories before the renewal of their accreditation In addition this organization also audited and evaluated 135 medical clinics but only certified 130 of those audited conducted training of Quality Management Representatives QMRs clinic administrators and other clinic staff and provide educational assistance to medical clinics In the same year the DOH also formulated the 5 year strategic plan on Quality Assurance Program QAP with the assistance from the Unite States Agency for International Development USAID In 1999 this program was renamed and became popularly known as Sentrong Sigla Centers of Vitality Movement SSM Its goal was to establish partnership between the DOH and the Local Government Units LGUs in providing quality health services The objectives of this program were to i institutionalize QAP through capacity building ii establish mech
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179. 000000 0 TOM 0 0 0 0 000000000 TOM 9 OOOO OOOOOOOOOOOOOOOOOOOOCOOOOOOOOOOCOOOOOOOOOOGO 20050 00000 000000000 0000198000000000 QC 9 p 1990000000 gt Starey 2003 p 1 gt www ndpjapan org newshtm 101010 DD 28 E E T F pJ EZT ET E E L EST E EF 21 E 7 7 FEES L1 ELE L E E E p Ek EST EST GOES EJ EST EZE TT E E ET ETT EST S EET ESI ESAE ES EST TT Ea UE es mT dq m
180. 000000000 1300 D U C C U D Quality Management Representative 1998 0000000000000 United States Agency for International Development USAIDDOOUOOO00000000000000 Quality Assurance Program QAP OOO lUUDUDUUUHn199JJJ DU DUUDUDBUDUDBUUDDUDUUUDUu DnHunu amp ahrl lSsSentrong Sigla Movement SSMOOOOOOOOOOOOOOOOOSSMOOOOOOOOOOOOOOOO 1 100 0 1 Information Education and Communication IEC D B HL B 1 HE U 0o OOU0000000000000 DUUDUDUDUDUDUDUDUDUUDUUuDDUDUDUDUGDUDUDGUDUUUDUGuDDUUUDUDUDUumD Oo og Lac oog Oc Lar oag Oo oog Oo og oag oog 11 Oo Oo oog GII oog oag o og oog oon now ooo ooo ooo ooo ooo EB GEE ooo oog oog oog oog Oon Ooo ogag oo ogag ogag ogag oo E13 64 33 Sentrong Sigla Certified Facilities 1999 2004 Facility Total Number T otal Certified 96 A c
181. 002 2004 essen 71 ra hri a Ra uuu tg siu deme cic Er fada eines 77 MA uuu uu 1 100 DAD 100 OHAD O gt 101 1 cd E D D 01 1111 11 ED RR EE A E Era nena pets 102 Table 0 Sentrong Sigla Certified Facilities 19992004 __ 113 Table A 0 Summary of the Different nstitutions Organizations that Contribute to the Quality Improvement Efforts in the Philippines 115 Table Status of Sentrong Sigla Certification and PhilHealth Accreditation Programs for Rural Health Units and Health Centers September 2005 120 Table Hospital Bill Collection 2002 2004 __ 122 Annex List of Respondents for the Key Informant Interview 125 21 gt 4 TME ED EDS EE SBE ED ED ED e hue uu uuu 9 ES RR T TR ERE D M RR I RD 10 Box AQ Quality Improvement Program in a Public Hospital 117 Box AQ Some Technical Assistance to Improve Quality of Care from External SoUrceS e nemen senem 993 94 9 939999949994949 9 119
182. 1 1 0 A a OU Japan International Cooperation Agency JICA D D Quality Management TOMO O0 0 0 0 0 0 0 E E c3 OU OU OOUUU OU OU 0 r3 r3 r3 r3 r3 r3 r3 r3 O 5 Ooo m 1 2 2 cH 2 cH 2 2
183. 10110111111 1111010 110111111111110111 OU OOOOGOOOOOOOOOOOOOCOOCOOOOOOOCOOOOOOOOG 0 0 1 010000000000000 0 0 000000090 8 11 1 1 000000 O Sarabun Regional Hospital TOM 0 0 nm HE ey E E ES E oO p ERU EET EST SESS Ea E DES EST EST SES I ESI E DEST ESI U L UU D U OU D U LU LU 199 DOO Regional Hospital B 1 1 General Hospital
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185. 111111 111111 111 1 11111 111111111111 11111 1 0 DU 1111111111111111111 111111111111111 111110 9 2 30 Opportunity QOOQ0000000000000000000000 Medium Term Expenditure Framework 4 1 111111 1 1 OA 10 00000 HIPC Completion Point 0 0 20 Q00000000000000000000 Lu HIPC Completion Point HD H BHL HD HH BH HH HH D Poverty Reduction Strategy Paper PRSPO 0000000 National Development Plang
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189. 9 Source the A uthor Figure A3 2 Chronological Development of Quality Improvement Efforts in the Philippines Non Govemment Organization PCAHO QAP SSM QIHP RA7875 Benchbook Standards RA 4226 Hospital Licensure Act RA 9165 DOH AOs on Health facility 1965 1975 1985 1995 2005 Licensing PCAHO Philippine Council on Accreditation of Health Care Organizations PSQua Philippine Society for Quality in Health Care Inc CQI Continuous Quality Improvement Quality Assurance Program QAP 1998 Sentrong Sigla Movement SSM 1999 Quality in Health Program QIHP 2003 Republic Act 7875 National Health Insurance Law as amended Republic Act 9165 Dangerous Drugs Act of 2002 Different Administrative Orders include AO 147 s2004 amended by AO 0029 s 2005 Source the A uthor 114 STI Table A3 2 Summary of the Different Institutions Organizations that Contribute to the Quality Improvement Efforts in the Philippines DOH BHFS PHIC SSM PHASE 2 DOH NCHFD PSQua PCAHO T ype of quality Licensing A ccreditation Certification Accreditation assurance Some accreditation Certification improvement instrument Nature of quality Mandatory Voluntary Voluntary Voluntary Voluntary Voluntary assurance improvement program Legal policy Basis RA 4226 RA 9165 RA 7875 AO 17 B s2003 AO 17260 3 Authorization most r
190. Audit HPSP Health and Population Sector Programme HSRI Health System Research Institut 00000000000 ICC Infection Control Committee B 0000000000 IMCI Integrated Management of Childhood Illness DO 1 IP In patient Department 0 ISO International Organization for Standardization OO J CAHO Joint Commission on Accreditation of Healthcare Organizations J 00000000000000 LFA Logical Frame Approach O0 0000000000000 LGUs Local Government Units D L H 0 H1 B D D DDD MOHFW Ministry of Health and Family Welfare 000000000000000 MQI Medical Quality Improvement DO MTEF Medium Term Expenditure Framework d B B B BH B DDD NDP National Demonstration Project NDP National Development Plang OO NGO Non Governmental Organization 00 0 NHSO National Health Security 066 OO 000000000 NIPH National Institute of Public Healtn ED E E D NQAP National Quality Assurance OFW Overseas Filipino Workers DOOHOOOOO00MO0000000000000000000 OJT On the J ob Training OP D Outpatient Department 0 J
191. D 0 0 0 0 0 0 EST Er OH E E O O C E dq dq t3 E 3 E E Ee E EJ Lr 3 5 1 0 1 1 oe m OOOOGOOOOOOOOOOOOOCOOCOOOOOOOCOOOOOOOOO 2002 00 JI 1 11 0 1 1 00 001 01 101 10 011111111111 0 00 009 00008 OOO nm 0 0 0 0 0 0 0 gt E E Ir ETE EJ E E J EJ 13 43 Es ET E L3 EE p EF A O GAGA S90 OO O o 30 00 OOOOOCOOOOOOOOOOOOOOOOBOCOOOOOOGO 19980
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195. Program NQAP This program is applicable to all accredited providers of PHIC for the delivery of health services The main focus of this quality assurance program is to establish a monitoring system that will safeguard against over and under utilization of services unnecessary diagnostic and therapeutic interventions irrational drug use inappropriate referral practices gross unjustified deviation from current practice guidelines and treatment protocols and use of fake adulterated or unregistered drugs In order to ensure these safeguards the NQAP has the following features utilization review of the claims filed with PHIC implementing the Rational Drug Use Program adopting the Drug Price Reference Index as the basis for reimbursing drugs and medicines updating of the Relative Value Scale for reimbursements and Philippine National Drug Formulary and setting the standards for accreditation of health care organizations through the Benchbook on Quality Assurance 3 4 Factors that Promote the Implementation of Quality Improvement Programs At present the quality assurance improvement programs and initiatives were at various stages of implementation Respondents identified several factors that promote the implementation and sustainability of these quality initiatives Leadership Respondents to the interview identified strong leadership as a significant factor in the implementation and institutionalization of various quality assurance and imp
196. Regulations Governing the Accreditation of Hospitals Engaged in the Conduct of Kidney Transplantation DOH Administrative Order 81s 2003 Manila Philippines 2005 Sentrong Sigla Program Updates Bureau of Local Health Development August 2005 unpublished Lakshminarayanan R 2003 Decentralization and its Implications for Reproductive Health The Philippines Experience Reproductive Health Matters 2003 11 21 96 107 Lamberte E E 2003 Sentrong Sigla A Formative Assessment and Program Implementation Review 4 Health Research for Action National Forum Health Policy Development and Planning Bureau Department of Health Manila Philippines Lieberman S S Capuno J J and Van Minh H 2005 Deventralizing Health Lessons from Indonesia the Philippines and Vietnam In The World Bank East Asia Decentralizes Making Local Government Work pp 155 178 Philippine Council on Accreditation of Healthcare Organizations PCAHO 2005 Journey to Quality in Health Care through Certification Accreditation 1 Annual Convention Manual Manila Philippines Philippine Health Insurance Corporation PHIC 2003 Promoting Quality health Care in the Philippines Paper presented to the 12 ASEAN Social Security Association Board Meeting Brunei 2004a Benchbook on Performance Improvement of Health Services Pasig City Philippines 2004b Implementing Rules and Regulations of Republic Act 7875 as amended Pa
197. Tal Tel HAB Ea O E Bee 0 0 le ess om Bre el 1 SS SS SS ISIS ISIS SS SSeS E Soe E3 E E resi 1 es E Ea Tear ear rear A E71 0O E23 L3 I I 5 Sy Ezu Ej iE 16 es sg 2 GEES SE den e fe31 5s es A E B E E ED ogg ED ogo erformance Drivers PDO PI D lt ak BIER REID BEB cna 81 2 Cy E ook i i8 za nmm 70 65086 2 ams cm REDHA E nu E 0 0 0 6 O lt mmm mm r3
198. al 1 11000 00 00 0 0 Excellent Center 11006 1 Teaching Hospital o0 000000000000000 Dr 8 OO 19900000000000 7000000 000000000000 00 300000 0 00000 2000 0 00000000000 40000 0000 20040 1 0 52 p 0 381 1 27 E a Gal EE P E EE 8 Epi Ell LI ESTERI F Es FE EIE m nm nm D D ET E WF ES National Health Security Office Coverage Po
199. al Director Quirino Memorial M edical Center Dr Angeles de Leon Chief of Clinics Quirino M emorial M edical Center 125 4 Quality Assurance and Clinical Governance in Bangladesh Hasan Aminul 4 1 Quality Assurance Programme 1 Background Quality Assurance Programme had been taken as a support service to improve health care quality under the leadership of separate line director in Directorate General of Health Services Quality of Health care is of great concern to Ministry of Health and Family Welfare MOHFW for its commitment to maintain quality in all level of services In HPSP Health and Population Sector Programme 1998 2003 period it had been working under the leadership of Director General of Health Services forming a cell named Quality Assurance Cell QAC which were looking after the quality aspect of Health care services at all level Public Private NGO In HNPSP Health Nutrition and Population Sector Programme ongoing programme document it is proposed that the Quality Assurance Programme will continue the activities under a full time line director for the period 2003 2010 2 The intended activities for the quality assurance programme during HPSP were a Formation of National QAC b Formation of National Quality Assurance Team c Formation of Regional Supportive team d Establishing in built QA mechanism in each primary secondary and tertiary care facilities establishing quality supervision a
200. anagement and outcomes Shared responsibility and co operation across health care team Ensure the development of a safe environment creating a no blame culture which is open transparent and encourages questioning Partnerships Partnerships and alignment with Colleges Universities and appropriate agencies are developed to maximize the effectiveness of healthcare delivery According to WHO there are four dimension of Clinical Governance Professional performance Resource use Risk management Patient satisfaction Performance Areas Clinical Performance and Evaluation Professional Development and Management Clinical Risk Consumer Value Foundation Stones of Clinical Governance These are the attributes of the organization on which successful Clinical Governance is dependent It is the responsibility of management to see that these attributes characterise the Trust Teamwork Management and everyone who works in the organization whether clinical or non clinical are committed to the aims of Clinical Governance Communication Effective two way communication exists within the organisation as well as between the organisation and its partners in the local health community Communication should also exist between the organization and its patients and the public at large Ownership Good ideas whatever their origin should be valued and incorporated in the Clinical Governance Strategy and Development Pla
201. and respected through participation and input Clinical Leadership and Involvement The continuous improvement of quality and safety needs to be clinician led with clinician involvement at all levels Ensure transparent responsibilities and accountabilities are defined and accepted by clinicians at all levels Clinicians need a commitment to quality and safety of patient management outcomes Shared responsibility and co operation across health care team Information and Data Based Ensure integrity and relevancy of data collection with the assurance of timely responsive feed back or access to data and information Emphasis on clinician defined data requirements interpretation analysis and improvement Focus on the development and understanding of trends minimizing variation and comparative analysis Sustainable Resource allocation decisions need to ensure that professional and technical requirements are met Commitment to continue with the resources required despite lack of external funding in the future 136 Transferable across Sites System wide Approach A systematic and system wide approach will ensure consistency of review and assurance Focus on the development of partnerships across the system Learning Culture Support the creation of a culture that supports promotes and encourages continuous learning in pursuit of excellence Clinicians need a commitment to quality and safety of patient m
202. anisms to coordinate support and monitor QA efforts iii develop and implement effective Information Education and Communication IEC and advocacy campaign and iv make clients active partners in health There were 2 strategies identified to implement this program The first strategy was the certification and recognition of public health facilities including district hospitals rural health units city health centers and Barangay Health Stations village health stations that have met the established criteria and the second was capacity building to internalize Continuous Quality Improvement CQI of health services in these facilities Table A3 1 shows the SSM accomplishment between 1999 and 2004 In 2001 the effort to raise the quality of health services was intensified leading to the expansion of quality efforts beyond the DOH LGU interaction At this point the quality efforts done outside the DOH LGU interaction was acknowledged The new and integrated Quality in Health Program QIHP included mandatory licensing by other offices of the DOH the accreditation and payment mechanism of the PHIC and other efforts to promote quality in health services done by professional societies which was formulated through DOH Administrative Order 17 B series 2003 This program replaced the QAP and SSM and adopted 3 components that include 1 mandatory licensing 2 voluntary accreditation through PHIC and other professional associations and Sentrong Sigla SS
203. ard Constitutional Law Establish HA T hai Develop Process Standard Publish Public Sector Standard Start 30 Baths Scheme Publish Guideline for Health Service Standard Constitutional Law Trial HNQA 4 provinces Expand HNQA 14 provinces Plan to Expand HNQA 30 provinces 21 52 OOUU0UO L1 E 57123 00000 Ly ET E OU E ESI OU Ww LU oo C 0 0 Oo p Fl 1 1 121727 E i Fy 3 27 21 E E 3 P TL EXE EZ 27 e E Eg p EH CIT L1 E LU NOA D 0 D U DU U uuu ESI L EST SES ESI 3 EET ET EST 2 E L1 L1 EJ L1 L1 L1 L1 L1 L1 L1 E L1 L1 E L1 1 1 00 0 0g g g 2006 0 0 30 0 00140000000 0 0
204. ase 2002 23 049 5245417182 2003 20 075 71 56156000 26 7 2004 19 515 103 391 892 85 30 8 OO0 QMMCIJ 2004 71 8 0 0 9 554 00 0 0 0 UIDDUDDDUDUDDUDUDDBDDBDGUDUDUDUDUDUDDUDUDUDUDUDDBDUUDUUDUDUUUDU
205. ately after the conduct of SS assessment and after receiving the SS Certification DOH 2005 Taleon 2005 Lamberte 2003 119 Table A3 3 Status of Sentrong Sigla Certification and PhilHealth Accreditation Programs for Rural Health Units and Health Centers September 2005 Total Number of RHUs HCs 2 835 Total Number of SS Certified RHUs HCs 1375 Total Number of Non SS Certified RHUs HCS 1 010 Total Number of PHIC Accredited RHUs HCs 841 SS Certified Facilities with PHIC Accreditation 660 SS Non certified F acilities with PHIC Accreditation 181 Source DOH 2005 3 5 Challenges in the Implementation of Quality Improvement Programs However there are also challenges to the implementation of quality improvement initiatives These range from organizational requirements to harmonization of quality policies and to readiness of health care providers to start and sustain their quality program All the respondents however agree that these problems are momentary setback and can be addressed in the future Organizational Requirements Despite the initial gains of the quality programs in increasing the awareness of the health care providers to improve the quality of health services that they provide both the DOH and the PHIC identified organizational strengthening and capacity building as barriers to full implementation of quality improvement program In PHIC for instance the experts on implementing the
206. ation Likewise the role of the different agencies and organizations that promote quality of health care must be defined and reconciled so that everybody contributes to the promotion of quality health care For instance PSQua can provide the training for health care providers prior to their application for accreditation Similarly PCAHO can also provide technical assistance to those providers who failed to pass the assessment for accreditation 120 Readiness of health care providers The readiness of the health providers to adopt quality improvement programs depends on their knowledge of the program their technical capacity to implement it and the availability of the resources to implement the program At present many health providers particularly the small hospitals are not ready yet to implement the PHIC Benchbook standards In a study done to assess Sentrong Sigla program 56 of the SS certified facilities are under the more affluent local government units showing a bias for those LGUs who can provide financial support to their quality improvement efforts Lack of financial resources is also one of the cited barriers in implementing quality programs in DOH retained hospitals For instance it is difficult to reduce the infection rate in hospitals if requirements for basic sanitary procedure like running water and washing facilities are not being maintained Financial resources are also critical in conducting research to establish an
207. ch Performance Area and be produced at regular intervals to assure transparency and accountability Generation of report detailing outcomes for the CE GM and subsequently for the Governing Body Independent review and audit of processes defining accountability will provide transparency and assurance 4 3 Reporting step Step 1 Direction Accountability And practical arrangements Step 2 Define where the organization is now Step 3 Design and agree on the development plan Step 4 Set in place internal and external reporting arrangement Health service will be required to provide annual reports on their clinical governance structure and activities In general each annual report should answer the question 131 Where did we start What progress have we made and how do we measure it What are we planning to do next 132 Chapter 1 Quality Assurance Introduction Quality of care should be defined in light of both technical standards and patients expectations While no single definition of health service quality applies in all situations the following common definitions are helpful guides Quality Assurance is that set of activities that are carried out to monitor and improve performance so that the care provided is as effective and as safe as possible Quality Assurance Project 1993 The application of medical science and technology in a way that maximizes its benefits to health without correspondingly increasing
208. changes and improvements in the health facility because of SSM In contrast resistance from the providers was observed when quality improvement requirements are included in licensing conditions Considering these two lessons the future quality improvement program in the Philippines will be linked with the PHIC accreditation and reimbursement of health insurance However incentive must not be the over all goal of quality improvement program Coupled with increasing awareness on improving the quality of health care orientation of the health providers on other benefits of implementing QIP must be done These include among others increased client satisfaction improved morale among the health facility staff and improving the health outcomes Sharing of quality improvement initiatives among health institutions increase the quality awareness of health providers Many lessons have been learned and shared from quality improvement Lamberte 2003 Interview with Dr Robert Enriquez Lamberte 2003 Interview with Dr Beauty Palong Palong 121 Table A3 4 Hospital Bill Collection 2002 2004 Y ear Number of Patients Income Collected US Increase 2002 23 049 52 454 171 82 2003 20 075 71 561 560 00 26 7 2004 19 515 103 391 892 85 30 8 Source QMMC 2004 efforts implemented by individual facilities through the annual convention conducted by the PSQua This yearly activity provides the ven
209. complishment Rural Health Units Health Centers 2 385 1375 5896 Barangay Health Stations 13540 390 396 Devolved Hospitals 631 97 1596 0 0 DOH 20050 4 13 Quality Framework of Quality in Health Program RESEARCH and TRAINING Hospitals Laboratories 0 1 Suppliers Traditional and Clinics to Healers amp Diagnostic Clinics Providers Other Professional p T 47 d Licensing to ensure basic safety 4 i1 Accreditation to stimulate continuous quality improvement Initial Phase Externally enforced regulations and standards with periodic evaluation of compliance Later P hases self regulation and self determination 0 96 OOOO000000d00 O Barangay Health Stations DUIDDUDDBDUDUDUUDUDDUDUDBDDBDDUDGUDUDUDUDUUDUDUDUDUDUDUDUDUDU uDULU 20060 0000 SSM C LU UU LI I 20010 Quality Improvement Health Program QIHP Q PHIC 1 B HH HH BL HH BH HH B HH D H D EL B E E DOH 0 11 10
210. d De pe 25 PDCAN MO 0 26 Bassa Ea D nana 20 TOM phayhuyqayayaquawwuu y asua iqu quy 40 19 7 sah a awi maaan saa ui 46 u uu E M Me 48 48 History OF sla 50 HAST gt ce sl 52 np m M 52 LEVEN p sn nan Pas ss 57 BEN BE aE ANNE AEN EN ORE nE EAT N 59 J men Do xe 8 61 Ba eee Eee eee qax aot nas 61 iB B eee eee 62 Quality Framework of Quality in Health Program 65 14 Chronological Development of Quality Improvement Efforts in the Philippines 66 Figure Quality Framework of Quality in Health Program 114 Figure AQ Chronological Development of Quality Improvement Efforts INTHE 22 5222055 114 BI Eg 1 11 DD D gg ataca cou kino ban u e rrr uu u 7 ES Te ERN MIM e u uu S u u A AEE 8 Dem 000000 BUE ace chide Pat ere ap khay aaa apika uka 11 D e DD B DDD t o Ne a n anasu 14 DODD EB OO 1997 0 19 xp e UO Dg EE aa aaa orae elata oan Se oru e
211. d update the quality standards 3 6 Lessons in Implementing Quality Improvement Program in the Philippines Despite the relatively recent development and implementation of the quality improvement programs in the Philippines few lessons can already be gleaned from its present form Policies on quality of care provide clear direction for its implementation The quality improvement initiatives in the Philippines are articulated and supported by several policies ranging from legislation to PHIC and DOH policies and guidelines These policy instruments provide clear directions to health care providers Moreover the organizational structure that will implement the quality improvement programs was identified However the formulation of these policies may have been done too fast without the sufficient leveling off between the policy makers and the health providers Quick development of policies may also lead to slow implementation since the health providers are not yet ready to comply with the standards Quality improvement is better implemented if linked with incentives The experience of Sentrong Sigla Phase 1 showed the local officials and health providers could accept quality improvement program more readily if this is linked with some form of incentives The assessment of SSM showed that 89 7 of the local government units included in the study were aware what the program was all about while 88 1 of the health workers perceived that there were observed
212. dio announcements 3 7 Conclusion The trigger factors that facilitated the development of quality improvement programs in the Philippine health sector continue to steer its progress The devolution which was the main reason for the development of SSM continues to be an opportunity for local officials to pursue quality in the health services that they are mandated to provide The Local Government Code that transferred the delivery of health services to the local government units is the same law that allows them to develop local health care system that is of quality efficient and appropriate to their locality There are on going initiatives among LGUs to promote quality of health under the technical guidance of the DOH On the other hand the felt need for quality improvement although a force that continues to promote QIP especially among the DOH hospitals must be a collective need in order to be sustainable If only the leaders in the institution organization felt the need for the QIP then the initiatives that are going strong now may not continue once the leaders leave their positions Legislation and policies although providing a more stable pressure to develop and sustain QIP must be well disseminated in order to be effective The mandate that these policies provide to the gt QMMC 2004 gt Lamberte 2003 122 implementing agencies offices is enough to ensure that QIP in the health sector will be sustained At present the cur
213. e as a benchmark for service performance in DOH retained hospitals and regulatory offices under the DOH Recently another department order is being drafted to establish the CQI program in DOH hospitals with the following core components committed leadership and participative management continuous quality improvement activities risk management system of reporting and documentation and funding Another policy that was drafted based on need to improve the quality of health services is exemplified by the Rules and Regulations Governing the Accreditation of Hospitals Engaged in the Conduct of Kidney Transplantation This DOH policy was developed when the staff of Renal Disease Control Program upon analyzing their records between 2001 and 2002 found out that 23 cases of post transplant complications were referred by different hospitals to the National Kidney and Transplant Institute This issue was further highlighted by the alarm raised by a foreign newspaper when they reported post kidney transplantation mortality and cases of kidneys bought from the Philippines that did not match the recipient Another identified need was to strengthen the regulatory mechanism for hospitals which led to the creation of the PCAHO Although originally created to provide accreditation to hospitals PCAHO at present provides certification accreditation to medical clinics that provide services to overseas Filipino workers PCAHO also fills the gap in this area since the
214. e d 27 go mu B nB GG OB MOU Gl u u u u uo u Eats 28 DO m u u S US SU SISI 32 00 0 National Quality Assurance Program NQA P 38 00 0 IDA WB Health Services Project 2005 2010 38 DO O u uQ Q 40 42 qo E EP B BU Ce TTL gt 45 DI ORDER MG MC 47 00 0 00000000000000 00g 51 I Li a 52 DO m 00000000000000 DD rirerire u u uu ul 53 LI 20 HA T T EE EL ET eese mcm tint n rte 54 uu usss 54 00 12 57 13 Sentrong Sigla Certified Facilities 1999 2004 sss 65 14 Summary of the Different Institutions Organizations that Contribute to the Quality Improvement Efforts in the Philippines seem 67 15 Status of Sentrong Sigla Certification and PhilHealth Accreditation Programs for Rural Health Units and Health Centers HCs September 2005 70 16 Hospital Bill Collection 2
215. ecent AO 0029 s2005 from DOH amendment Purpose of QA QI Ensure safety Participation to NHIP Prerequisite for PHIC Quality Quality Requirement instrument Permit to operate Quality improvement accreditation Improvement Improvement for DOH Quality improvement Quality Improvement accreditation Quality improvement Target facilities Licensing Hospitals and other health Hospitals out patient Rural health units DOH hospitals Tertiary Confirmatory facilities excluding medical and dental clinics including hospitals drug testing dinics rural health units and Barangay ambulatory surgical laboratories Health Stations clinic dialysis clinic OFW and Accreditation drug testing laboratory maternity clinic anti Seafarer confirmatory drug testing laboratory T B DOT S centers medical hospitals conducting kidney rural health units clinics transplantation OF W and Seafarer Medical Clinic References for QA QI AO 147 52004 AO 002952005 PHIC Benchbook Sentrong Sigla Quality Department Training Quality Standards List Order Manual for Standards QA QI Systems Quality assurance Desk review of document Desk review of Desk review of Training Training TA Training TA improvement activities On site evaluation document document T echnical showcasing of accreditation On site evaluation On site evaluation assistance Qlactivities certification training and TA review Source the A uthor organization
216. ed results outcomes of care are achieved Efficiency of service delivery The ratio of the outputs of services to the associated costs of producing those services Interpersonal relations Trust respect confidentiality courtesy responsiveness empathy effective listening and communication between providers and clients Continuity of services Delivery of care by the same healthcare provider throughout the course of care when appropriate and appropriate and timely referral and communication between providers Safety The degree to which the risks of injury infection or other harmful side effect are minimized Physical infrastructure and comfort The physical appearance of the facility cleanliness comfort privacy and other aspects that are important to clients Choice As appropriate and feasible client choice of provider insurance plan or treatment Why Quality assurance is important Many countries have made considerable efforts to improve access to health services However public 133 health resources have been so stretched that the quality of services has declined markedly over the last decade Policy makers have realised that health services of inferior quality do not promote equity or maximise health gain As a result of this the public is becoming attracted more to private providers than to public health clinics and hospitals For many reasons such as low staff morale and reduced income this has led to further decli
217. ervision of the standards which are on implementation g Small scale yearly hospital and community based survey for finding out quality gaps and level of client satisfaction 127 h Workshop on QA policy decisions and strategy development 1 Consultative meetings with other organizations related to quality issues and organization workings GO private and NGO on health care quality j Capacity building staff development of QA staff associated with Line Director LD at DGHS through foreign training study tour 9 Trigger factor Implementation of Standard Operating Procedure SOP Continuous resource mobilization Monitoring and evaluation 10 Strategy In accordance with SIP Strategic Implementation Plan Quality Assurance will focus to provide quality health care services to the people appropriate to their special needs through setting standards monitoring standards regulating services and taking quality control measures The strategic implementation plan confirms government commitment to pro poor health service provision where QA has direct role by improving service quality It is speculated that outcome of actions such as improving bad service changing bad attitude by service providers changing behavior of physician towards poor increasing consultation time etc QA action will be designed incorporation standards that will have responsiveness to gender based discrimination violence against women and also to people wit
218. h disabilities elderly and other socially marginalized groups including HIV positive AIDS patients QA programme also has its very alertness and sensitive to pro poor health policy policies for reducing health inequalities and stress on the importance of community and stakeholders participation In every stage of its action QA programme will have its readiness to play a positive and supportive role with all theses strategic issues 4 2 Clinical Governance Committee Strategic Statement 4 2 1 Objectives Monitor and make appropriate recommendations on performance in all areas of Clinical Strategy Monitor the implementation of the Clinical Governance Strategy and Development Plan 1 Review and approve strategies for Clinical Effectiveness Clinical Audit and Research Patient and Public Involvement Education and Development Clinical Risk Management 128 4 2 2 Key Areas Receive report from and make recommendations to Clinical Effectiveness Group On audit and research activity Public and Patient Involvement Committee Complaints and commendations Patient and user surveys Risk Management sub committee Identified areas of clinical risk Identified areas of prospective clinical risk associated with changes in practice Identifying and implementing risk treatment mechanisms Including training and review of procedures and protocols Consider as standing agenda items Communication Effectiveness Ensure that changes to cli
219. he Philippine Council for Accreditation of Health Care Organizations PSQua Annex 1 shows the list of DOH and PHIC officials that have been interviewed for this study 3 2 Historical Development of Quality Improvement Efforts in the Philippines Health service delivery in the Philippines has changed tremendously in the last 14 years New legislations related to health and evolving health management practices contributed to the present health system in the Philippines The DOH is mandated by law to ensure that accessible and quality health services are provided to the Filipino people Through the years the main policy instrument that the DOH used to ensure quality in health services was embedded in the licensing requirements for hospitals and other health facilities in the Philippines Although the policies for licensing of health facilities only look at the inputs for the provision of health services the Bureau of Health Facilities and Services also encouraged facilities to establish their quality improvement programs In 1995 the National Health Insurance Law the legislation that created the PHIC was passed Under this law health care providers are required to have ongoing quality assurance program as a prerequisite for accreditation The Quality Assurance and Research Policy Development Group QARPDG of the PHIC is Interview with Dr Beauty Palong Palong 111 the office that is mandated to ensure that this provision of the law is be
220. he poor Poor people can not get good treatment without patronage relationship Women again then in most disadvantaged position because of their less access to patrons and resources The document PAD 2005 also critically felt need of developing feasible and acceptable strategies for regulating and enforcing regulation of quality and volume for health services and pharmaceuticals The key quality issues that come up from current situation analysis are lack of medicine or poor quality medicine bad service bad staff attitude difficult to reach waiting time inadequate seats for waiting very brief consultation time worse privacy arrangement doctor s behavior towards patient providers bad behavior towards the poor cleanliness unregulated services 7 Priority areas a Service improvement b Creation of positive staff attitude c Shortening of waiting time d Adequate seat for waiting e Adequate consultation time f Improving privacy arrangement g Improving doctors behavior towards patient h Cleanliness i Regulated service 8 Priority activities of the OP a Reorganization of QAC including establishment of a resource centre b Updating amp dissemination of standards Standard Operating Procedure c Advocacy and orientation on QA d Strengthening of National QAC and formation of regional Quality Assurance team e Training on QA of manager and service providers at service delivery points f Monitoring Evaluation and Sup
221. hilippine Soc oO nm L1 Lr r3 Lr OU OU 0 EJ 5742 OOOO E3 E3 E3 OOO 4 4 goood In 0 5 iety for Quality in Health Care PSQua 000000 nm D 0000000000000 0000000000000 OU UUIDUDUDUDUDBDUDUDUDUDUDUUDUDDUDUuDUDUnunmD nm L1 L3 L3 L3 L3 L3 E3 E3 E E E E E 3 EST IET Ps E E E EX E E rE 3 E I GS E EZE E 1 EEE E TE l D E ESTES EE E E E E l UU U uuu D uuu DU uu 0 OH Ee E Ea EI 5 15 ES Eat EE dB P EE 3 0 EE EHI OOOOOOOOCOOCOOOOOOOOOCOOOOOOOOOGO naaRPogoogooogogoloooooooooooooolooln 6
222. ilities Felt need One of the triggers noted by the respondents was the need for quality improvement program in order to respond to their clients This was especially true for the public hospital sector The DOH retained hospitals developed their individual quality improvement program based on their own initiative usually starting with the implementation of 5S program from Japan Some of these quality programs are more advances than others See Box A3 1 With different programs being developed the Interview with Dr Francisco Soria R Lakshminarayanan 2003 Lieberman et al 2005 Interview with Mr Jose Basas 116 BoxA3 1 Quality Improvement Program in a Public Hospital It was the clients clamor for better health services that triggered the development of quality improvement program in Quirino Memorial Medical Center QMMC QMMC is a 350 bed tertiary hospital located in Quezon City Metro Manila The hospital management started implementing quality improvement activities in 2001 when they received many complaints from their clients despite the improvements in their facilities and manpower capability This kind of feedback coupled with the hospital management s desire to provide the best service possible led to the development of their quality improvement program Their quality improvement activities include among others compliance to updated clinical guidelines of specialty societies hospital wide discipline infection co
223. ing implemented QARPDG is responsible for the development and enhancement of quality assurance programs policies and guidelines for institutional and professional health care providers In addition it develops and continuously reviews health care standards performance monitoring and evaluation systems feedback and intervention mechanisms This office also conducts utilization review health technology and outcome assessments The mandate of QARPDG to ensure quality services in PHIC accredited facilities is further operationalized through the development of the Benchbook on Performance Improvement of Health Services This manual will be used as a yardstick for measuring and assessing the quality of health services provided by PHIC accredited facilities This reference also strengthens the connection between the accreditation process of PHIC and the quality assurance health care Thus the Benchbook provided an updated list of standard and criteria that health providers can use for self assessment before they apply for PHIC accreditation It also identified the following areas as the focus of PhilHealth Quality Standards for Health Care Patient s Rights and Organizational Ethics Patient Care Leadership and Management Human Resource Management Information Management Safe Practice and Environment Performance Improvement In 1996 a group of individuals representing professional societies academic institutions and govern
224. is project EPQI helped the hospitals to 1 organize and train QA practitioners and advocates among health providers 2 establish health system indicators for quality health assurance that is aligned with the standards in the PHIC Benchbook 3 establish a QA program and encourage QA innovations and 4 achieve better health outcomes and satisfied health consumers Source Quality Assurance Research Policy Development Group PHIC Training of Trainers on QAP and Benchmarking In 2003 the APO through the Productivity Development Center of the Development Academy of the Philippines PDC DAP provided the expertise of Ms Lucia Berte to PSQua in conducting training for trainers on Quality Assurance Program for hospitals Moreover in 2004 APO in partnership with the Center for Knowledge Management of DAP CKM DAP provided the services of Mr Bruce Searles to assist PSQua to conduct a benchmarking project on patient safety with particular focus on medication error Source Philippine Society for Quality in Healthcare 2004 External support through foreign assistance Although quality improvement program can be implemented in the face of scarce material human and financial resources the development of the quality improvement programs in the Philippines had the advantage of getting technical and financial assistance from foreign donors Among others SSM and the creation of PCAHO were outputs of assistance from USAID PHIC on the other ha
225. l Conduct monthly review meeting at institutional level amp Monthly reviews of Quality Secretariat Budget A pprox Rs 700 000 Product Quality Secretariat will be organized to facilitate quality of care in pilot hospitals QA standard review mechanism will be developed for the NQA P Institutionalize the monitoring mechanism at hospital level A Quality culture is developed in tertiary care hospitals 00 0 IDAAVB Health Services Project 2005 2010 Sri Lanka Health Sector Development Project Components Support to district health authorities to improve service delivery and outreach Support to central programmes and hospitals Support to policymaking budget formulation and monitoring and evaluation Project management Subcomponents Family health programme and nutrition Immunization G Non communicable diseases and mental health Hospital efficiency and quality 8 nm oO E EI qr OO 85 Ooo yo OOOH m iE 2 1 r3 bz En mT 3 TT 217 1 129 027 021 211 ian i usa eT SETA maa Eg ET IU 1 11 ET 7 57 21 p r EX E LT
226. lantation OF W and Seafarer Medical Clinic References for QA QI AO 147 s2004 AO 0029 s2005 PHIC Benchbook Sentrong Sigla Quality Department Training Quality Standards List Order Manual for Standards QA QI Systems Quality assurance Desk review of document Desk review of Desk review of Training Training TA Training improvement activities On site evaluation document document T echnical showcasing of accreditation On site evaluation On site evaluation assistance Qlactivities certification review 0 NHIP National Health Insurance Program 5 OFW Overseas Filipino Workers TA Technical Assistance E 0 UUDDDDUDBDDUDUDUUDDUDUDUDUDUDBDDUDUGUDUUDBDUGUUDUGuDUuDUUUuUD UUDDUDDUGUUDDUDUDUDUUDUUUDUUDUDUDDDUDUUDUDDUDBDUDUUDUDUDUDuD OU OU DUUDUDDUDDDDUDUDDUDUDUDBUDUDBDBUDUUDBDUUDGuDUDUUUDUUDuND OU OU Duguuuu L1 Lr EST Es E NET E 1 5 1 11 27 E L1 o r3 EX E Boc Soo Ee Et EH HL BL D 1 C D 1
227. li E EST EM ONO ara oo C C 5 1 EE CES E ESI ep ESL ESI ESI SEET EI UUDDUDUDUDUDBDUDBDDUUDUGUDUDUDUDUDUDUDUDUDUDUDUDUDBDU uDULDLU 4E ESI 5E En EIC E HT E E E E23 P EST BT I P E E I 3 3 9 E P E E 0 0 0 0 0 0 L1 L1 L1 E L1 5 OU OU OU OU ON 5 El DU P O00 O00 O00 O00 DU O00 O00 DU n 0o00 ustaina 0o00 udo System wide A un n p 0 0 D a 2 U U U U Le g Culture U U U U Ez C3 C3 CJ C3 00 00 UD D D D D D D D D D D 00 0 0 0 0 0 0 S 0 0 0 0 0 0 0 0 0 DU O00 DU atient Outcome Base Clinical Leadership amp Involvement
228. ment agencies got together to establish the PSQua This Society aims to 1 promote the quality assurance quality improvement and quality management among the public and private providers of health care 2 organize scientific meetings workshops and seminars on quality in health care 3 promote research on quality in health care in the health sector and 4 collaborate with government agencies in establishing scientifically sound and practical rules in accreditation process of the health organizations As of 2004 PSQua developed the Essential Elements of Quality Assurance Quality Management QA QM in Hospitals in the Philippines a guiding principle to promote quality in Philippine hospitals The Society also formulated the Training Methodology in QA QI Quality Improvement for health services conducted more than 35 training workshops across the country trained trainers on quality with the assistance of Asian Productivity Organization APO and conducted 81 QI study contests in which hospitals vie for the best innovation in health services In 1998 the PCAHO was organized to strengthen the regulation of hospitals PCAHO is a non government non profit independent accrediting and certifying body whose primary objective is to promote quality improvement in health care services through accreditation education training and research Seven years after its establishment PCAHO has conducted the Certification of Quality Standards System QSS of
229. n so that these are owned by all members of staff Leadership lt is the responsibility of the leadership of the organization to develop a long term strategy to improve the quality of clinical care This should build on the desire of individual staff members to 137 provide high quality clinical care and foster an environment in which clinical excellence can flourish Systems awareness The organization must recognize the importance of enveloping structures within which Clinical Governance can operate It must also recognize the role systems play in hindering as well as facilitating good clinical care Criticism should generally be leveled at systems and not individuals 138 0 0 OOO 0000000 00000 0000 0000 19720 0 5 0 D uuu 0 0 1 1 1
230. nd was able to pilot test a QA tool called Evidence Based Participatory Quality Improvement EPQI System through the assistance of World Health Organization WHO This management system introduced in the Philippines by a Japanese QA expert Dr Nauro Uehara of Tohoku University s School of Medicine is expected to promote continuous improvement in health care quality in hospitals The APO through the Development Academy of the Philippines provided assistance to PSQua through technical experts in training trainers on quality assurance and implementing benchmarking in the health sector See Box A3 2 Acceptability of Quality Assurance Program Another factor that facilitates the implementation and sustainability of quality improvement programs is acceptability to the health care providers The implementation of PHIC Benchbook for instance is acceptable to health care providers that they are already using this as reference in establishing their quality improvement program even before PHIC uses this manual for accreditation purposes Likewise the implementation of SS Certification is still going strong six years after it was first established Currently around 1371 or 5896 of the Rural Health Units RHUs or Health Centers HCs are SS Certified and 660 of these facilities or 48 are accredited by PHIC Program review of SS also showed that most of the providers perceived that there have been observed changes and improvement in the facilities immedi
231. nd monitoring system at all level e Review development of quality management of protocols for National District and Upazilla level f Conducting surveys on consumers and providers perception of quality of care 3 Performance accounts till date The programme developed standards on the following areas which includes the areas for hospitals services and for the field level preventive service as follows 4 Hospital services OPD services House keeping IPD services Drug management Emergency services Nursing services Diagnostic services Record keeping Emergency Obstetric Care EOC 5 Preventive services Health education BCC Diarrhoea EPI services ARI Limited curative care Malaria TB Kala azar Leprosy ANC 126 There were also some proposed areas OT management Malnutrition Infection control Hand washing waste management etc 6 Current situation Quality of Health care provided in the country is generally believed as not good The Nation wide service delivery survey SDS CIET survey indicate public opinion about quality of health and family planning services provided by the government are not good The perceived problem that has been identified are as Lack of medicine long waiting time poor service bad attitude of the staff etc World Bank s project appraisal document 2003 reiterated the quality issues prevailing such as lack of medicines long waiting time bad attitude of the service provider to t
232. nes in the quality and efficiency of public sector health services It remains a challenge to find innovative approaches that improve the quality of health service delivery National QA Programmes are one way to improve standards but strategies to implement QA at district and sub district level are sometimes ill conceived or may not exist at all This is surprising in view of the fact that health sector reform policies usually include quality as an explicit priority Whilst greater decentralisation of responsibility and resources might allow enthusiastic districts to remedy this situation staff need models of good practice to bolster morale and indeed improve their quality of care The questions are 1 What is Quality Assurance in health care 2 What kind of QA policy is needed to ensure good quality of care 3 Can governments introduce an off the shelf QA package 4 How can a QA policy be put into practice Why QA in health care QA comes in many guises and may be known as Total Quality Management Continuous Quality Improvement Clinical Audit Clinical Governance or Quality Circles Quality of care has different meanings to different stakeholders for example doctors and patients All QA systems should encompass three perspectives on quality Clinical standards Performance management Client satisfaction Hence there are usually several elements within the QA system such as clinical audit quality control of laborato
233. nical practice are systematically disseminated to all relevant staff Consider the clinical implications of the Communications Strategy Resource Effectiveness Consider existing operational arrangements to enhance their Clinical Effectiveness Right person Right place Right time Ensure a balance exists between the operational needs and the educational needs of the staff Strategic Effectiveness Consider changes in the overall strategy and how they impact on the Clinical Governance Development Plan Ensure that Clinical Governance issues inform the development of the overall strategic development 1 Clinical Performance and Evaluation Intent Clinical review monitoring evaluation and benchmarking of standards guidelines protocols pathways which are evidence based Elements of Performance Intent Process Standards Based on best Determined by department or unit based on evidence practice college expert opinion Examples defined local national international evidence based protocol policy compliance with best practice protocols correct use of treatment modalities clinical pathway compliance 129 2 Professional Development and Management Intent Professional Human Resource development and management Elements of Performance Intent Process Demonstrated competency Ensure Credentialling professional and technology professional Performance development competency J DF
234. nsurance organizations both private and public to purchasers of health care like employers and labor unions and to the patients themselves However quality of care must be defined in the light of the provider s technical standards and the patients expectations Moreover improving the quality should maximize the effectiveness and efficiency of the current system The problems in working conditions in developing countries can be overwhelming which include insufficient number of personnel lack of continuing education poor physical facilities and inadequate drugs and other medical supplies In the countryside poor road network and lack of communication hinder efficient referral system Cold chain for vaccines is compromised by erratic supply of electricity As a result studies on quality of care in such settings are often discouraging However there is a growing body of evidence that quality of care can take root and eventually flourish in developing countries sometimes despite lack of human and material resources Methods and processes may vary across developing countries but they echo the same goal of providing quality of care to the patients Some of the interventions to improve the quality of care were so simple that they can provide lessons to the health care organizations in developed countries Developing countries around the world have joined the quality care bandwagon for different reasons and through different mechanisms
235. ntrol and client feedback mechanism They have established several management systems which include internal control of their resources to prevent wastage and pilferage proper monitoring of pharmacy including the price and quality of drugs and any occurrence of adverse drug reactions infection control and hospital wide discipline among others One of the most visible continuous quality improvement mechanisms in the hospital is the client feedback mechanism where the management distributes Patient Satisfaction Survey forms to their clients The management also put up 15 suggestion boxes in strategic locations around the hospital which they open once a month to see if there are any suggestions or comments that they need to act on As of 2004 the hospital management received 34 official complaints and the Medical Center Chief verified 32 of them The hospital wide committee handled seventeen of these cases and 6 cases resulted to penalty to the employee concerned Source QMMC 2004 head of the hospital cluster felt the need for a template for quality program in DOH hospitals In order to address this Department Order 310 J s2001 was developed to create the DOH steering committee and technical working group that will establish the continuous quality improvement program for the health regulation cluster and DOH hospitals The rationale of this health department policy was to establish a set of standard measures and procedures that will serv
236. ol Committee ICCQ D 1 UUDUDUDDUUDUUUDUDUuuu D Sao hai Hospital TQM 000000 2 Community Hospital OO 1 Public amp Private Administration L1 E LH HA 1 111111 20040 0 D Healthy Health Promotion 1 B U d d d U 7 7 7 U D Thai JJ
237. pulation 1 user Charger OOOOOOOOOAccessdOOOOOOODO 300 1111 1110 utut Hospital Network Quality Audit 19900 45 43 OO3000000000000000000000 Social 000000000000 0000000000000000 000 urity servic 1000 800 800 90 080 00 900000000 0
238. rent environment for the implementation of quality improvement program in the Philippines remains bright and hopeful the gains from implementing these programs in the past few years look slow and uneven However the formulated policies and planned harmonized processes have yet to result to improvement in health outcomes More leaders and proponents of quality health care must be identified and equipped synchronized processes and procedures must be put into practice appropriate investments to upgrade facilities and services must be done and implementation of the quality improvement program must be tracked and evaluated Evaluating the quality improvement programs is particularly critical in order to see that the inputs and processes resulted to improved outcomes and this will iteratively provide lessons for the next cycle of implementation 123 References Berwick D M 2004 Lessons from Developing Nations on Improving Health Care BMJ 2004 328 1124 9 Blumenthal David 1996 Quality of Health Care Part 1 Quality of Care What is it New Engl J Med 1996 335 12 891 894 Brown L D Franco L M Rafeh N and Hatzell T Quality Assurance of Health Care in Developing Countries Quality Assurance Project Bethesda MD U S A Department of Health DOH 2003a Sentrong Sigla Volume 1 Handbook on Administrative Issuances and Directives Bureau of Local Health Development Manila Philippines 2003b Rules and
239. rovement programs The former Undersecretary for Health Dr Susan Mercado was instrumental in developing and promoting the SSM Dr Elvira Dayrit who pushed for a wider and more comprehensive Quality in Health Program further strengthened the momentum In hospital and regulatory cluster Undersecretary Margarita Galon pushed for a standardized quality improvement program for the DOH hospitals In QMMC Dr Arandia is considered as the driving force in the improvement of health services provided by the hospital and a charismatic proponent of the quality improvement program in hospitals In private sector Dr Maramba is seen as a strong advocate of quality improvement program in the country as he is both an officer of PSQua and PCAHO PHIC 20045 PHIC 2003 118 BoxA3 2 Some Technical Assistance to Improve Quality of Care from External Sources Evidence Based Participatory Quality Improvement EPQI System In 2003 recognizing that the delivery of quality health care lies on a working district health system that is well managed by local health executives and provided technical guidance by the DOH PHIC introduced the EPQI system in the province of Benguet to test a quality improvement package Innovations and new ways of improving quality of health care were introduced by Dr Uehara to key personnel of Benguet province They were trained on different EPQI tools in training workshops conducted between November 2003 and January 2004 In th
240. ry services standards setting and client satisfaction surveys These components do not have to be introduced simultaneously but can be introduced as distinct packages What kind of QA policy ensures good quality of care It has become fashionable for government health policies around the world to include statements on the quality of their health services The QA statements usually reflect a concern for ensuring that health services are both cost effective and responsive to public needs How can a QA policy put in to practise Implementing QA systems is as much a people issue as a technical one Providers implementing QA should guard against over ambition They may wish to start by focusing on a single issue then as a quality culture develops in the health service add additional elements to the QA programme 134 Districts should be encouraged to develop their own QA initiatives that should be part of the annual work plan with their own budgets Care should be taken to ensure that these initiatives are guided by national policies with nationally agreed standards and indicators of quality of care Menus of practical options for QA strategies should be collected centrally and actively promoted to support weaker districts where QA development is not taking place However ownership by local service providers remains the secret to success in turning policy on quality of care into practice Interdisciplinary QA teams represent the best
241. s com business guide mgmt kaizen tqc main html Medical Hot Zone No 1Vol513 2003 00 10 000 0 www yozemi ac jp johoshi 03 journal 4 hotzone html Simcoe County Mental Health Centre CQID CQI D 2008 D 0 http www mhcvaon ca CQI cqibibl htmr T QC Development Center http www tqc com hk index htm t 20051 00000000000000 Castle Street Hospital then and now Rodrigo J Nalin Sri Lankan Family Physician 1999 22 50 54 www medinet Ik journals slcgp familyphysician 1999 castle str eet hospital htm Creating T oyotas in health service Hospitals learn from industrial sector www sundayobserver k 2004 01 11 fea24 html Institute of Policy Studies of Sri Lanka Health Policy Programme Research Note 1999 1 August 1999 O http www ips Ik health research financinghealth downloads hpp rn slnha pdf 00000000000 Wen 0 Development of Health Promoting Hospitals in T hailand http unpanLun org intradoc groups public documents A PCIT Y UNPANOO9705 pdf Health sector reform in T hailand an update http medinfo psu ac th smj2 164 smj9 h
242. s that implement and promote quality assurance and improvement programs in health services in the Philippines However this figure only focuses on the beginning of the implementation of the policies but not on the degree of their implementation operationalization For example although the PHIC Benchbook was developed in 2003 and was published in 2004 this tool will only be used as basis for PHIC accreditation starting 2006 Table A3 2 summarizes the characteristics of different offices that are mandated to operationalize the different policy instruments for quality assurance and quality improvement The information included in the table is limited to what is currently being done but it does not include the future intention or plans of these offices For example SS certification also covered locally managed public hospitals and Barangay Health Stations in Phase 1 but in Phase 2 of SSM under QIHP SS certification focuses on the rural health units On their own initiative and to increase their competitive advantage hospitals and other health facilities sought accreditation with International Organization for Standardization ISO JCAHO and accreditation of other countries like Taiwan and Saudi Arabia As of 2005 DOH listed 137 OFW medical clinics and hospitals accredited by PCAHO and ISO and one tertiary private hospital with JCAHO 3 3 Factors that Trigger the Development of Quality Improvement Programs The results of the interview of key informants
243. se clinics must be accredited first before international employers honor their medical certification PSQua was likewise organized because of the Interview with Dr Rosalinda Arandia Interview with Dr Robert Enriquez DOH 2003a Interview with Dr Beauty Palong Palong 117 growing need to support and institutionalize the quality improvement programs initiated by the health care providers Legislation Republic Act 7875 National Health Insurance Law was the reason for the reason for the creation of Philippine Health Insurance Corporation and its various offices including the Quality Assurance Research and Policy Development Group This office is mandated to operationalize Rule XVII of the Implementing Rules and Regulations IRR of RA 7875 which focuses on the quality assurance of health care providers According to the IRR the quality assurance program 01 PHIC shall 1 ensure that health care professionals of the accredited health institution possess the proper training and credentials to render quality health services to members of the National Health Insurance Program ii work towards the promotion of uniform health care standards throughout the country and iii ensure appropriateness of medical procedures and administration of drugs and medicines consistent with generally accepted standards of medical practice and ethics PHIC operationalized these legal provisions through the implementation National Quality Assurance
244. sig City Philippines Duties and Responsibilities Quality Assurance Research and Policy Development Group www philhealth gov ph Philippine Society for Quality in Health Care PSQua 2004 A Road Map to Achieving Quality 9 Annual Convention Proceedings Mandaluyong City Philippines Quirino Memorial Medical Center QMMC 2004 Annual Accomplishment Report 2004 unpublished Reerink I H Sauerborn R 1996 Quality of Primary Health Care in developing countries recent experiences and future directions Int J Qual Health Care 1996 8 131 139 Taleon J D 2005 Sentrong Sigla Report and Recommendations Powerpoint material presented to Harmonization of Sentrong Sigla Certification and PhilHealth Accreditation Meeting Manila Philippines 124 Annex A List of Respondents for the Key Informant Interview Name Designation Organization Dir Maylene Beltran Director VI Health Policy Development and Planning Bureau DOH Dr Robert Enriquez Division Chief National Center for Health F acilities Development DOH Dr F rancisco Soria Medical Officer VI Quality Assurance Research and Policy Development PHIC Dr Beauty Palong Palong Division Chief Quality A ssurance and M onitoring Division Bureau of Health F acilities and Services Mr Jose Basas Chief Health Program Officer Quality in Health Program Bureau of Local Health Development DOH Dr Rosalinda A randia Hospit
245. t Level Risk Management System in Quality Hospital Clinical Quality and Safety IT and Quality Improvement Individual Patient Case Management Drug Dispensary System in Quality Hospital 00 11 OOOO OOOOOOO O4000000 DU uuu LU uu L1 E DU 0 D 0 Q Uu Uu 0 EJ E EJ ESI Ez EIE E ear E L1 L1 OOOO r3 L1 MD D U m 0 0 Basic Intermediate Advance 1 General Quality Development HA301 HA 100 HA 302 2 Being a Coach HA400 3 Inspection HA401 HA 403 4 Resource Administration HA 501 HA 502 5 Particular Development HA 303 HA 305 HA 601 HA 603 HA 602 HA 604 HA 605 000 TOM OU L1 54 UUIDDUDUUDDDBDUDUGUDUDDUDUGDUGDUDUUDUUDUuDnnuD 199230 00000 Ll Social Security Service 5551 1 U 1993
246. tml Implementing A ccreditation in a Developing Country Issues Challenges and Lessonsl SQua2003QA P Diana Silimperi and J CRO Anne Rooney Facilitating http www urc chs com pdf isquaprez A ccreditationWrkshp pdf 91 UOUUU UO Ov a LG UO Uu UO UD Dr Hasan A minul Medical Office Hospital amp Clinics Directorate General of Health Services Ministry of Health Republic of Bangladesh Dr Leizel P Lagrada Chief Officer Health Policy Development and Planning Bureau Department of Health Republic of Philippines 93 JOH D Uu 1111 1111111111111011 110111101111111111111 111 1 111 1111 1111 11 0 0100 0000 0 5 8 D uuu D O Providing Quality Health Care in the Philippines Basis and Lessons Leizel P Lagrada QQ Quality Assurance and Clinical Governance on Bangladesh Hasan A minul JUUUU National Demonstration 7 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
247. ue to increase awareness for quality improvement in the health sector It also encourages more health providers to adopt and implement their quality improvement programs Quality improvement can lead to better use of limited resources and increase in revenues Health facilities developed their quality improvement programs because of limited financial resources In QMMC for example along with their expanded and improved services they have implemented a system to closely monitor and evaluate their patients capability to pay which led to increased collection They also give proper advise to indigent patients so that these patients can apply for financial assistance from foundations and endowment funds Table A3 4 shows the increase in hospital income Increasing the awareness of the community for quality improvement in health care led to higher utilization Through the implementation of Sentrong Sigla there has been an increase in the awareness on quality health care among the clients of primary health facilities the leaders of NGOs and community based organizations the LGU officials and the health providers In a study to assess the impact of SS 46 of the respondents reported that they sought services from the SSM certified facilities because of the perceived delivery of quality health services The common sources of information that the facilities were SSM certified include DOH representatives health providers and LGU posters banners and ra
248. urces Review of Documents Relevant documents were reviewed including legislation Philippine DOH policies and agency performance reports Key Informant Interview Agencies and offices that implement and promote quality programs were identified and key informants were interviewed using an open ended interview tool See Annex A for the list of the respondents Quality improvement activities processes were observed at the public hospital This descriptive study developed a chronological presentation of the development and implementation of the quality improvement program in the Philippines The events that triggered the development of the quality improvement program were also identified Performance reports of the appropriate agencies were analyzed in relation to their contribution to the implementation of the quality improvement program A public hospital was selected to see how the quality improvement policy has been implemented 2 Results Seven key informants who are engaged in promoting and implementing quality assurance and improvement programs were identified and interviewed The list includes program managers policy makers and implementers from the Department of Health DOH and Philippine Health Insurance Corporation PHIC Additional institutions outside the DOH that also contribute to the efforts to promote quality in health services were identified These include the Philippine Society for Quality in Health Care PCAHO and t
249. ure DO SQC Statistics Quality Control B SSM Sentrong Sigla Centers of Vitality Movement DD sss Social Security Service TQM Total Quality Management WB World Bank 0000 WHO World Health Organization 08 Dual UIDDUDUDUDUDUDUDDDUDDBDBDUBDUGUDUDDUDUUDUDUDUUDUDUDBDUDUGuDUUDUUDU a a a UUDDDUDDBDUDUDUDUDDUDUDBDBDUDUGUDUDUUUDUGUDUDUDUDUDUDUDUDUUD uDLDL 6
250. uu c 3 E L3 4 1 Oo EE E Oo N O o EJ E E 3 OU 10 1 09 0 1 9 0 0000 11111111111111111101111 11111111111111111 111111171111011 111111111 1 0 1111111111111111 11111 111011 1 11 6111 i B B 20 National Health Care Quality Plan Uu OOO OOO 0 UU 11111 O National Health Strategic Pilang 1 010100100000000000080000 411111 11111 11111 1 11111111111 111111 1 1 11 1111111011 11111111 0 0900 0 1110100000 111111 1111 1 111111 1111111111 11 nm oO 9 UIDUDDUDDUDBDUDUDUDUDUDUDUDBDBDUDUDUDUUDUGUDGuDUuuUunun
251. uuu U uuu OOUUUU unn 0 0 OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 0 9 10000000 2004 204000000000 HIPC Heavily Indebted oor Country Completion Point UUIDULDDDDUDUDDDUDUDUUDDUDUDUDDUDUGDUDUDDUDUGDDUDBDUDUuDBUDUDUDUL 9 1 000000000008008080 0800909089 8 0 8 199600000000 Central Board of Health CBoHQ cBeHi

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