Professional Documents
Culture Documents
SCORECARD
( QUALITY
OBJECTIVES)
for the CY 2013,
CY 2014 & CY
2015
Key Officials
Emmanuel M. Bueno, MD, FPCS
Medical Center Chief II
Joanna V. Remo, MD, MHA, FPPS
Chief Medical Professional Staff II
Rodolfo T. Sedano, CE, SE, MBA
Chief Administrative Officer
Nora B. Mangahas, RN, PhD
Nurse VII
Jocelyn S. Casida, CPA, MBA
Financial & Management Officer II
HOSPITAL SCORECARD
( QUALITY OBJECTIVES)
for the CY 2013 , CY 2014 & CY 2015
AMANG RODRIGUEZ
MEMORIAL MEDICAL CENTER
Sumulong Highway Sto. Nino, Marikina City
Authorized Bed Capacity:
300 beds per RA 9419 of 2007
History
May 15, 1966
Blessed and inaugurated as Marikina Emergency Hospital
Authorized for 25 beds (R.A. 3662 of 1964)
July 1969
Increased bed capacity to 50
Renamed as Eulogio Rodriguez Sr. Memorial Hospital
July 1974
DOH approved accommodation to 75 beds
History
In 1992, under RA 7209 bed capacity increased to
150
November 24, 1995
renamed as Amang Rodriguez Memorial
Medical Center
February 7, 2005 Republic Act No. 9419
(Specialty/Medical Center/Regional/
Medical Center
Provincial/District/ Sanitarium/Special)
Category
PhilHealth Accreditation
CY 2016 Budget
PS P194,817,000.00
MOOE P80,748,000.00
CO P86,373,000.00
(Infrastructure-P56,737,000.00/
Equipment P30,000,000.00)
Organizational Chart
VISION
MISSION
A Center that continuously:
Ensures the well-being of patients through
standard and innovative healthcare
practices
Enhances staff development by providing
opportunities for professional education and
training
Engages in and conducts research that is
beneficial to the community.
CORE VALUES:
Professionalism
Respect
Accountability
Commitment
Teamwork
Integrity
Compassion
Excellence
Social Responsibility
QUALITY POLICY
A renowned center of excellence, Amang Rodriguez Memorial Medical
Center is committed to render holistic, reliable and unparalled quality
health care, medical training and research services at all times.
Guided by our core values, we:
Adhere
Acknowledge
Gather,
Indicator # 1
Philhealth Rate
(Philhealth reimbursement/Total hospital income x 100)
Report of Collection
Finance Service
Accounting Section
Indicator # 1
Philhealth Rate
90%
60%
30%
0%
30%
2013
30%
2014
30%
Benchmark
Philhealth Rate
2015
Indicator # 2
No Balance Billing Compliance
Benchmark required by DOH:
70% of Qualified Patients
Source of Data:
Division:
Section:
Hospital Bills
Finance Service
Billing Section
Indicator # 2
No Balance Billing Compliance
Performance 2015:
100%
Performance 2014:
Indicator # 3
Philhealth Utilization Rate
Benchmark required by DOH:
87% Philhealth Coverage
Source of Data:
MDR, Patients Record
Division: Finance Service
Section:
Philhealth Section
Indicator # 3
Philhealth Utilization Rate
87%
87%
87%
Benchmark
Utilization Rate
2013
2014
2015
Performance 2015:
Performance 2014:
Performance 2013:
87.00%
54.00%
39.00%
Indicator # 4
Average Length of Stay (ALOS)
Benchmark required by DOH: 3.7 days
Source of Data:
Statistical Report
Division:
Medical Service
Section:
Health Information
Management Section
Medicine
Obstetrics
7.029
4.949
7.376
4.757
5.679
4.700
6.694
4.802
Gynecology
4.954
3.493
3.614
4.020
Pediatrics
7.325
7.120
6.415
6.953
Surgery-Adult
7.577
8.621
6.818
7.672
Surgery-Pedia
4.705
6.148
11.741
7.531
Ophthalmology
2.105
2.677
2.712
2.498
ENT
5.756
5.263
5.286
5.435
Ortho
3.463
2.535
2.134
2.710
Indicator # 4
Average Length of Stay (ALOS)
Performance 2015:
Performance 2014:
Performance 2013:
7.00 days
6.00 days
6.00 days
Indicator # 5
Discharged Improved and Recovered
Benchmark required by DOH:
70% Patients Discharge Improved and
Recovered
Source of Data:
Statistical Report
Division: Medical Service
Section:
Health Information
Management Section
Indicator # 5
Discharged Improved and Recovered
100%
80%
70%
70%
60%
70%
Benchmark
Discharge Rate
40%
20%
0%
2013
Performance 2015:
Performance 2014:
Performance 2013:
2014
89.00%
88.58%
87.50%
2015
Indicator # 6
Unfilled Prescriptions/ Supplies (Inpatient
only)
Benchmark required by DOH:
2% - 5% Unfilled Prescriptions/ Supplies
Source of Data:
Statistical Report
Division: Medical Service Division
Section:
Pharmacy Section
Indicator # 6
Unfilled Prescriptions/ Supplies (Inpatient only)
5%
5%
5%
5%
Benchmark
Unfilled Rate
0%
2013
2014
2015
Indicator # 7
Safety Precautions
Benchmark required by DOH:
0 - 5% Hospital Infection Rate
Source of Data:
Statistical Records
Division: Medical Service
Section: Health Information
Management Section
Indicator # 7
Safety Precautions
10%
5%
5%
5%
0%
2013
2014
Benchmark
Hospital Infection Rate
2015
Indicator # 8
Cleanliness and Orderliness
Benchmark required by DOH:
90% of clients rate the hospital as
good or better
Source of Data:
Customer Satisfaction
Division: All Division
Section: All
Indicator # 8
Cleanliness and Orderliness
90%
60%
30%
0%
90%
90%
90%
Benchmark
Client Rating
2013
2014
2015
Performance 2015:
85.00%
Performance 2014:
Indicator # 9
Safe Water & Proper Waste Disposal
Benchmark required by DOH:
Passed ; Testing done at least twice a
year
Source of Data:Laboratory Result
Division:
Medical Service
Section:
Laboratory Department
Indicator # 9
Safe Water & Proper Waste Disposal
15
10
5
0
2013
2014
2015
Benchmark
Test done and Passed
Performance 2015:
Passed
Performance 2014:
Passed
Indicator # 10
Quality Improvement Program
Source of Data:
Division:
Section:
All Division
All Sections
Indicator # 10
Quality Improvement Program
Initiatives from ARMMC:
1. Continuing quality improvement
education: RCA analysis
2. Support for several trainings for
employees re: CQI
3. Continue calibration of equipment
4. Regular review and improvement of
Quality Objectives
Indicator # 10
Quality Improvement Program
Plans:
1. ISO external audit to be
scheduled twice a year
2. On-going cable infrastructure
3. Surveillance audit to be
conducted every six months
Indicator # 10
Quality Improvement Program
60
40
20
0
No. of QI Projects
2013
2014
2015
Performance 2015:
Implemented
Performance 2014:
Implemented
8 Projects
8 Projects
Indicator # 11
Manpower Development & Ethics/ Training
Source of Data:
Training Needs Analysis,
Training Plans
Division: Training and Research
Division
Section:
All
Indicator # 11
Manpower Development & Ethics/ Training
Performance 2015:
Performance 2014:
Performance 2013:
62 Trainings Organized
29 Trainings Organized
47 Trainings Organized
Indicator # 11
Manpower Development & Ethics/ Training
Initiatives from ARMMC:
1. In House trainings:
TB-HIV Orientation
Provider-Initiated Counseling and Testing Orientation
Gender and Development (GAD) Planning and
Budgeting
ISO Awareness/Documentation Training/Seminar
Strategic Performance Management System (SPMS)
End-Users Forum on Project Procurement Management
Indicator # 11
Manpower Development & Ethics/ Training
Indicator # 11
Manpower Development & Ethics/ Training
Indicator # 11
Manpower Development & Ethics/ Training
Indicator # 11
Manpower Development & Ethics/ Training
Breastfeeding Orientation
Customer Service Training
Training in Environmental Management
Workshop on Medical Certification on the
Cause of Death
Hazard Analysis Critical Control Point Training
Seminar on Leprosy and other Tropical
Diseases
Good Clinical Practice Training
Indicator # 11
Manpower Development & Ethics/ Training
Initiatives from ARMMC:
1. Outside trainings:
Indicator # 11
Manpower Development & Ethics/ Training
Initiatives from ARMMC:
1. Outside trainings:
a.
POAP
b.
DBM
c.
AGIA
d.
PAGBA
Indicator # 12
Certification/ Recognition Given by an
External Body
Benchmark required by DOH: ISO Certified
Source of Data:
Certificates
Division:
All Division
Section: All Sections
Indicator # 12
Certification/ Recognition Given by an
External Body
Red Orchid Award
Hall of Fame
April 21, 2016
Mother and Baby Friendly Hospital
July 28, 2014
Indicator # 12
Certification/ Recognition Given by an
External Body
Philippine Health Research Ethics Board
Certificate of Accreditation
Level 3 Research Ethics Committee
March 17, 2016
Department of Health
Gold Awardee
Ospital ng Bayan: Malinis at Mabango
January 31, 2011
Indicator # 12
Certification/ Recognition Given
by an External Body
Philhealth Accredited
Center of Excellence
May 1, 2012 to April 30, 2015
NTP-Dots Accredited
ISO 9001:2015 Certified
May 2016
Indicator # 12
Certification/ Recognition Given by an External
Body
Initiatives from ARMMC:
1. Compliance of QMS
2. Regular conduct of ISO internal audit
3. Conduct of management review Plans
4. Certification for 18001
Indicator # 13
Customer Institutional Relations
Benchmark required by DOH:
90% of clients rate the hospital as
good or better
Source of Data:
Customer Satisfaction
Indicator # 13
Customer Institutional Relations
Initiatives from ARMMC:
1. Regular monitoring of our client satisfaction survey
2. Timely response to clients complaints
3. Strengthen awareness of patients rights
Plans:
1. Operationalization of pinoy kiosk
2. Improve patients waiting areas
Indicator # 13
Customer Institutional Relations
90%
90%
90%
80%
Benchmark
Client Satisfaction Rating
40%
0%
2013
2014
2015
Performance 2015:
Performance 2014:
Performance 2013:
92.93%
88.74%
83.86%
Indicator # 14
Functional Referral System
Source of Data:
Division:
Section:
Indicator # 14
Functional Referral System
Initiatives from ARMMC:
1. Working with Department of Health regarding
Province wide referral system ( DOH Manual)
2. Service Delivery Network
Indicator # 14
Functional Referral System
20
15
10
5
0
2013
2014
2015
Indicator # 15
Patient Engagement Programs
Source of Data:
Division: Medical and Nursing Divisions
Section: All Department and Wards
Indicator # 15
Patient Engagement Programs
40
20
0
2013
2014
2015
Performance 2015:
Performance 2014:
Performance 2013:
6 Projects
6 Projects
6 Projects
Indicator # 15
Patient Engagement Programs
1.
2.
Indicator # 15
Patient Engagement Programs
3. OB-Gyne
a. Buntis Day
b. Cervical Cancer Awareness Program
c. Basic Emergency Obstetric and Newborn
Care (BEmONC)
4. Internal Medicine
a. Asthma Club
b. Diabetes Organization of Eulogio
Rodriguez Sr.
Indicator # 15
Patient Engagement Programs
5. Anesthesia
6. Radiology
7. Psychiatry
a. Mental Health Program
8. Urology
a. DRE program
b. Prostatic Awareness
Indicator # 15
Patient Engagement Programs
9. Ophtha
a. Sagip Mata
b. Sight saving awareness
c. Cataract prevention and free
surgeries
Indicator # 15
Patient Engagement Programs
Plans:
1. Animal Bite Clinic
- For accreditation this year (2016)
- Training at RITM and DOH on:
a. RITM: May 16-18, 2016 to be
attended by selected ARMMC doctors and
nurses
b. DOH: May 23-25, 2016 to be attended
by selected ARMMC doctors and nurses
Indicator # 16
Programs on Good Governance and
Management
Source of Data:
Division: All Divisions
Section:
All Sections
Indicator # 16
Programs on Good
Governance and Management
20
No. of ongoing programs to improve governance
10
0
2013
2014
2015
Performance 2015 :
7 Programs
Performance 2014: 8 Programs
Performance 2013: 7 Programs
Indicator # 16
Programs on Good Governance and Management
Initiatives from ARMMC:
1. Compliance to Anti-Red Tape Act
2. ISO 9001:2015 Certification
3. Invitation of NGO representative during public
bidding
4. Presentation of proposed budget during civil
society forum organized by Regional Health Office
5. Membership of private professionals in Ethics
Committee
6. Continuing Training for RA 9184
- END OF PRESENTATION -