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HOSPITAL

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

An Act Increasing the Bed Capacity of Amang


Rodriguez Memorial Medical Center from 150 to
300 beds and Appropriating Funds thereof.

Authorized Bed Capacity

300 beds per R.A. 9419 of 2007

(Specialty/Medical Center/Regional/
Medical Center
Provincial/District/ Sanitarium/Special)
Category

DOH License Accreditation (2016)

150 beds: Level 3

PhilHealth Accreditation

150 beds/ Center of Excellence

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

Amang Rodriguez Memorial


Medical Center, a globally
responsive tertiary healthcare
facility providing patient-centered
service, excellent training and
relevant research.

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

to strict clinical and ethical standards of practice to assure


patients safety.

Maintain and acquire modern equipment, instruments and facilities to


guarantee hospital service reliability.

Acknowledge

the value and importance of our people who are


competent, dedicated and compassionate.

Nurture beneficial and harmonious relation with our service providers


and stakeholders

Gather,

evaluate and analyze clients feedback and continually


improve our management system.

Iyong kalusugan aming aalagaan

Accredited Training Programs

Indicator # 1
Philhealth Rate
(Philhealth reimbursement/Total hospital income x 100)

Benchmark required by DOH:


30% Philhealth Utilization Rate
Source of Data:
Division:
Section:

Report of Collection
Finance Service
Accounting Section

Indicator # 1
Philhealth Rate
90%
60%
30%
0%

30%
2013

30%
2014

30%

Benchmark
Philhealth Rate

2015

Performance 2015: 72.00%


Performance 2014: 61.00%
Performance 2013: 48.00%

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

(NBB qualified patients without OP


expenditure/NBB qualified patients x 100)

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

(No. of PHIC eligible patients admitted /


Total number of admissions x 100)
90%
60%
30%
0%

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

Length of Stay per Department


Department

CY 2015 CY 2014 CY 2013 Average

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

Performance 2015: 4.60%


Performance 2014: 3.70%
Performance 2013: 1.50%

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

Performance 2015: 0.86%


Performance 2014: 0.65%
Performance 2013: 1.00%

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

12 Test done and


12 Test done and

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

National Simultaneous Earthquake Drill

Indicator # 11
Manpower Development & Ethics/ Training

Violence Against Women and Children (VAWC)


Seminar
Wound and Stoma Seminar
Meningococcemia and Proper Use of Personnel
Protective Equipment
In-service IVT Updates/Seminar
GSIS Policies and Programs
Psychiatric Emergencies
Inpatient Product Team of Philhealth Benefits
Development
Suturing Workshop

Indicator # 11
Manpower Development & Ethics/ Training

Nutrition Workshop for Pediatric Residents


Brief Advice Tobacco Intervention Workshop
Seminar on Nutrition
Lecture on Prostate
Patient Safety and Safe Medication Practices
Workshop
Pedia Nutrition
Preparatory Meeting on Metrowide Earthquake Drill
Voluntary Blood Donation and Recruitment Program
Orientation on Guidelines for the Use of Various
Medical Equipment

Indicator # 11
Manpower Development & Ethics/ Training

Lactation Management Seminar


Essential Intrapartum Newborn Care Program
Counseling, Gender and Sexuality Seminar
Orientation for Newly Appointed / Promoted
Personnel
ARMMC Department of Internal Medicine Post
Graduate Course
Basic Life Support / Advance Cardiac Life
Support Course
Garantisadong Pambata Program

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:

a. Outside training conducted by:


- Civil Service Commission
- Commission on Audit

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

Division: All Division


Section: All Sections

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:

Medical Service and


Nursing Divisions
All Departments

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

No. of networking pro

15
10
5
0
2013

2014

Performance 2015: 8 Programs


Performance 2014: 8 Programs
Performance 2013: 5 Programs

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

No. of ongoing patient engagement projects for st

20
0
2013

2014

2015

Performance 2015:
Performance 2014:
Performance 2013:

6 Projects
6 Projects
6 Projects

Indicator # 15
Patient Engagement Programs
1.

2.

PATIENT ENGAGEMENT PROGRAMS


Pediatrics
Garantisadong Pambata
Kangaroo mother care
Breastfeeding clinic
General Surgery
Operation Bukol
Dugo Ko Buhay Mo in partnership with PCS
Surgical Outreach Program

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 -