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benchbook

scoring
guidelines
Accomplishing the Benchbook
Self-assessment Forms

2010 edition
BENCHBOOK SCORING GUIDELINES

INTRODUCTION ------------------------------------------------------------------------------------- 2

CHAPTER I: THE BENCHBOOK INDICATORS -------------------------------------------- 4

A. Indicators ----------------------------------------------------------------------------------------------------------------4

B. Evidences ---------------------------------------------------------------------------------------------------------------5

C. Code ----------------------------------------------------------------------------------------------------------------------9

CHAPTER II: BENCHBOOK SELF-ASSESSMENT FORMS -------------------------- 11

A. Self-assessment and Survey Tool ------------------------------------------------------------------------------ 11

B. Score Sheet----------------------------------------------------------------------------------------------------------- 11

C. Self-assessment Summary --------------------------------------------------------------------------------------- 14

CHAPTER III: CONDUCT OF SELF-ASSESSMENT/SURVEY ------------------------ 16


A. The PhilHealth Survey Process ---------------------------------------------------------------------------------- 16

B. Hospital Self-assessment ----------------------------------------------------------------------------------------- 21

CHAPTER IV: COMPUTATION OF SCORES --------------------------------------------- 22

A. Self-assessment and Survey Tool ------------------------------------------------------------------------------ 23

B. Score Sheet----------------------------------------------------------------------------------------------------------- 24

C. Self-assessment Summary --------------------------------------------------------------------------------------- 28

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BENCHBOOK SCORING GUIDELINES

INTRODUCTION

The Benchbook lays out the new standards for quality of care that PhilHealth will use for
accrediting hospitals into the National Health Insurance Program. The Benchbook
represents a shift from the old standards that govern only inputs to health care into the new
standards that also evaluate processes and outcomes of care.

The Benchbook is divided into seven performance areas: (1) Patient Rights and
Organizational Ethics, (2) Patient Care, (3) Leadership and Management, (4) Human
Resource Management, (5) Information Management, (6) Safe Practice and Environment
and (7) Improving Performance. Each performance area is divided into sub-areas except for
Patient Rights and Improving Performance. The sub-areas are broken down into several
standards with one or several criteria to each standard; one or several indicators to each
criterion; and one or several evidence to each indicator.

• Goal: declares the overall intent of the standards under it; picture of the desired-for
situation targeted by a performance improvement program
• Standard: delineates the best possible condition that should exist in the organization
for it to attain quality performance; sets the maximum achievable performance
expectations for activities that affect the quality of care
• Criterion: lays down specific actions that need to be done to meet the standard
• Indicators: measurable variables or characteristics that can be used to determine the
degree of adherence to a standard or achievement of quality goals
• Core indicators : characteristics that should be present for a hospital to
function as a facility providing care, treatment and diagnosis in a manner that
is safe and efficient for the patients and its staff
• Evidence: proof of compliance to the indicator which may be: document, interview or
observation

Since commitment to quality begins within the organization, PhilHealth employed a different
process in the new accreditation system using the Benchbook. Hospitals will now be
required to conduct a self-assessment as a requirement in the application for accreditation.
The self-assessment allows the hospital to evaluate itself and discern clearly its strengths
and areas in which improvements can be made. The self-assessment culminates in planned
improvement actions which are then monitored for progress.

Figure 1. The Benchbook accreditation process

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The new accreditation system using the Benchbook starts with the self-assessment by the
hospitals. The hospitals will set their own schedule (date and frequency) and process for the
conduct of the self-assessment.

The hospitals have to accomplish the Benchbook Self-assessment and Survey Forms
which consist of three parts:
1. Self-assessment and survey tool
2. Score sheet
3. Benchbook self-assessment summary

All three documents along with the PhilHealth application form for accreditation and other
documentary requirements for accreditation, once accomplished, are submitted to the
PhilHealth Regional Office (PhRO). Once the documents are assessed as complete and the
hospital has paid the corresponding fees, the PhRO and the hospital shall agree on the
schedule of the PhilHealth survey. Once conducted, the results of the PhilHealth survey are
forwarded to the Accreditation Committee and the PhilHealth president for decision.

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CHAPTER I: THE BENCHBOOK INDICATORS

A. Indicators

The seven performance areas of the Benchbook, including the goals, standards and
criteria have been published and disseminated as early as 2004. The indicators and
evidences came out a few years later, in 2009, after several workshops and
consultations with various stakeholders. In these workshops, the indicators, which
measure the adherence to the standards, were formulated for each criterion or standard
(if the standard has no criterion).

Indicators can be categorized as either qualitative or quantitative.

1. Qualitative indicators ask for the presence or absence of the listed evidences.
Examples are as follows:
• 1.2.a.1 Presence of policies regarding active participation of patients and
families in health care decisions
• 2.5.5.b.2 Presence of resources allocated for training, supervision and
evaluation of professionals who administer drugs
• 6.3.2.b.1 Presence of a coordinated system-wide procedure for isolation of
core nosocomial infections

2. Quantitative indicators, on the other hand, ask for the proportion of a certain
population that meets the requirements of the indicator, hence sampling is usually
employed. These indicators have corresponding formulas for computation stated in
the evidence. A few examples are:
• 1.1.a.1 All patient charts have signed consent.
core
• 2.2.3.b.1 Percentage of charts with unique identifiers for each patient
• 6.1.2.d.1 Percentage of personnel who understand and fulfill their role in
safe practice

During several workshops with stakeholders, core indicators were also identified.
These are characteristics that should be present for a hospital to function as a facility
providing care, treatment and diagnosis in a manner that is safe and efficient for the
patients and its staff. Core indicators are mandatory/non-negotiable. The hospitals must
comply with all 51 core indicators from all the seven performance areas. Table 1
shows a summary count of core indicators with corresponding examples for each of the
seven performance areas.

Table 1: Summary of indicators and core indicators per performance area


CORE Example of CORE
Performance Area Indicators
Indicators indicator
1. Patient Rights and All patient charts have
19 1
Organizational Ethics signed consent
All patients have
comprehensive history
2. Patient Care 112 15
and PE within 24
hours from admission

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CORE Example of CORE
Performance Area Indicators
Indicators indicator
Proof of creation of all
committees within the
3. Leadership and organization which
14 3
Management includes terms of
reference for
membership
Presence of policies and
4. Human Resource procedures for
27 2
Management credentialing and
privileging of staff
Presence of policies and
5. Information
15 3 procedures on filing
Management
and retrieval of charts
Presence of
generator/emergency
6. Safe Practice and
38 25 light, water system,
Environment
adequate ventilation or
air conditioning
Presence of Quality
7. Improving Performance 12 2
Improvement Program
TOTAL 237 51

B. Evidences

There may be one or several evidences or proofs of compliance under one indicator.
The evidence may come in any of the following types:

1. Document

The documentary requirements of the benchbook may come in a variety of forms.


Policies and procedures comprise the majority of the documents. Licenses,
logbooks, memoranda, issuances, reports and minutes of meetings are other
examples.

The documents are classified further into document review, chart review and
document:

o Document review

These are general documents relevant to the whole hospital. These include the
licenses and permits from regulatory agencies, contracts or memoranda of
agreement, minutes of meetings, hospital-wide policies and procedures,
memoranda and issuances, etc.

These are prepared by the hospital prior to the PhilHealth survey, properly
identified as to which standard they belong to, and placed in a suitable,
conveniently located room where the surveyors can review them. Examples are
shown in Table 2.

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Table 2. Sample of indicators with document review as part of evidence
CODE INDICATOR EVIDENCE
1.4.a.1 Presence of policies for DOCUMENT REVIEW
routinely determining and 1. Policies for routinely determining
improving the level of and improving the level of patient
patient satisfaction satisfaction
2. Patient satisfaction
questionnaire/survey or patient
satisfaction survey results or
documentation of actions to
address the identified gaps
2.1.1.b.1 Presence of facilities DOCUMENT REVIEW
core consistent with clinical 1. List of services available
service capability based 2. DOH License
on DOH license in
accordance with the OBSERVATION
hospital’s level (e.g. level 2 Look at the facilities, structure,
– surgical capability, level manpower, equipment and supply.
3 – ICU, level 4 – teaching Check if the service capability of the
and training hospital) hospital is in accordance with the
CORE hospital level.

o Chart review

These are randomly chosen patient charts or medical records (medical and
surgical) from the medical records office of the hospital. Examples are shown in
Table 3.

Table 3. Sample of indicators with chart review as part of evidence


CODE INDICATOR EVIDENCE
2.3.3.d.3 All patients for CHART REVIEW
core surgery have Patient chart from medical records (surgery
undergone pre- patients)
operative
anesthetic Note: Look for pre-operative anesthetic
assessment evaluation in the patient chart. Pre-
CORE operative assessment should be done for
patients requiring more than local
anesthesia.

Formula: Number of patients with pre-


operative anesthesia/ Number of patients
for surgery reviewed x 100
2.5.5.c.2 Percentage of CHART REVIEW
charts with orders Doctor’s orders in patient charts from medical
for drug records
administration that Orders that were made by interns should
were made by be countersigned by licensed residents or
licensed doctors consultants

Formula: Number for charts with orders for


drug administration made by licensed
doctors/number of charts reviewed x 100

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o Document

These are specific documents relevant to specific areas of the hospital: wards,
emergency room (ER), out-patient department (OPD), intensive care unit (ICU),
operating room (OR), pharmacy, laboratory, imaging, medical records, facilities
and maintenance, human resources and others. These may include logbooks,
licenses of personnel, protocols, clinical practice guidelines, operations manual,
etc and exclude documents that are applicable to the whole hospital, which are
categorized under “document review” discussed earlier.

Patient charts will also be assessed in some areas – wards, ER, etc. This is
separate from “chart review” done for patient charts or medical records already
stored in the medical records office. Examples are shown in Table 4.

Table 4. Sample of indicators with document as part of evidence


CODE INDICATOR EVIDENCE
2.2.2.c.1 Percentage of patients DOCUMENT
correctly assigned to Patient chart from ward and ICU
the clinical services
appropriate to their Note: Determine if the service the patient
needs is admitted to coincide with the patient’s
chief complaint and working diagnosis.

Formula: Number of patients correctly


assigned to the clinical services
appropriate to their needs/total number
of patients interviewed x 100
6.1.1.c.2 Presence of operations DOCUMENT
core manuals of the medical Operations manuals for the medical
equipment equipment
CORE

2. Interview

To validate the implementation and monitoring of certain policies, procedures or


programs of the hospital, the surveyors will interview leaders, doctors, nurses, other
hospital staff as well as patients and their families or caregivers. Examples are
shown in Table 5.

Table 5. Sample of indicators with interview as part of evidence


CODE INDICATOR EVIDENCE
1.5.a.2 Presence of DOCUMENT REVIEW
programs on Documents related to implementation of the
improving staff program e.g. copy of lectures on professional
awareness on conduct and related topics
codes of
professional INTERVIEW
conduct and other Ask staff (HR) about the programs on awareness
statutory standards on codes of professional conduct and other
statutory standards

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CODE INDICATOR EVIDENCE
2.1.1.c.1 Percentage of INTERVIEW
patients who are Ask patients or relatives/caregivers from ER and
aware of the OPD if they are aware of the clinical services
services provided offered and times of availability
by the hospital
Note: Ask only about the services relevant to the
patient or caregiver

Formula: Number of respondents who are aware


of the services/number of respondents x 100
3.1.3.x.1 Proof of the DOCUMENT REVIEW
core creation of all Proof of the creation of all committees which
committees within includes the terms of reference for membership
the organization e.g. memo, office order, etc.
which includes the
terms of reference INTERVIEW
for membership Ask leaders what the committees in their hospital
CORE are and ask for the order that created these
committees

3. Observation

Certain structures (signages, facilities, equipment, supplies, etc) and some


procedures (hand hygiene, drug administration, etc) will also be observed. Examples
are shown in Table 6.

Table 6. Sample of indicators with observation as part of evidence


CODE INDICATOR EVIDENCE
2.1.1.a.1 Presence of signages, OBSERVATION
posters and other 1. Look for signage/s of services offered
information or presence of flyers, posters,
materials/media detailing pamphlets about the services offered
the clinical and ancillary and the hours of availability at the ER,
services offered and OPD, lobby and hospital perimeter
hours of availability 2. The hours of availability are indicated in
the signage/s , flyers, posters or
pamphlets at the ER, OPD, lobby and
hospital perimeter
3. “PhilHealth accredited” signage, if
applicable
5.2.1.a.1 Percentage of charts OBSERVATION
retrieved within the Ask the records keeper to retrieve charts,
standard set by the then note the actual length of time of
organization retrieval

Formula: Number of charts retrieved within


the time interval set by the organization
/number of charts asked to be retrieved x
100

Note: If the organization has not set a time


interval, use 15 minutes.

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CODE INDICATOR EVIDENCE
6.3.3.a.1 Presence of policies and DOCUMENT REVIEW
core procedures on the 1. Policies and procedures for prevention
prevention and treatment and treatment of needle stick injuries
of needle stick injuries 2. Policies and procedures on proper
and safe disposal of handling and safe disposal of
needles sharps/needle sticks
CORE
INTERVIEW
Interview hospital staff on how they handle
and dispose needles

OBSERVATION
Presence of receptacles for proper disposal
of sharps

C. Code

For easier reference, each of the 237 indicators of the Benchbook is assigned
alphanumeric codes, which are based on the levels or divisions of the benchbook
indicators – performance area, sub-area, standard, criterion and indicator.

The code may be 4 or 5 characters depending on whether the performance area has a
sub-area or none. Both patient rights and organizational ethics and improving
performance have only one sub-area under them and thus have only 4 characters in
their codes as follows:

Figure 2. Four-character code

The other performance areas – patient care, leadership and management, human
resource management, information management and safe practice and environment, all
have 2 or more sub-areas under them, hence the codes are as follows:

Figure 3. Five-character code

Note also that in both cases, the criterion is always represented by a letter code. This
will be of importance during the discussion of the scoring system later on.

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As mentioned, the performance areas have one or several sub-areas. Each sub-area is
further divided into one or several standards; the standards into criteria; and criteria into
indicators. However, there are cases when the standard does not have a criterion
under it such as in patient care, leadership and management, safe practice and
environment and improving performance. In these instances, the standard serves as the
criterion and the criterion is represented by an ‘x’ in the code. Examples are shown in
Table 7.

Table 7. Sample of indicators with ‘x’ in indicator code


CODE Standard Criterion Indicator
2.7.1.x.1 The discharge plan is part of All charts have discharge
core the patient’s care plan and is plans.
documented in the patient CORE
chart.
3.1.4.x.1 The organization’s Presence of evaluation and
core management team regularly monitoring activities to
assesses its own assess management and
performance and the organizational performance.
performance of the CORE
organization.
6.3.4.x.1 When needed, the Presence of policies and
core organization reports procedures on reporting of
information about infections infections to personnel and
to personnel and public public health agencies
health agencies. CORE
7.5.x.1 Managers and staff evaluate Proof of evaluation of the
the effectiveness of the quality improvement
quality improvement program
program and take action to
address any improvements
required.

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CHAPTER II: BENCHBOOK SELF-ASSESSMENT FORMS

A. Self-assessment and Survey Tool

The self-assessment to be conducted by the hospitals utilizes the same tool that will be
used during the PhilHealth accreditation survey. This tool, called the Self-assessment
and Survey Tool, contains the goals, standards, criteria, indicators and evidences under
each performance area.

The self-assessment and survey tool has eight columns as shown in Table 8. The first
column, ‘CODE,’ contains the unique alphanumeric code for each indicator and the tags
for the core indicators. The second, third and fourth columns contain the STANDARDS,
CRITERIA and INDICATORS respectively. The standards and criteria that appear in the
self-assessment and survey tool are the same standards and criteria that were published
in the “Benchbook on Performance Improvement of Health Services” (PhilHealth, 2004).
The next two columns, labeled ‘HOSP’ and ‘PHIC,’ contain blank spaces, which shall be
used to indicate compliance to the evidence marked with a check ‘’ or noncompliance
marked with an ‘x’. The evidences are listed in the 7th column. The last column, 8th,
labeled ‘REMARKS’ may be used by the hospital and surveyor for comments and
explanations.

The self-assessment and survey tool is divided into 15 sections representing 3 process
areas (document review, chart review and leadership interview) and 12 hospital areas
(wards, ER, OPD, ICU, OR, pharmacy, laboratory, imaging, medical records, facilities
and maintenance, human resources and others). These sections contain all the
applicable indicators, which means that an indicator may be found in one or several
sections. This also means that the indicators are not arranged successively from 1.1.a.1
(the first indicator under patient rights) to 7.7.x.1 (last indicator of improving
performance).

In Table 9, a sample page from the masterlist (the complete listing of all indicators of the
benchbook), the sixth column labeled ‘SECTION’ indicates the applicable sections (or
process/hospital areas) where an indicator may be appropriated (the applicable sections
may also be found in the fifth column of the Score Sheet – refer to Table 10). To
illustrate, Indicator 2.2.1.b.1 is found in one section of the self-assessment and survey
tool only – the document review section (section 1). Indicator 2.2.1.b.2, on the other
hand, can be found in 5 sections: ER (section 5), OPD (section 6), wards (section 4),
imaging (section 9) and laboratory sections (section 10).

For reference, the labels for each section are found on the upper right hand corner of
each page of the Self-assessment and Survey Tool.

B. Score Sheet

The score sheet will be used to document consolidation of the findings from the survey of
the different hospital areas including the document review, chart review and the
leadership interview. As shown in Table 10, the score sheet has eight columns. As in
the self-assessment and survey tool, the first column contains the alphanumeric code for
each indicator. But in contrast with the self-assessment and survey tool, the indicators in
the score sheet are arranged successively starting with the first indicator of patient rights
to the last indicator of improving performance, much like in the masterlist found in Table
9.

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Table 8. Sample page of Self-assessment and Survey Tool – Document Review Section

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Table 9. Sample page of masterlist of Benchbook indicators showing the applicable sections per indicator

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The second (HOSP) and third (PHIC) columns contain blank spaces which correspond to
the evidences listed in the fourth column (EVIDENCE) and shall be used to mark (as 
or X) the consolidated findings per indicator. The sixth column (SECTION) lists the
applicable sections per indicator and shall serve as a guide for the survey team as to
which sections to consolidate for each indicator.

The hospital and the PhilHealth surveyor shall indicate the appropriate scores in the
seventh (SELF-ASSESSMENT SCORE) and eight (SURVEYOR SCORE) columns
respectively, by encircling the corresponding number (1, 2, 3 or 4). For this, the hospital
and the surveyor may refer to the scoring scale found at the bottom left corner of each
page of the score sheet as shown in Table 10. This will be further elucidated in the
discussion of the scoring.

The last column, REMARKS, may be used by the hospital for comments and
explanations for non-applicability of certain evidences or indicators in their setting and by
the surveyors for comments and explanations regarding differences of scores with the
self-assessment. Equivalent evidences found in the hospital which fulfill the
requirements of the indicator may also be recorded here. Proportion of samples
interviewed for certain evidences may also be written the REMARKS column. This will
be discussed further in Chapter IV. A.

C. Self-assessment Summary

The hospitals will use the


Benchbook Self-assessment
Summary, the third of the
Benchbook Self-assessment
Forms, to document the scores of
the hospital in the different
performance areas and their
compliance with the core indicators.

The first seven rows of the first


table ask for the general profile of
the hospital. In the last row, the
hospital, based on their scores in
the different performance areas will
need to choose which of the
accreditation awards they want to
apply for. The requirements for the
different accreditation awards will
be discussed at length in the
section on Computation of Scores.

Computations for the numbers and


percentages needed for the second
and third tables will be explained in
the Chapter IV.

Figure 4. Benchbook Self-assessment


Summary

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Table 10. Sample page of the Score Sheet

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CHAPTER III: CONDUCT OF SELF-ASSESSMENT/SURVEY

A. The PhilHealth Survey Process

The following process shall be utilized by PhilHealth during the accreditation survey.
The hospitals may employ the same process for self-assessment or they may opt to
devise their own system.

PhilHealth and the hospital shall agree on the schedule of the survey. The hospital on
the other hand, shall prepare the necessary documents – policies and procedures,
licenses and permits, logbooks, charts, etc. before the survey. To facilitate the survey
process, the hospital shall tag or label their policies with the corresponding codes of the
indicators that they apply to. Also, the management team and relevant hospital
personnel (committee heads and members, program heads, etc) should be available
during the survey for interview.

The survey shall be done by a team of at least three surveyors regardless of the level of
care (Levels I, II, III and IV). The team leader should be a doctor while the rest of the
team may be allied medical professionals or other technical staff. The 15 sections of the
Self-assessment and Surveyor Tool shall be divided among the three surveyors
depending on their competencies and expertise.

The survey process will generally proceed as follows:

1. Opening conference

The survey team meets with the hospital management and briefly discusses the
survey process. The hospital shall orient the survey team regarding the general
layout of the hospital and introduce the hospital coordinator to the survey team. The
hospital coordinator shall assist the surveyors throughout the duration of the survey.

2. Document review session

Table 11. Sample of Section 1 – Document Review Section taken from the Self-
Assessment and Survey Tool

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Policies and procedures, permits and licenses, logbooks, charts, contracts,
memoranda, etc. shall be prepared and placed by the hospital in a suitable,
conveniently located room (from hereon shall be referred to as the document review
room) where the surveyor team can go through them. The first section of the self-
assessment and survey tool – the document review section (see Table 11), shall be
used and filled out by all surveyors during this time. However, only evidences
marked as document review should be assessed at this point. Indicators with
evidences marked as document, interview, chart review or observation shall be
assessed in other sections.

The other sections – wards, laboratory, leadership interview, etc, with evidences
marked as ‘document review’ should also be filled out at this point. An example can
be found in Table 12. The procedures in asepsis for indicator 6.3.2.b.3 and both
policies and procedures for indicator 6.3.3.a.1 will be part of the documents prepared
by the hospital prior to the survey and placed in the document review room and
should be assessed by the surveyors during the document review session.

Table 12. Sample of Section 10 – Laboratory Section taken from the Self-
Assessment and Survey Tool. Evidences marked as document review in all sections
of the self-assessment and survey tool should be assessed during the document
review session. The rest of the evidences will be assessed during the tour of the
different hospital areas.

3. Presentation of hospital’s quality improvement program

The management team or the Quality Assurance Committee shall present the
hospital’s quality improvement (QI) program to the survey team. Questions or
clarifications regarding the QI program especially those pertaining to the indicators
on Improving Performance (refer to Table 13) should be addressed during this
session.

4. Leadership interview session

The management team consists of the hospital director, or chief of hospital or chief
health officer together with the administrative officer and/or service/department
heads. Clarifications regarding the documents reviewed during the document review
session shall be discussed. The second section of the tool – the leadership interview
section (see Table 14) shall be used and answered at this point. Questions for the
management team as enumerated in the different indicators (and corresponding
evidences) from section 2 (leadership interview) should be raised.

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The survey team leader should take charge in interviewing the management team;
however, anyone from the survey team may ask questions. Also, one member of the
survey team should be assigned to mark (as  or X) the responses of the
management team in section 2 of the self-assessment and survey tool.

Evidences labeled as ‘document review’ such as policies and procedures or permits


and licenses, etc. should have been assessed during the document review session.

Table 13. Sample of Section 1 – Document Review Section taken from the Self-
Assessment and Survey Tool.

Table 14. Sample of Section 2 – Leadership Interview Section taken from the Self-
Assessment and Survey Tool

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5. Tour of hospital facilities

Armed with the section tools assigned to them, the surveyors shall now tour the
hospital facilities – wards, ER, OPD, ICU, OR, pharmacy, laboratory, imaging,
medical records, facilities and maintenance, human resources and others or
whichever are applicable. Each surveyor should go to his/her assigned hospital area
to look at documents, interview doctors, nurses, patients and other staff and observe
for presence or absence of certain facilities/equipment and the practice of hospital
policies and procedures. The surveyor should mark the findings (as  or X) in the
appropriate sections of the self-assessment and survey tool (fifth column for hospitals
and sixth column for PhilHealth surveyors).

Evidences labeled as ‘document review’ such as policies and procedures or permits


and licenses (see Table 15 and 16) should have been assessed during the document
review session.

The surveyors need only assess the applicable hospital areas. For example, in a
primary hospital that does not have an operating room or an intensive care unit
(ICU), sections 7 (ICU) and 8 (operating room) need not be filled out.

Table 15. Sample of Section 4 – Wards Section taken from the Self-Assessment and
Survey Tool

Table 16. Sample of Section 5 – Emergency Room Section taken from the Self-
Assessment and Survey Tool

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The chart review is part of the sections distributed to the surveyors and is also a part
of this session. Charts for chart review shall be taken from the medical records
section. The charts shall be reviewed by an assigned surveyor in the document
review room using Section 3 – Chart Review of the self-assessment and survey tool.
An example is shown in Table 17.

Table 17. Sample of Section 3 – Chart Review Section taken from the Self-
assessment and Survey Tool

*For surveys lasting more than a day, the survey team should conduct wrap up
meetings at the end of each day to discuss significant findings, problems and
difficulties. The problems or issues encountered should be discussed by the survey
team with the hospital through the coordinator at the start of the following day during
the daily hospital briefings.

6. Surveyor meeting

After filling out all applicable sections of the self-assessment and survey tool, the
surveyors can already meet at the document review room to discuss and consolidate
their findings.

First on the agenda is the finalization of the findings in all of the sections of the self-
assessment and survey tool. The surveyors should make sure that all blanks have
been answered in all sections assigned to them. Compliance (), noncompliance (X)
or non-applicability (NA) of each evidence should have been assessed and
documented (fifth column for hospitals and sixth column for PhilHealth surveyors).
Details on how to score will be discussed under the Chapter IV.

After finalizing the findings for each evidence, the survey team can now begin
consolidating the findings for each indicator. The survey team has to go through
each indicator, using the fifth column of the score sheet (SECTIONS) as guide on
what sections they should consolidate. After consolidating the ’s and the X’s, the
survey team should score each indicator (1, 2, 3 or 4) using the scoring scale (refer
to Chapter IV for a more detailed discussion). The score should be indicated in the

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sixth and seventh columns (SELF-ASSESSMENT SCORE and SURVEYOR SCORE
respectively) by encircling the corresponding number. Comments and notes should
be documented in the REMARKS column.

There is no need for the survey team to compute for the percentage of compliance of
the hospitals at this point. They do, however, need to summarize the general
findings for presentation during the closing conference. Important points to include
are core indicators not complied with, high performing or low performing hospital
areas and the general performance on the different Benchbook performance areas.

In contrast, the hospitals using this same process for their self-assessment need to
do the computations and fill out the third part of the Benchbook forms – Benchbook
Self-assessment Summary.

7. Closing conference

Again, the survey team meets with the hospital top management and summarizes the
findings of the survey. Percentage compliance for each performance area and the
accreditation award achieved by the hospital is not part of the summary given to the
hospital. The results of the survey will be forwarded to the Accreditation Committee
for deliberation. The recommendations are forwarded to the PhilHealth president for
decision.

B. Hospital Self-assessment

The self-assessment is a venue for the hospital to assess its own strengths and
weaknesses and evaluate what it already has and what it still needs. It is an evaluation
of the hospital’s own performance measured against the standards, criteria and
indicators of the Benchbook. Also, it allows the hospitals to demonstrate to the
PhilHealth surveyors their level of achievement of the Benchbook indicators.

The process described in The PhilHealth Survey Process under Chapter III: Conduct Of
Self-Assessment/Survey may be adopted by the hospital or they may devise their own
way of conducting the self-assessment and accomplishing the Benchbook and Self-
assessment and Survey Forms.

Should the hospital choose to adopt the PhilHealth survey process, then the first step is
to form a self-assessment survey (SAS) team of three who will conduct the survey. The
SAS team may consist of employees from the hospital or independent quality/technical
experts commissioned by the hospital. The SAS team shall simulate the PhilHealth
survey – review the documents of the hospital, interview the top management, tour the
entire hospital facility, interview doctors, patients and nurses and review patient charts,
and in the process accomplish the Benchbook and Self-assessment and Survey Forms
(self-assessment and survey tool, score sheet and self-assessment summary). The
hospital management should decide, based on the results of the self-assessment, which
accreditation award to apply for. For the detailed discussion of the accreditation award
and scoring, please refer to Chapter IV.

The hospitals need to do the self-assessment at least once a year, in time with the
application for accreditation. However, the hospitals may choose to do it more frequently
depending on their targets.

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CHAPTER IV: COMPUTATION OF SCORES

For the Benchbook accreditation, the hospitals will need to compute for their percentage of
compliance. Depending on their computed scores, the hospitals may apply for and be given
any of the following awards (Table 18): center of excellence, center of quality or center of
safety.

The minimum award a hospital may be given is the center of safety award. To qualify as
center of safety, the hospital must have 100% compliance to all applicable CORE indicators
(from all 7 performance areas) and 60% compliance to patient’s rights and organizational
ethics, 60% compliance to patient care and 60 % compliance to safe practice and
environment. For center of quality, the hospital must comply with 3 more performance
areas: leadership and management, human resource management and information
management. Also, there is a higher percentage requirement: 75% for each of the six
enumerated performance areas. For the highest award – center of excellence, the hospital
needs 90% compliance to each of the seven performance areas. For all three awards, the
hospital must comply with 100% or all of the applicable CORE indicators. A summary of
the accreditation awards is in Table 18.

Table 18. Summary of Accreditation Awards


AWARD REQUIREMENTS
Compliance to 100% of CORE indicators AND
Center of Excellence
90% Compliance to each of the 7 performance areas
Compliance to 100% of CORE indicators AND
75% Compliance to each of the following:
• Patient’s Rights and Organizational Ethics
• Patient Care
Center of Quality
• Leadership and Management
• Human Resource Management
• Information Management
• Safe Practice and Environment
Compliance to 100% of CORE indicators AND
60% Compliance to each of the following:
Center of Safety • Patient’s Rights and Organizational Ethics
• Patient Care
• Safe Practice and Environment

In case a hospital does not meet the requirements for the minimum accreditation award
(center of safety), it is not automatically denied accreditation. If the percentage compliance
of the hospital to each of the safety standards – patient rights and organizational ethics,
patient care and safe practice and environment, is at least 50% and the hospital has
complied with at least 70% of the CORE indicators, then the hospital may be given
provisional accreditation. Additional requirements for provisional accreditation include a
temporary plan of action to address the gap and a plan for attainment of the minimum
accreditation award including the time of achievement. The hospitals given provisional
accreditation shall be monitored by their respective PhilHealth Regional Offices and will be
given 6 months to correct the deficiencies. The hospital will be assessed at the end of six
months and shall be given the appropriate accreditation decision.

The computation of percentage compliance for each performance area involves a series of
steps which starts with the consolidation of findings from all 15 sections (or whichever are
applicable to the hospital) of the self-assessment and survey tool during the surveyor
meeting (see Chapter III)

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The succeeding section discusses in detail the procedure for the computation of the
percentage compliance for each performance area.

A. Self-assessment and Survey Tool

The first step in the computation of scores is the finalization of findings for each evidence
in all sections of the self-assessment and survey tool. All blanks should have been filled
in. Generally, for qualitative indicators (refer to Chapter I), a  is used to indicate
compliance with the evidence; an X to indicate noncompliance; and NA to indicate
that the evidence is not applicable to the hospital. However, some evidences of
qualitative indicators require the surveyor to get samples. In these cases, the proportion
of samples evaluated expressed as fraction is indicated in the REMARKS column. Table
19 shows examples of such evidences. In indicator 1.5.a.2, the remarks column
indicates that during the self-assessment of the hospital, 5 HR staff were interviewed and
all 5 satisfactorily validated the presence and the implementation of programs of the
hospital on awareness on codes of professional conduct (HOSP – 5/5). During the
PhilHealth survey, however, only 4 of the 5 interviewed were able to validate the
programs (PHIC – 4/5). Nonetheless, the hospital still gets a  for the evidence. For
evidences of qualitative indicators that require a sample, a hospital area is said to
be compliant if more than 50% of the samples satisfy the requirements of the
evidence. Thus in the example, indicator 1.5.a.2, the hospital area was considered
compliant () because 80% of the staff were able to validate the program.

Table 19. Sample of Qualitative Indicators Requiring Samples

For quantitative indicators (refer to Chapter I), instead of a  or an X, the proportion


of samples evaluated expressed as fraction is indicated in the blank space under
the HOSP (for hospitals) and PHIC (for PhilHealth surveyors) columns. This is
illustrated in Table 20.

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Table 20. Sample of Quantitative Indicators

B. Score Sheet

The second step is the consolidation of findings from all the 15 sections of the self-
assessment and survey tool. The surveyor team will go through each indicator and
agree, based on the findings during the tour of the different areas and guided by column
5 (SECTION) of the score sheet (see Table 10), on the score for every indicator.

An indicator may be appropriated in one or more sections and should be consistently


implemented in all those sections. To consolidate findings for each indicator, the
surveyors (SAS team or PhilHealth) should:

1. Look at each enumerated section and make sure all applicable blank spaces are
filled in. Column 5 of the score sheet shows all the applicable sections per indicator
(Table 10).
2. For each section, count the number of evidences complied with ( ) by the hospital.
3. Determine which among the enumerated sections has the lowest ratio of complied
evidences ( ’s) versus the available evidences ( ’s + X’s) (Figure 5). Note that if
an evidence is not applicable in that section (NA), then this is not included in the total
count of evidences for that indicator in that section, hence is not included in the
formula.

Figure 5.

When determining the section with the lowest ratio based on the formula in Figure 5,
only 13 sections are considered –chart review, wards, emergency room, OPD, ICU,
operating room, imaging, laboratory, human resource, medical records, pharmacy,
facilities and maintenance and others. The document review and the leadership
interview sections are never considered unless they are the only sections
enumerated for that indicator.

An example is shown in Tables 21 to 24. Indicator 1.2.b.1 is evaluated in 4 sections:


document review, ER, wards and ICU (refer to Table 26, fifth column). Notice that in
Table 21, only the document review was assessed. The findings in the document
review session, as recorded in the document review section, apply to the same
 for policies
evidences found in the other sections. Therefore, the same findings (

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and procedures on involvement of patients and their families in making decisions on
their health care…) may be noted in all sections (document review, ER, wards and
ICU). This also means that the document review evidences need not be assessed in
the other enumerated sections once evaluated during the document review session.
However, the findings are recorded in all the applicable sections.

To determine the section with the lowest ratio, each section is assessed individually.
For 1.2.b.1, only 3 of the 4 sections are considered. The document review section is
not part of the sections considered during consolidation.

Table 21. Sample of Section 1 – Document Review

Table 22. Sample of Section 4 - Wards

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Table 23. Sample of Section 5 – Emergency Room

Table 24. Sample of Section 7 – Intensive Care Unit

In Table 22 (Section 4 – Wards), of the three evidences enumerated, all of which are
).
applicable in the area, only two of the three evidences have been complied with (
In Table 23 (Section 5 – ER), only two of the three evidences are applicable and both
have been complied with. In Table 24 (Section 7 – ICU), all three evidences are
applicable but only two of the three have been complied with. To summarize:

Table 25. Summary of findings for Indicator 1.2.b.1 (Based on


Tables 21 to 24)
Section /(
Ratio [  + X)] Source
Section 1 – Document review Not considered Table 21
Section 4 – Wards 2/3 Table 22
Section 5 – ER 2/2 Table 23
Section 7 – ICU 2/3 Table 24

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The lowest ratio based on the findings is 2/3 – wards and ICU (Table 25). In such
cases when two or more sections have equivalent ratios, any of the sections may be
used for recording to the score sheet. In Table 26, Section 4 – Wards (Table 22) was
used.

Table 26. Sample of Score Sheet showing the consolidated findings and the self-
assessment score for a qualitative indicator

For quantitative indicators, as was discussed in Chapter IV. A, instead of ’s and
X’s, the proportion of samples evaluated expressed as fraction is indicated in the
blank. In consolidating therefore, the section with the smallest fraction is selected.

Table 27. Sample of Section 5 – Emergency Room

Table 28. Sample of Section 6 – Outpatient Department

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Table 29. Sample of Score Sheet showing the consolidated findings and the self-
assessment score for a quantitative indicator.

4. Input the findings from the selected section into columns 2 – HOSP (for SAS team) or
3 – PHIC (for PhilHealth surveyors).
5. After consolidating the findings, the hospital can now be scored per indicator. For
this, the scoring scale is used as a reference (Table 30).

Table 30. The Scoring Scale

For qualitative indicators, the number of ’s is divided by the total number of
evidences for the indicator (Evidences marked as not applicable are not included in
the count). The quotient is then converted to percentage and the equivalent score is
determined based on the scoring scale. For quantitative indicators, the fraction is
converted to percentage and the corresponding score is determined using the
scoring scale.

In Table 26, 1.2.b.1, a qualitative indicator, has three evidences and 2/3 or 66.67%
has been complied with. Based on the scoring scale, the indicator score is 3, hence,
3 is encircled. In Table 29, 2.1.1.c.1, a quantitative indicator, has only one evidence
with 5/10 compliance (Figure 20) or 50%. Using the scoring scale, the equivalent
score is 3.

C. Self-assessment Summary

The Self-assessment Summary, the last of the three parts of the Benchbook Self-
assessment Forms (see Figure 4), is accomplished by the hospital only. This form will
show the final percentage compliance of the hospital for each performance area and
thus will serve as their guide in determining which accreditation award to apply for.

The following are the steps to get the percentage compliance for each performance area:

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1. Compute for the score for each criterion.

The criterion score is the average of all the core and non-core indicator scores, (also
known as the self-assessment score or the surveyor score) under that criterion. It is
thus necessary to determine which indicators are under which criterion.

As mentioned in Chapter I: Benchbook Indicators under C. Code, the letter codes


always denote the criterion. The letter codes are used to identify the criterion and the
indicators under it. Each change in the letter code denotes a different criterion. For
example, in Table 31, which shows the performance area Improving Performance,
7.1.x.1 is the lone indicator for criterion 7.1.x; 7.2.a.1, 7.3.x.1, 7.4.x.1, 7.5.x.1 and
7.7.x.1 are also all lone indicators for their criterion – 7.2.a, 7.3.x, 7.4.x, 7.5.x and
7.7.x respectively. In contrast, criterion 7.2.b and 7.6.x both have 3 indicators under
them – 7.2.b.1, 7.2.b.2 and 7.2.b.3 and 7.6.x.1, 7.6.x.2 and 7.6.x.3, indicated by the
boxes.

To get the average of the indicator scores, the sum of the indicator scores is
computed and then divided by the number of indicators and can be summarized as
follows:

2. Get the sum of all the criterion scores for each performance area.
3. Count the number of applicable criteria for each performance area. Criteria that are
not applicable for the hospital should not be included.
4. Compute for the maximum possible score for each performance area.

The maximum possible score is computed as follows:

5. Compute for the percentage compliance per performance area or performance area
score.

The formula for the performance area score is:

The steps are repeated until all performance area scores for all seven performance
areas have been computed. The results are then recorded in the Benchbook Self-
assessment Summary.

SAMPLE COMPUTATION:

The step-by-step process of computing the performance area scores will be illustrated
using the sample score sheet in Table 31. Table 31 shows the hypothetical self-
assessment scores of a hospital for the last performance area of the Benchbook –
Improving Performance.

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Step 1:
For criteria with lone indicators, the
criterion score is equivalent to the
indicator score:

Criterion score = indicator 1 ÷ 1


= indicator 1

Hence, the indicator scores for 7.1.x.1,


7.2.a.1, 7.3.x.1, 7.4.x.1, 7.5.x.1 and
7.7.x.1 (which are all lone indicators) will
also be the criterion scores (refer to
Table 31).

For 7.2.b and 7.6.x, the computation is


as follows:

7.2.b = (7.2.b.1 + 7.2.b.2 + 7.2.b.3) ÷ 3


= (3 + 3 + 1) ÷ 3
=7 ÷3
= 2.33

7.6.x = (7.6.x.1 + 7.6.x.2 + 7.6.x.3) ÷ 3


= (4 + 1 + 1) ÷ 3
=6 ÷3
=2 Table 31

A summary for the computation of criterion scores is found in Table 32.

Table 32. Summary of Criteria Scores


SELF-ASSESSMENT CRITERION
CODE
SCORE SCORE
7.1.x.1
4 4
core
7.2.a.1 4 4
7.2.b.1 3
7.2.b.2 3 2.33
7.2.b.3 1
7.3.x.1 3 3
7.4.x.1 3 3
7.5.x.1 1 1
7.6.x.1
4
core
2
7.6.x.2 1
7.6.x.3 1
7.7.x.1 3 3

Steps 2 and 3:
Steps 2 and 3 are straightforward. The sum of all the criterion scores is:

Sum of criterion scores = 4 + 4 + 2.33 + 3 + 3 + 1 + 2 + 3


= 22.33

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The total number of criteria for improving performance is 8. Criteria with ‘x’ codes
which technically don’t have criteria are also counted because in these instances, the
standard serves as the criterion.

Step 4:
As counted in step 3, there are 8 criteria for improving performance. The maximum
possible score is computed as follows:

Maximum Possible Score = 8 x 4


= 32

Step 5:
The performance area score is computed as follows:

Performance Area Score = (22.33 ÷ 32) x 100


= 0.6978 x 100
= 69.78 %

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