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Full Compliance to Standards Presentation - SPC - 2012

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  • 1. Full Compliance with the Quality and Performance Standards (Local and International) Champions: Dr. Filipinas Rojo/Atty. Jhihann C. Hairun-Natividad Members: Karren Mae Masuhud; Celita P. Calma; Engr. Nicanor Daguro; Edsel Cariz Tiu; Eileen Joy Maralli
  • 2. CMZ Business Plan / BSC (2013-2015) Strategic Objective Perspective Goal (Strategic Objective) Tactical Objectives Key Performance Measure Key Performance Indicators (Metrics) Champeons Y1 Y2 Y3 Process Full compliance with the quality and performance standards (local and interna-tional) • Master Plan • Deployment • Evaluation / Continual Improve-ment Integrated Program / System F (B/E) SS (C) LL (A) J. Natividad/Dr. F. Rojo *F= Laying of Foundation; S = Strengthening; L = Leading the Way **B = Beginning ; E = Expanding; C = Consistent; A = Advanced
  • 3. CMZ Business Plan / BSC (2013-2015) Operational Objective Perspective Goal (Operational Objective) Tactical Objective Key Performance Measures Key Performance Indicators (Metrics) Initiatives Programs/ Projects Champion s / Coordinat ors Y1 Y2 Y3 Process Structured, comprehensi ve and integrated system for full compliance with local and international standards Achieve full compliance with the quality and performan ce standards (local and internation al) Compliance with integrated checklists – rating scales on quality and performance standards (local and international) 100% 100% 100% Full Complianc e with Quality and Perfor- mance Standards Program J. Natividad and F. Rojo/ C. Calma, K.M. Masuhud, N. Daguro, E. Tiu, E.J. Maralli
  • 4. CMZ Business Plan - List of Focused Initiatives (2013 – 2015) Initiatives Strategic /Operational Objectives Y1 (2013) Y2 (2014) Y3 (2015) Full Compliance with Quality and Performance Standards Program To make the hospital fully compliant with quality and performance standards Accreditation Office (for PQA and PhilHealth) created Center of Excellence granted by PhilHealth in February 2013 Integrated Checklists of all the agreed standards (Balridge/PQA, PhilHealth, ISO, JCI, Investors in People) – a CMZ Handbook/Guide formulated Deployment Plan formulated Monitoring Plan formulated Evaluation and Continual Improvement Program formulated Clinical pathway implemented Full installation of Automated Fire Sprinkler System Review of Checklist on its relevance Revision of Checklist, if necessary Deployment Monitoring and Evaluation Waste Management Program – Waste Treatment Facility Review of Checklist on its relevance Revision of Checklist, if necessary Deployment Monitoring and Evaluation
  • 5. CMZ Business Plan - Dashboard of Initiatives (2013 – 2015) Name of Initiative Objectives (KRAs) Performance Measures: Outcome /Target (KPIs) Resources Timelines Persons-in-charge Full Compliance with Quality and Performance Standards Program To formulate a master design and development plan on establishing and developing a well-defined integrated system in which all the requirements of the local and international quality and performance standards are complied with. Presence of a master design and development plan (MDDP) on establishing and developing a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with: PhilHealth Benchbook and PQA standards. -Presence of a document containing the MDDP approved by top management. - Presence of an integrated checklist on all the requirements of the standards Staff Budget Document March 30, 2013 Champions and members; Dr. Albert T. Tan
  • 6. CMZ Business Plan - Dashboard of Initiatives (2013 – 2015) Name of Initiative Objectives (KRAs) Performance Measures: Outcome /Target (KPIs) Resources Timelines Person-in-charge Full Compliance with Quality and Performance Standards Program To deploy the approved master design and development plan across and at all levels in the hospital.. Evidence of deployment of the approved MDPP. Presence of a deployment plan – leadership, communication and education, with needed resources and infrastructure Evidence of effective deployment across and at all levels in the hospital. Staff IT System Budget Document April 30, 2013 Champions and members; Dr. Albert T. Tan
  • 7. CMZ Business Plan - Dashboard of Initiatives (2013 – 2015) Name of Initiative Objectives (KRAs) Performance Measures: Outcome /Target (KPIs) Resources Timelines Person-in- charge Full Compliance with Quality and Performance Standards Program To evaluate and continually improve the master design and development plan to ensure sustainable achievement of full compliance to the standards. Presence of monitoring, evaluation, and continual improvement plan on the implementation of the MDPP. -Presence of monitoring, evaluation and continual improvement plan. - Evidence of effective implementation of the monitoring and continual improvement plan. Staff Budget Document June 30, 2013 Champions and members; Dr. Albert T. Tan
  • 8. CMZ Strategic Plan (2013 to 2015) Balanced Scorecard (2013 to 2015) Strategic Objective + Goal + Action Plan (Initiative) + Deployment Plans Strategic Objective for CMZ (2013-2015) Goal Action Plans Deployment Plans Full compliance with quality and performance standards (local and international) There is a structured, comprehensive and integrated system in which all the requirements of agreed local and international quality and performance standards are complied with and thereby promoting performance excellence for the hospital. PhilHealth Benchbook: Year 1 : Center of Excellence Philippine Quality Award: Year 1: Recognition for Commitment in Quality Management Year 2: Recognition for Proficiency in Quality Management Year 3: Recognition for Mastery in Quality Management, even PQA for Performance Excellence (see Action Plan) Formulate Deployment Plan, for approval by top management, employing the following steps: Identify stakeholders of the initiative – internal and external stakeholders Communicate to stakeholders the initiative Educate the stakeholders about the initiative Implement action plan of the initiative, with resources allocated and infrastructure in place Monitor, evaluate, and undertake continual improvement
  • 9. Action Plan Year 1 Year 2 Year 3 Remarks with persons- in-charge Application for PhilHealth Benchbook - Re-compute scores re: compliance - Seek direction of the Board if the application is for Center of Excellence - Monitoring of compliance through Mock Survey by QC - Review of policies and revise according to relevance - Formulate and finalize “lacking” policies - Re-orientation - Comply with application process - Prepare for PhilHealth inspection November 2012 December 2012 December 2012 December 2012 January 2013 January 2013 January 2013 February 2013
  • 10. Action Plan Year 1 Year 2 Year 3 Remarks with persons- in-charge Planning - Drafting of MDDP - Finalization of MDDP Starting on November 18, 2012 March 31, 2013 Champions, TTCP, EXECOM, TTCP staff members Presence of an integrated checklist of all the agreed standards - TTCP to meet to study standards, and study checklists of PhilHealth Benchbook and PQA -Integration of standards into one checklist/ finalization of checklist - draft -final December 2012 December 2012 January 2013 Champions, TTCP, EXECOM, TTCP staff members, QC Approval by Top Management of: - Checklist - MDDP January 2013 March 2013 Creation of Accreditation Office March 2013
  • 11. Action Plan Year 1 Year 2 Year 3 Remarks with persons- in-charge Deployment - Presence of Deployment Plan - Formation of internal training team - Communication - Education on standards - Reinforcement on standards April 2013 April 2013 April to May 2013 Every quarter Every semester Every quarter Every semester Every quarter Every semester Champions, EXECOM, TTCP staff members, QC, HRD Implementation Assistance Starting May 2013 All year round All year round All year round Initial Assessment 2nd Semester Review of MDDP, Checklist, Deployment Plan Filling in the gaps 2nd Semester
  • 12. Action Plan Year 1 Year 2 Year 3 Remarks with persons- in-charge Monitoring All year round All year round All year round Champions, EXECOM, TTCP staff members, QC, HRD Evaluation of compliance and Continual Improvement -Identification and training of internal auditors - Internal auditing September 1st Semester Once a year September Once a year September Once a year Application for PQA -Attendance at Preparatory Development Course Involving more officers and key personnel 1st quarter Commitment Level of Recognition Proficiency Level of Recognition Mastery Level of Recognition Champions, TTCP, Execom, Board

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