Module I Harmonization SPMS PGS QMS.pptx

Harmonization and Integration of the
SPMS to the QMS and the PGS
for Middle Managers
PGS StrategicCommittee

Module I:
ACloser Look at the Performance
Governance System and theQuality
Management System

PART I:
The PerformanceGovernanceSystem

PerformanceGovernanceSystem
What is it in DOH? A holistic, collaborative
performance management and measurement tool
that aims to translate organizational goals into
breakthrough results guided by a set of
performance indicators and metrics
What is it in CRH? A performance management
tool that goes hand in hand with the requirements
of the QMS (ISO) and requirements of our SPMS
(IPCRs, SPCRs, DPCRs and OPCR)

What is the Goal of PGS? It aims to close the gap
between strategy formulation and execution to
ensure the attainment of the vision, mission and
goals of the agency.
What does it employ? It uses strategy road maps,
scoreboards and deliverables to track whether the
plans and strategies of the agency are achieved

What are the stages of PGS?
1. Initiation --- involves the setting of strategy roadmap of
the agency, scorecards and deliverables
2. Compliance --- involves the cascading to individuals
and alignment of individual functions to the strategic
goals and the creation of the OSM and MSGC
3. Proficiency --- involves the continued implementation
of strategies and recalibration of strategies to make
breakthrough results
4. Institutionalization --- agency can be institutionalized
once breakthroughs are made and best practices are
shared with other agencies

Where are we in the stages of PGS?
1. Initiation --- We have set our Vision, Mission, Goals
and strategy roadmaps to meet our VMG, we have set
deliverables for the different units in the agency,
technically, we have also passed this stage in 2020
through the Revalida participated by our MCC and the
PGS Core Team
2. Compliance --- we have cascaded things already, if
one can remember, the online activities that PSMO
conducted among the employees in 2022 is an activity
under compliance stage, but the understanding of our
employees are still weak in terms of the PGS

Where are we in the stages of PGS?
3. Proficiency --- We are not there yet, but we can be if
we truly achieve our roadmaps
4. Institutionalization --- We are certainly not there yet,
but, if we just cooperate and try to help out the
organization as well, we can reach this stage. Now the
question is, what can we do to help the organization
become PGS Institutionalize?

What are the
elements of
PGS ? When we
say elements,
these are the
requirements we
have to satisfy for
the
institutionalization

Elements for Design:
1. Basic Governance Document
a. Vision, Mission and Core Values
b. Strategic Position
c. Strategy Map
d. Deliverables
e. Scorecards

A trusted apex hospital committed to deliver
patient-centered care to the community.
We provide evidence-based healthcare services and
professional development to improve people’s lives
Visio
n
Missio
n
Integrity | Competence | Compassion | Collaboration
Core Values
Performance Governance System

STRATEGIC POSITION
2023 2028 2034
300-bed level II hospital
hospital serving Caraga and
Caraga and Southern Leyte
500-bed level III hospital
hospital with four
accredited residency
training programs and four
four specialty clinics
primarily serving Caraga
Caraga
1000-bed Regional Apex
Apex Hospital with basic
basic comprehensive
capability in heart, lung,
lung, eye, and infectious
infectious diseases
primarily serving Caraga
Caraga

STRATEGYMAP 2028
CARAGA REGIONAL HOSPITAL
VISION | A trusted apex hospital committed to deliver
patient-centered care to the community.
Impact
Support
Core
MISSION | We provide evidence-based healthcare services and
professional development to improve people’s lives
.
COREVALUES
Integrity |Competence |Compassion |Collaboration
500-bed level III hospital with four accredited residency training programs
and four specialty clinics primarily serving Caraga
Ensure sustainability through
revenue generation, sound
financial management, and
efficient procurement
Position
Better HealthOutcomes
Undertake preventive
and promotive
programs in adopted
communities in
collaboration with the
LGU and the private
sector
Ensure full functionality
of all service areas and
provide additional
services for specialty
clinics catering to both
in-patients and out-
patients
Achieve a fully
functional PETRU with
Level I PHREB
accreditation
overseeing research of
residents and all
divisions
Establish additional
training programs in
major clinical
departments and
develop homegrown
specialists to improve
service delivery
More Responsive HealthSystem More Equitable HealthCare Financing
Maintain a secure and reliable
hospital IT equipment, system and
network and upskill the IT staff and
end-users
Implement an integrated HR
system with a fully functional
HRIS to maintain high employee
engagement
Aim to be recognized as Best
Practice in the Green, Safe and
Climate Resilient Health Facility
Pursue evidence-based
continual policy
innovations in all
aspects of safety
guided by international
safety standards
Impact
Position
Core
Support

Limited functionality of service
areas due to lack of manpower
with specialty clinics serving
mostly in-patients
SERVICE
• Decrease in referrals to
higher facilities
• Patient Census of tertiary
and specialty services
Full functionality of all service
areas and additional services
for specialty clinics in
compliance to the RSF catering
to both in-patients and out-
patients
Accredited residency training
program in Family Medicine
and service accreditation of
OB-GYN and training initiatives
dictated by budget availability
TRAINING
Number of resident trainees of
accredited residency programs
Establish additional accredited
residency training programs in
major clinical departments and
develop homegrown
specialists to improve service
delivery
Research outputs as part of
academic requirements and
personal initiatives of medical
personnel
RESEARCH
Number of research outputs
presented/ published/utilized
A fully functional PETRU with
Level I PHREB accreditation
residents and all divisions
according to a hospital
research agenda
Preventive and promotive
programs in one adopted
community, and conduct of
trainings and capacity building
for staff and employees from
district hospitals and LGUs
LINKAGES
Decrease in uncoordinated
referrals from adopted
communities
Preventive and promotive
programs to improve health
outcomes of
adopted communities in
collaboration with the LGU and
the private sector
A committee implementing
safety protocols based on
SAFETY
Hospital safety index
Evidence-based continual
policy innovations in all
STRATEGIC
CHANGE
AGENDA
FROM
TO

Process-defined HR with a
functional HRIS and a staff
complement for a 300-bed
HUMAN RESOURCE
Employee satisfaction rating
Integrated HR with a fully
functional HRIS fully integrated
with Hospital Information
System and a staff
complement for a 500-bed
Limited functionality on
network infrastructure and
manpower capability
ICT
% of integrated systems to the
ERP
Secured data and network with
high availability access
managed by highly competent
personnel with updated
knowledge and trainings.
Recognized as above average
practice (3 Green stars) in the
DOH Green, Safe and Climate-
Resilient Health Facilities
INFRASTRUCTURE AND
Green Viability Assessment
Rating
Recognized as best practice (5
Green Stars) ) in the DOH
Green, Safe and Climate-
supported by a functional
Maintenance Management
Information System
Efficient revenue generation
leading to greater than
historical performance with
low budget utilization for
infrastructure due to delayed
procurement processes
RESOURCE MANAGEMENT
• 100% budget utilization
• 20% increase in hospital
income yearly
Sustainable revenue
generation equal or more than
the needed requirement for
that period with efficient and
effective logistical support
observing green procurement
STRATEGIC
CHANGE
AGENDA
FROM
TO

STRATEGIC POSITIONSCORECARD
Position # Measure BL 2028
500-bed level III hospital with four
four accredited residency training
training programs and four specialty
specialty clinics primarily serving
servingCaraga
1 Staffing Pattern for 500-bed
2
Number of accredited residency
residency training programs
3
RSF compliance of the four clinics

IMPACT INDICATORS
Impact Indicator # Measure BL 2028
A
Better Health
Outcomes
1
Discharged improved/recovered
B
Responsive Health
Health System
2 Client satisfaction rating
3 Average length of hospital stay
C
Financial Risk
Protection
4 No balance billing

CORESCORECARD (1/2)
Objective # Measure BL 2023 2024 2025
Ensure full functionality of all
all service areas and provide
additional services for specialty
specialty clinics catering to both
both in-patients and out-patients
patients
1a
Decrease in the referrals
referrals from specialty
specialty clinics to higher
higher facilities
TBD
Establish baseline Decrease from
baseline
Decrease from
previous year
1b
Increase patient census of
census of tertiary and
specialty services
TBD
Establish baseline Increase from
baseline
Increase from
previous year
Establish additional accredited
accredited residency training
training programs in major clinical
clinical departments and develop
develop homegrown specialists to
specialists to improve service
service delivery
2
Number of resident
trainees of accredited
residency training
programs
7 7 7 15
Achieve a fully functional PETRU
PETRU with Level I PHREB
accreditation overseeing research
research of residents and all
divisions
3
Number of research
outputs
presented/published/utiliz
utilized
0 0 At least 1 At least 2
Undertake preventive and
and promotive programs in
programs in adopted
communities in 4
Decrease in
uncoordinated referrals
referrals from adopted -NA
Establish baseline
20% decrease 20% decrease

SAFETYSCORECARD
Pursue evidence-
based continual
policy innovations in
all aspects of safety
guided by
international safety
standards
5
Hospital
safety
index
Sentinel events 0 0 0 0
HAI 0.26% ≤ 2% ≤ 1.5% ≤ 1.5%
Food Poisoning 0 0 0 0
% of unsafe
practices acted
upon
TBD 50% 65% 75%
DOH Safe
Hospitals Checklist
Checklist
Compliance
C B B A
Environmental
Management and
and Monitoring
Compliance
TBD 100% 100% 100%

SUPPORTSCORECARD
Implement an integrated HR
HR system with a fully
functional HRIS to maintain
maintain high employee
engagement
1
Employee satisfaction
satisfaction rating
dissatisfied
d
(based on
2019
survey)
75% 80% 85%
reliable hospital IT equipment,
equipment, system and
network and upskill the IT staff
IT staff and end-users.,
2
% integrated systems
systems to the ERP.
NA NA
Establish
baseline
90%
Aim to be recognized as Best
Best Practice in the Green,
Green, Safe and Climate
Resilient Health Facility
3
GreenViability
Assessment Rating
TBD
3 green stars
(82.98%)
3 green stars
(85%)
4 green stars
(90%)
through revenue generation,
generation, sound financial
and efficient procurement
4A
Budget Utilization for
for Infrastructure
50% 75% 100% 100%
4B Hospital Income 404m 20% increase 20% increase 20% increase

Limited functionality of
service areas due to lack
of manpower with
specialty clinics serving
mostly in-patients
SERVICE
• Decrease in referrals
to higher facilities
• Increase patient
census of tertiary and
specialty services
Full functionality of all
service areas and
additional services for
specialty clinics in
compliance to the RSF
catering to both in-
patients and out-
patients
STRATEGIC
CHANGE
AGENDA
FROM
TO

SERVICE ROADMAP (1/4)
Ensure full functionality of all service areas and provide additional services for
services for specialty clinics catering to both in-patients and out-patients
patients
Decrease in the referrals from specialty clinics to higher facilities
higher facilities
Increase patient census of tertiary and specialty services
services
KRA
DELIVERABLES
2023 2024 2025 2028
ServiceArea
Functionality
Full operation of some clinical
clinical and ancillary clinics
Full operation of all wards, and
and ancillary and clinical clinics
clinics including ambulatory
ambulatory surgery
Partial operation of
geriatric ward
Full operation of the geriatric ward
Specialty
Clinics
Eye
Partial operation of temporary
temporary eye clinic for in-
patients and outpatients
Full operation of permanent eye
permanent eye clinic at theOPD
OPD complex building
Established Department of
Ophthalmology
Lung
• Pulmonary function test
• Chest physiotheraphy
• Mechanical ventilation
• High flow nasal cannula
• Non invasive ventilation
Flexible bronchoscopy
Pulmonary Rehabilitation
• Thoracic Surgery
• Sleep study
• CT guided lung biopsy
rdiovascular
• 2DED
• 2de Plain
• ECG12I
Add onVascular Studies
Preparation of Cath Lab
Lab Procedures
• StressTest
• Stress Echo studies
• ABPM
• Holter Studies
• Preparation for cardiacCT and MRI
MRI

patients
Decrease in the referrals from specialty clinics to higher
higher facilities
services
KRA
DELIVERABLES
2023 2024 2025 2028
Specialty
Clinics
Infectious
Disease
Referral facility for EREIDCases
Cases
Department of Infectious
Diseases andTropical Medicine
Service
Enhancements
Clinical
• Mother Baby Friendly
Accreditation
• CPG of common pediatric
pediatric diseases
• NICU Level IIAccreditation
Accreditation
• Adoption of Community for
Community for Programs
Programs
PICU Level 1Accreditation
Accreditation
Pediatric Level ITraining
hospital
Ancillary
Dental
ManCom approved service fee
service fee of oral prophylaxis
• Full implementation of oral
oral prophylaxis
• ManCom approved service
service fee of restorative
restorative treatment
Full implementation of
restorative treatment
Comprehensive dental services
Physical
Medicineand
Rehabilitatio
Fully functional out-patient
patient physical therapy
services
• Occupational therapy
services
• Speech and language
• Diagnostic and
interventional procedures
procedures (UTZ)
• Cardiac Rehab
• CPET and EMG

patients
higher facilities
services
KRA
DELIVERABLES
2023 2024 2025 2028
Ancillary
Pathology
Approved molecular laboratory
laboratory LTO
• Molecular testing for
infectious agents
• Laboratory Redesign
• Apheresis services
• Anatomic pathology
additional capabilities
(frozen section)
• Anatomic pathology
additional capabilities
(immunohistochemistry)
y)
• Antibodies screening,
irradiation of blood
products
• Functional pneumatic tube
tube system
Medical
Imaging
Department
• with Schistosomiasis
• Radiation Safety Campaign
Campaign to hospital staff
staff and OPD patients
• Additional CT Scan Services
Services
• Additional Digital Portable
PortableXRAY Machine
Machine
• Upgraded PACS and RIS
RIS
• Operational Digital
Radiologic Fluoroscopy
Fluoroscopy Machine
Increase in the number of
special radiographic
procedures by the department
department

patients
higher facilities
services
KRA
DELIVERABLES
2023 2024 2025 2028
Enablers
HR
• Addition ofTraining AMS Clinical
Clinical Pharmacist
• Addition of Board Certified
Pediatric Infectious Disease
Specialist
• Interventional Radiologist
• Speech Pathologist
• OccupationalTherapist
• At least two additional
ophthalmologist/s
• Addition of Board CertifiedAdult and
Adult and Pediatric Infectious Disease
Disease Specialist
• Full-time one child specialist social
social worker atWCPU
• CriticalCare Specialist/Pediatric
Specialist/Pediatric Intensivist
Fully functional clinical
pharmacist in all wards
StaffComplement Required for
Required for Staffing Pattern
Pattern
ICT
Procurement of EMR
system and medical chart
chart database
• Fully Operational EMR System
System
• Queuing system for Pathology
Operational medical chart database
database system
INFRA
AND
EQUIPM
ENT
OPDComplex
Completion of GeriatricWard
• Multi-specialty Building

patients
higher facilities
services
KRA
DELIVERABLES
2023 2024 2025 2028
Enablers
Resource
Management
Philhealth Konsulta
Z Benefits Package:
Cardiac Rehab
PostAngioplasty

SERVICESCORECARD
Ensure full functionality
functionality of all service
service areas and provide
provide additional
services for specialty
clinics catering to both
both in-patients and out-
out-patients
1a
Decrease in the
referrals from
specialty clinics to
to higher facilities
facilities
TBD
Establish
baseline
Decrease from
from baseline
Decrease from
from previous
year
1b
Increase patient
census of tertiary
tertiary and
specialty services
services
TBD
Establish
baseline
Increase from
baseline
Increase from
previous year

Accredited residency
training program in
Family Medicine and
service accreditation of
OB-GYN and training
initiatives dictated by
budget availability
TRAINING
Number of resident
trainees of accredited
residency programs
major clinical
departments and
develop homegrown
service delivery
STRATEGIC
CHANGE
AGENDA
FROM
TO

TRAINING ROADMAP (1/3)
Establish additional accredited residency training programs in major clinical
departments and develop homegrown specialists to improve service delivery
Number of resident trainees of accredited
KRA
DELIVERABLES
2023 2024 2025 2028
Accredited Residency
Training Programs
Training Programs for
Family Medicine
Compliance to Philippine
Obstetrical and
Gynecological Society
Training Programs for OB-
GYN and Internal
Medicine
Training Program for
Pediatrics
Trained
Medical
Specialists
Cardiovascular
• 1 adult interventional
cardiologist sent for
training or hired
• at least 1 CV surgeon
sent for training
Lung
1 MO IV sent for training
in Pedia Pulmonology
Eye 1 Ophthalmologist fellow
Infectious
Disease
1 MO IV sent for training
in Pediatric Infectious
Disease

Establish additional accredited residency training programs in major clinical
departments and develop homegrown specialists to improve service delivery
Number of resident trainees of accredited
KRA
DELIVERABLES
2023 2024 2025 2028
Trained
Nurse
Specialists
Cardio
At least 2 nurses are ICU
NCP-certified
At least 2 additional
nurses are ICU NCP-
certified
At least 20% of ICU
nurses are NCP-
certified
Infectious
Disease
At least 2 nurses are
Infectious Disease
NCP-certified
nurses are Infectious
Disease NCP-certified
At least 25% of EREID
Nurse
Leaders
at least 4 nurse
leaders/managers are
CSC- or ANSAP
certified
at least 4 additional nurse
leaders/managers are
CSC- or ANSAP certified
At least 20% of nurse
leaders are CSC- or
ANSAP Certified

Establish additional accredited residency training programs in major
clinical departments and develop homegrown specialists to improve
service delivery
Number of resident trainees of accredited residency
training programs
KRA
DELIVERABLES
2023 2024 2025 2028
CPD Provider
Accreditation
Compliance to
requirements for the
CPD provider
accreditation
• Application for annual
for CPD accreditation
program
• Offering of CPD-
approved training
courses
Offering of additional
CPD-approved training
courses
Additional income
generated from CPD-
approved training
courses
Enablers
Infrastructure
and
Equipment
Conference Room,
Doctors’ Quarter and
offices for all clinical
departments
Learning
Management
System
designation of Learning
Development Officers per
unit
Capacitated Learning
Development Officers
Implementation of the
online LMS

TRAININGSCORECARD
major clinical
departments and
develop homegrown
improve service delivery
2
Number of
resident
trainees of
accredited
residency
training
programs
7 7 7 15

Research outputs as part
of academic
requirements and
personal initiatives of
medical personnel
RESEARCH
Number of research
outputs presented/
published/utilized
A fully functional PETRU
with Level I PHREB
accreditation overseeing
research of residents and
all divisions according to
a hospital research
agenda
STRATEGIC
CHANGE
AGENDA
FROM
TO

RESEARCH ROADMAP (1/2)
Achieve a fully functional PETRU with Level I PHREB accreditation overseeing
research of residents and all divisions
presented/published/utilized
KRA
DELIVERABLES
2023 2024 2025 2028
Research
Outputs
Residents
At least 1 Family Medicine
Medicine completed
At least 1 Family Medicine
Medicine completed At least 1 research completed
completed in each accredited
accredited department
(Family Medicine, OB-GYN,
GYN, Pediatrics)
Other
Divisions
At least 1 research completed At least 1 research completed
completed
• At least 1 research
completed
• Research Presentation
Presentation
PHREBAccreditation Identified REC members
Online PHREBTraining for
for PETRU Staff and REC
members
25% compliant to Level I
PHREB Requirements
Level 1 PHREBAccreditation
Accreditation
Capacity Building Capacitated PETRU Staff
Enhanced capability of Family
Family Medicine Residents
Residents
CapacitatedOB-GYN
Residents
Capacitated Residents of
Pediatrics, Internal Medicine,
Medicine, and Surgery

RESEARCH ROADMAP (2/2)
Achieve a fully functional PETRU with Level I PHREB accreditation overseeing
research of residents and all divisions
presented/published/utilized
KRA
DELIVERABLES
2023 2024 2025 2028
Enablers
Human Resources
• One statistician hired
• One IT Specialist hired
hired
Information
Communication
Technology
Establishment of E-Library
Library
Infrastructure and
Equipment
HR/Training Room
Renovation for Research
• Hospital Library
• Fully functional REC
Office

RESEARCHSCORECARD
Achieve a fully
functional PETRU with
Level I PHREB
accreditation
residents and all
divisions
3
Number of
research
outputs
presented/publi
shed/utilized
0 At least 1 At least 2

Preventive and
promotive programs in
one adopted
community, and conduct
of trainings and capacity
building for staff and
employees from district
hospitals and LGUs
LINKAGES
Decrease in
uncoordinated referrals
from adopted
communities
Preventive and
promotive programs to
improve health
outcomes of
adopted communities in
collaboration with the
LGU and the private
sector
STRATEGIC
CHANGE
AGENDA
FROM
TO

LINKAGES ROADMAP (1/2)
Undertake preventive and promotive programs in adopted communities in
communities in collaboration with the LGU and the private sector
Decrease in uncoordinated referrals from adopted
adopted communities
KRA
DELIVERABLES
2023 2024 2025 2028
AdoptedCommunities
Draft MOA for one additional
additional identified
community (Pediatrics)
MOA with identified
community (Pediatrics)
Identify on new possible
adopted community (Family
(Family Medicine)
Improved health condition of
condition of adopted
communities of Family
Medicine and Pediatrics
based on impact assessment
assessment report
Health ReferralSystem
Implementation of HCPN
HCPN referral system in
collaboration with CHD and
and LGUs of Region XIII
Evaluation of HCPN referral
referral system
Initiation of CRH HCPN online
online referral system
Fully functional CRH HCPN
HCPN online referral system
system
Capacity Building
Capability training of LGU
LGU RHU Staff (ex. BEMONC
BEMONC training, BLS, etc.)
etc.)
• Capacitated RHU Staff
Staff
• Clerkship/internship for
for medical students
External Partnerships Draft MOA on PPP
MOA with Level 2 hospitals
hospitals
Implemented MOA of PPP
PPP

LINKAGES ROADMAP (2/2)
Undertake preventive and promotive programs in adopted communities in
communities in collaboration with the LGU and the private sector
Decrease in uncoordinated referrals from adopted
adopted communities
KRA
DELIVERABLES
2023 2024 2025 2028
Enablers
Human Resources
Assignment of doctors and
and additional nurses
dedicated to referral system
system
Information
Communication
Technology
Creation of E-Referral System
System
Infrastructure and
Equipment
Renovation of HEMB
Resource
Management
Procurement of additional IT
additional IT equipment

LINKAGESSCORECARD
Undertake
preventive and
promotive
programs in
adopted
communities in
collaboration with
with the LGU and
and the private
sector
4
Decrease in
uncoordinated
d referrals from
from adopted
communities
-NA
Establish
baseline
20% decrease 20% decrease

A committee
implementing safety
protocols based on
national standards for
compliance
SAFETY
Evidence-based
continual policy
innovations in all aspects
of safety guided by
standards
STRATEGIC
CHANGE
AGENDA
FROM
TO

SAFETY ROADMAP (1/2)
Pursue evidence-based continual policy innovations in all
aspects of safety guided by international safety standards
KRA
DELIVERABLES
2023 2024 2025 2028
Safety
Units
IPC
• Hospital-Acquired Infection
Infection Training Design
Design
• Top Hands Hygiene
Program
• HAITraining
• Revised Reporting Tool for
for HAIs
• HAITraining
• Active surveillance of
HAIs
Compliant to IPSG set
set by the Joint
Commission
International
EFMS
Review/Revision of CRH
Occupational Safety Protocols
Protocols
• Training Needs Analysis
• ToT forTNA requirements
requirements
• Employee Wellness Plan
In-house training on hospital
hospital on Occupational
Occupational Safety
Compliant to ISO
45001 Health and
Safety atWork
Nutritionand
Dietetics
Review/Revise Food Safety
Safety Protocols
• Gap Analysis of Food
Protocols
• ToT for HAACP
• Continual implementation
implementation of HAACP
HAACP gaps
• In-house food safety
Training
Compliant to HAACP
HAACP
Disaster Risk
Reduction
Management -
Health
Innovations to the DRMM-H
DRMM-H Plan
Additional innovations to the
the DRMM-H Plan
CRH as Regional Gawad
Kalasag Awardee
CRH as national
Gawad Kalasag
Awardee

SAFETY ROADMAP (2/2)
Pursue evidence-based continual policy innovations in all
aspects of safety guided by international safety standards
KRA
DELIVERABLES
2023 2024 2025 2028
Environmental
Safety
Additional environmental
environmental Safety
Officer
• Training of Environmental
Environmental Safety Officer
Officer
• Crafting on Environmental
Environmental Safety
Protocols based on
international standards
Implementation of
Environmental Safety
Safety Protocols
based on international
international
standards
Compliant to 14001:2015
14001:2015 Environmental
Environmental
Management System
PatientSafety
• Review /Revise the
Manual of Operations for
Operations for Patient
Patient Safety
• Training on Patient
Safety
Implementation of Patient Safety
Safety Standards
Evaluate Patient
Safety risk
Compliant to IPSG set by
by JCI
Enablers
• Infection Prevention Control and
Control and Safety Database
Database
OSH Unit

SAFETYSCORECARD
Pursue evidence-
based continual
policy innovations in
all aspects of safety
guided by
standards
5
Hospital
al safety
safety
index
Sentinel events 0 0 0 0
HAI 0.26% ≤ 2% ≤ 1.5% ≤ 1.5%
Food Poisoning 0 0 0 0
% of unsafe
practices acted
upon
TBD 50% 65% 75%
DOH Safe
Hospitals Checklist
Checklist
Compliance
C B B A
Environmental
Management and
and Monitoring
Compliance
TBD 100% 100% 100%

Process-defined HR with
a functional HRIS and a
staff complement for a
300-bed
HUMAN RESOURCE
Employee satisfaction
rating
Integrated HR with a
fully functional HRIS
fully integrated with
Hospital Information
System and a staff
complement for a 500-
bed
STRATEGIC
CHANGE
AGENDA
FROM
TO

HR ROADMAP
Implement an integrated HR system with a fully functional HRIS to maintain
high employee engagement
Employee satisfaction rating
KRA
DELIVERABLES
2023 2024 2025 2028
HR Prime
Accreditation
HR Prime recognition for L&D
and R&R
Level II Prime HR
accreditation (Bronze)
Recognition for HR Prime
Level III (1 Pillar)
HR Prime level III
Accreditation (Silver)
Staffing
Pattern
100% of downloaded positions
for first tranche filled
At least 50% of downloaded
positions for second
tranche filled
100% of downloaded
positions for second
tranche filled
• 100% of 500-bed
staffing pattern filled
• Proposal for approval
of Hospital
Development Plan and
IRR for increase to
1000-bed capacity
HRIS
• Procurement of HRIS module
• Baseline data on manual
processing time
Tailor-fitting of the proposed
system to the HR
operations
Fully functional HRIS
integrated to ERP System
Impact assessment of the
full HRIS integration
Setting up of
Employee
Satisfaction
Rating
Modified Employee Satisfaction
Survey anchored on PRIME HR
Pillars and based on 2019
Results
Roll out of the updated
annual employee survey
Evaluation of implemented
policies
Impact assessment of HR
Prime on employee
satisfaction

HRSCORECARD
Implement an
integrated HR system
with a fully functional
HRIS to maintain high
employee engagement
1
Employee
satisfaction
rating
3.8
dissatisfied
(based on 2019
2019 survey)
1 highest, 5
lowest
NA 2 2

Limited functionality on
network infrastructure
and manpower
capability
ICT
% of integrated systems
to the ERP
Secured data and
network with high
availability access
managed by highly
competent personnel
with updated knowledge
and trainings.
STRATEGIC
CHANGE
AGENDA
FROM
TO

ICT ROADMAP (!/2)
Maintain a secure and reliable hospital IT equipment, system and network and
network and upskill the IT staff and end-users
% integrated systems to the ERP.
KRA
DELIVERABLES
2023 2024 2025 2028
System
Upgrade
Procurement of fully integrated
integrated ERP System
Tailor-fitting and deployment of
deployment of ERP system
Fully functional ERP System
Highly maintained ERP with
with dashboards
Hardware
• Hyperconverged
Infrastructure (HCI)
• Network Attached Storage
Storage
• Access points (AP) for
employees and
patients/watchers
• 15 computer units for IT
training room installed
LAN expansion for MS Building
Building withAP
• Robust and resilient hardware
hardware and infrastructure
infrastructure
• Upgraded firewall appliance
appliance with end points
Software
50% of hospital workstations
workstations enrolled and
registered to hospital network
network
• Network based IT Job
Request Portal and
Monitoring
• Network –based EFMS Job
Job Request Portal and
Monitoring
IT and EFMS maintenance
dashboard
Integrated dashboards with
relevant data for decision makers
Training and
Capacity
Building
1 training per regular employee
employee (cybersecurity, and
and technological trends)
• 50% of target audience with
with productivity training
training
• At least 1 IT staff trained in
in data analytics,
cybersecurity and current IT
• At least 30 participants in
in office productivity annually
annually
• At least 1 IT staff trained in
in data analytics,
cybersecurity and current IT
• At least 50 participants in
in cybersecurity annually
• Semi-annual report on
internalVAPT assessment
assessment and mitigation
mitigation

ICT ROADMAP (2/2)
Maintain a secure and reliable hospital IT equipment, system and network and upskill the
network and upskill the IT staff and end-users
% integrated systems to the ERP.
KRA
DELIVERABLES
2023 2024 2025 2028
ManpowerComplement for
Workload Delegation
Request for plantilla positions
• Implementation of Data
DataAnalytics services
services
• Implementation of
System Development
Services
Updated workload delegation
delegation according to filled
filled plantilla positions
Full manpower complement
complement with fields of
of specialization
Infrastructure
• Office area, workshop
workshop and training
training room
• Secondary ISP for
secondary static IP
address and redundancy
redundancy
• ACU equipment for
OR/DR server room
Migration to the new fiber
fiber network
Implemented redundant fiber
fiber network
Entry server rooms with gas-
gas-type fire suppression
suppression system

ICT SCORECARD
Maintain a secure and
and reliable hospital IT
IT equipment, system
system and network and
and upskill the IT staff
staff and end-users.,
2
% integrated
systems to the
the ERP.
NA NA
Establish
baseline
90%

Recognized as above
average practice (3
Green stars) in the DOH
Green, Safe and Climate-
INFRASTRUCTURE AND
EQUIPMENT
Green Viability
Assessment Rating
Recognized as best
practice (5 Green Stars) )
in the DOH Green, Safe
and Climate-Resilient
Health Facilities
supported by a
functional Maintenance
Management
Information System
STRATEGIC
CHANGE
AGENDA
FROM
TO

INFRASTRUCTURE AND EQUIPMENT ROADMAP
Aim to be recognized as Best Practice in the Green, Safe and Climate
Resilient Health Facility
Green Viability Assessment Rating
KRA
DELIVERABLES
2023 2024 2025 2028
Green
Star
Rating
Energy
Management
Installation of solar
streetlights
Upgrading of electrical
system with 1-750
KVA Generator Set
Installation of solar
power system for
existing and newly
completed buildings
Annual output of
250,000 kWh
generated from solar
power systems
Water
Management
Implementation of water
sanitation for health facility
improvement tool (WASH
Fit)
• Additional water
tank storage capacity
of 130 cu m
• Upgrading of water
purification facility to
comply to ISO
standards
• Additional water tank
with storage capacity
of 700 cu m
• Upgrading of Sewage
Treatment Plan in
accordance with
DENR standards
Water storage capacity
that can last up to 7
days
Waste
Management
Recycling of pulverized
vials converting it into an
additive in concrete mix
Functional Material
Recovery Facility
Acquisition of hospital
waste incinerator
powered by thermal
treatment technology
Zero hazardous waste
transport
Equipment
Management
Procurement of
Maintenance
Management System
module
• Fully functional
CMMS integrated to
ERP
• Procurement of
calibrating
Adoption of in-house
calibrating system
50% reduction in
calibration cost based
on 2023 baseline

INFRA STRUCTURE AND EQUIPMENT SCORECARD
Aim to be recognized
as the Best Practice in
the Green, Safe and
Climate Resilient
Health Facility
3
Green
Viability
Assessment
Rating
TBD
3 green stars
(82.98%)
3 green stars
(85%)
4 green stars
(90%)

Efficient revenue
generation leading to
greater than historical
performance with low
budget utilization for
infrastructure due to
delayed procurement
processes
RESOURCE
• 100% budget
utilization
• 20% increase in
hospital income
yearly
Sustainable revenue
generation equal or
more than the needed
requirement for that
period with efficient and
effective logistical
support observing green
procurement
STRATEGIC
CHANGE
AGENDA
FROM
TO

RESOURCE MANAGEMENT ROADMAP (1/2)
Ensure sustainability through revenue generation, sound financial management, and efficient
management, and efficient procurement
Budget Utilization for Infrastructure
Hospital Income
KRA
DELIVERABLES
2023 2024 2025 2028
Sufficient
Hospital
Funding
Philhealth
Packages
Accreditation of PHIC
e-Konsulta Package
Accreditation of PHIC
z-benefit package
Linkages to
Healthcare
Funders
1 HMO/Charity Foundation
Foundation
1Additional HMO/Charity
HMO/Charity Foundation
Foundation
1Additional HMO/Charity
HMO/Charity Foundation
Foundation
5 total HMO/Charity
Foundations
Major PPPs 100% Documentation
Implementation of 1st PPP
PPP Project
100% Documentation of 2nd
Completion of 2nd PPP
Project
Reducing RTH Equal or less than 8% Equal or less than 7% Equal or less than 6% Equal or less than 5%
QFS 20% of IGF 20% of IGF 20% of IGF 20% of IGF
Preparation of
Statement of
Account of Patient
Patient should
include 100% of
of the treatment
Fully implemented Fully implemented Fully implemented

RESOURCE MANAGEMENT ROADMAP (2/2)
Ensure sustainability through revenue generation, sound financial management, and efficient
management, and efficient procurement
Budget Utilization for Infrastructure
Hospital Income
KRA
DELIVERABLES
2023 2024 2025 2028
Efficient
Fund
Utilization
Procurement
Tracking System
80% operational Fully operational Fully operational Fully operational
Multi-year
Framework
Agreement for fast
fast moving items
items
Implants
(ortho, plastic and
reconstructive)
30% of drugs, medicines,
medicines, medical supplies
supplies and laboratory
laboratory
laboratory
laboratory
Competency
Upgrade
Personnel Upgrade
Upgrade
Create pool of potential
potential trainees
Send 1 for formal training in
training in finance
Send 2 for formal training
training in finance
Complete training of 3
champions
Compliance to
Sustainable
Procurement
Guidance and Green
Green Procurement
Establishment of ISO
20400:2017 standard and
and requirements
Gap Analysis
• Validation of gaps
• 30% of identified gaps
gaps addressed
• Annual accomplishment
accomplishment of 25%
25% in addressing the
ISO 20400:2017 Compliant
Compliant (Sustainable
Procurement Guidance)
Guidance)

SCORECARD
Objective # Measure BL (2022) 2023 2024 2025
Ensure sustainability
through revenue
generation, sound
financial management,
management, and
efficient procurement
4A
Budget
Utilization for
Infrastructure
50% 75% 100% 100%
4B
Hospital Income
404m 20% increase 20% increase 20% increase

SUPPORTSCORECARD
Implement an integrated
HR system with a fully
functional HRIS to maintain
high employee
engagement
1
Employee
satisfaction rating
dissatisfied
d
(based on
2019
survey)
75% 80% 85%
reliable hospital IT equipment,
equipment, system and
network and upskill the IT staff
IT staff and end-users.,
2
% integrated systems
systems to the ERP.
NA NA
Establish
baseline
90%
Aim to be recognized as
Best Practice in the Green,
Safe and Climate Resilient
Health Facility
3
GreenViability
Assessment Rating
TBD
3 green stars
(82.98%)
3 green stars
(85%)
4 green stars
(90%)
through revenue generation,
generation, sound financial
and efficient procurement
4A
Budget Utilization for
for Infrastructure
50% 75% 100% 100%
4B Hospital Income 404m 20% increase 20% increase 20% increase

CRH’s PGS Elements of
Execution:
2. PGS Core Team
People who are
champions of PGS in the
institution
These people in the Org Chart of the PSMO, and
YOU if you allow yourselves to be champions of
the PGS

Execution:
3. Cascading Framework
Aligning everyone’s
performance tasks to the
strategy * In our IPCR we can see PGS aligned tasks
under strategic functions

Execution:
4. Office of the Strategy
Management
Oversees the
implementation
Reiterating the Org Chart so you will not
forget that we have the PSMO as the OSM

Execution:
5. Strategic Performance
Assessments
Usually OSM led, but can also be the
Management Reviews done by the
Divisions and the MANCOM, can also
be the function of the PMT
Remember Mancom Meetings like the picture on
the right? PGS, ISO and other endeavours are also
discussed during these meetings

Sustainability:
6. Multisector
Governance Council
Formalized external partnership in
the region, such as St. Paul
University, Taganito Mining, what
else? PHT? LGU?

Sustainability:
7. Governance Culture
Refers to culture of governance in the
agency, i.e are everyone involved? Are our
leaders supportive of us? Do we have
budget back up for our projects and
deliverables? Do we have meritocracy in our
processes? Do we practice transparency?
Examples of culture of governance would be the emphasis of a transparent
government agency and the practice of meritocracy and excellence in human
resource management. Oh, so is PRIME-HRM linked to PGS? Yes

Sustainability:
8. Governance Sharing
Refers to Best Practices sharing in the
industry. We have not had shared our best
practices yet but, perhaps the Scoreboard
contests and other PGS related awarding
that we had in 2022 can be linked to
governance sharing
A clear example of an agency that certainly shares best practices with other
agencies is the Development Academy of the Philippines. They conduct these best
practices sharing every year.

PGS Elements:
9. Breakthrough Results
The attainment of targets and goals that
are long term and part of the VMG of the
agency. What are our directions that we can
label as breakthrough results? Example
would be becoming a teaching and training
hospital. This is in general, NOW WHAT ARE
YOUR BREAKTRHOUGH RESULTS?
Think about the deliverables of your unit, are these deliverables only
one time projects or are these steps to achieving bigger projects that are
aligned to the agency’s Roadmap?

PART II:
Awareness on theQuality Management System described in ISO
9001:2015

OurQuality Management System
What is QMS?
A quality management system (QMS) is
a system that documents the policies,
procedures, and controls necessary for
an organization to create and deliver
high-quality products or services to
customers, and therefore increase
customer satisfaction
https://reciprocity.com/resources/what-is-a-quality-management-system-qms/
What is the QMS being practice in CRH? It’s 9001:2015. There are
others actually but we are accredited under this QMS only. This
QMS approach involves the concept of Plan-Do-Check-Act
Methodology and provides a process oriented approach on
documenting structures, plans, procedure, reviewing and
evaluating mechanisms

What are our Major QMS
related documents?
Familiar with SWOT Analysis? Needs and
Expectations? These are the first two
documents that each unit would need to
come up for our QMS. From these, Risk
Registers and Opportunity Registers are
prepared as well as Quality Objectives and
Plans. When the QOP is established, the
Quality Objective Monitoring Tool comes
next.

What are the basic
documentations for our
processes?
The basic ISO related document that we have
in CRH is the SERVICE MANUAL. The
manual contains Job descriptions, Process
flows, Procedures of a process, Work
Instructions, Guidelines and Policies. The
content of the service manual must be
updated in accordance to the developments
in the unit.

When do we monitor ISO
related objectives?
This depends on the unit but, we actually
have a semestral Internal audit to see our
compliances with our processes and an
annual external audit to check our
weaknesses in our processes. When we have
nonconformances during our audit, we are
issued the Request for Action document.
Which we need to answer using a Fishbone
Diagram.

What are the principles
of a Quality Management System
under ISO 9001:2015?
1. Customer Focus: covers customer needs and
service
2. Leadership: refers to agency direction as led
by top management
3. Engagement of People: each one is involved
in ISO tasks, such as the DCUs, the writers of
documents etc
4. Process Approach: processes are efficient and
effective to prevent wastage and reduce cost

What are the principles
of a Quality Management System
under ISO 9001:2015?
5. Improvement: The system does not stop with
the achievement of a goal, but should instead be
continuous
6. Evidence Based Decision Making: decisions
are always backed with data
7. Relationship Management: Stakeholders and
other interested parties are considered in the
decisions

Why do we need to consider the 7 Principles as Valid
and Important? Let’s look at things this way..
1.Customer focus
2.Leadership
3.Engagement of people
4.Process approach
5.Improvement
6.Evidence-based decision making
7.Relationship management
1.Customer exploitation
2.Irresponsible leaders
3.Uncommitted staff
4.Random approach
5.Regression
6.Decisions based on a coin toss
7.Disregarded stakeholders
If the 7 principles are not maintained, the reverse might happen in
the organization, thereby, disorienting from the concept of a QMS

I’d like to remind everyone
though that, discussing PGS,
QMS and a little bit of PMS
actually boils down to knowing
and doing your KPIs. What are
KPIs?

It’s actually "Key
Performance Indicator”.
However, for the Top
Management and the
middle managers,

to ensure the success of
the different
Performance Tools,
KPI should mean

Module I Harmonization SPMS PGS QMS.pptx

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