This document outlines the strategic plan and action plan of CMZ Hospital to achieve full compliance with quality and performance standards from 2013 to 2015. The key initiative is the "Full Compliance with Quality and Performance Standards Program" which aims to establish an integrated system to comply with standards. The action plan includes applying for accreditation with PhilHealth and recognition levels with the Philippine Quality Award. It details the objectives, measures, resources and timelines for deployment of standards, monitoring, evaluation and continual improvement efforts over the three year period to ensure sustainable achievement of full compliance.

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