The document discusses implementing a quality assurance program through accreditation, health technology assessment, peer review, feedback mechanisms, and performance monitoring. It outlines PhilHealth's accreditation of different types of healthcare providers like physicians, hospitals, rural health units, and more. Minimum requirements for accreditation include 100% compliance with core indicators and 60% compliance in key areas like patient rights, care, and safety for centers, or 75% compliance in additional areas like leadership for assistant centers. The document emphasizes continuous quality improvement.

1. Shirley B. Domingo, MD, MPH
Vice President
PRO NCR & Rizal
1

2. “ The Noblest Search is the
Search for Excellence.”
Lyndon B. Johnson

3. Legal Mandate
• R.A. 7875 (as amended by R.A. 9241) Sec. 37. Quality
Assurance
…health care providers shall take part in programs of
quality assurance, utilization review, and technology
assessment …
• IRR Rule IX, PhilHealth shall…
– Implement a QAP applicable to all HCPs for delivery of
health services
– Ensure that health services are of quality necessary to
achieve the desired health outcomes and member
satisfaction

4. 4
Coverage
Accreditation
Premiums
Payment
VALUE
Health care
QUALITY
Relationship bet. Phil Health, the health care providers and
its members.

5. Minimal threshold standards
Inspection - “find what’s wrong”
Focus on inputs
Improvement of Process and Outcomes
Continuous quality improvement
Self-assessment and demonstrating
achievements

6. Rationale for Benchbook Standards
• Legal mandate
• Existing standards do not promote quality improvement culture among
hospitals
• Need to influence provider behavior to increase likelihood of better
outcomes at affordable costs- member protection
• Tougher competition (Provider)
• Frequent medical errors- safety issues
lawsuits!
• Rising demand and costs, limited health expenditures/resources -
efficiency
• Concern with variation in health care practice, outcomes and costs
• Patient satisfaction

7. Relative Performance of Government and Private
Government Hospitals Private
Leadership and Management
Most could present an assessment of their Difficulty identifying proof of assessment of
performance. Annual activities and targets are their performance/ not always documented
well documented
Patient Care
Procurement policies for drugs are not readily Procurement policies for drugs are readily
available (local government) available
Human Resource Management
Recruitment, selection, and hiring policies are Most have these policies
usually not available (local government)
Safe Practice and Environment
Preventive and corrective maintenance services L3 and hospitals usually have good safety
are not readily available which may be a result of programs compared to government
delayed procurement of services as these hospitals. Personnel responsible of
services were not assured from vendor when the maintaining security and conduct of
equipment was purchased. preventive and corrective maintenance of
equipment are always available

8. Government vs Private

9. National Performance

12. Implementing a Quality Assurance Program
• Accreditation
• HTA
• Peer Review
• Feedback Mechanism
• Performance Monitoring
– Utilization Review
– Outcomes Assessment
• Medical evaluation of claims/PNDF
• Program Review/Formulation of policies

13. Providers being accredited by PhilHealth:
• Professionals • Institutions
– Hospitals
– Physicians – Rural health units/ health
– Dentists centers (RHU)
– Midwives – Ambulatory surgical clinics
(ASC)
– Maternity clinics
– TB-DOTS centers
– Free-standing dialysis
centers
– OUTPATIENT MALARIA
PROVIDER (OMP)

14. 14

15. Performance Area Standards Criteria Indicators Core
n=78 n=141 n=239 Indicators
n=51
Patient Rights 6 14 19 1
Patient Care 30 75 112 15
Leadership & 6 4 14 3
Mgt
HR Mgt 8 19 27 2
Info Mgt 5 11 15 3
Safe Practice 16 16 40 25
Improving 7 2 12 2
Performance

16. Benchbook Awards

17. Patient Rights & Organizational
Ethics
Goal:
• To improve patient outcomes by respecting patients’ rights and
ethically relating with patients and other organizations
Indicators:
 Policies and procedures for patient’s needs for
confidentiality,privacy, security, religious counselling
 Policies and procedures to resolve patient’s complaints
 Policies to resole ethical issues arising from patient care

18. Patient Care
Goals:
• The organization is accessible to the community that it aims to serve
• The entry processes meet patient needs and are supported by
effective systems and a suitable environment
Indicators:
• Presence of services addressing most common diseases of the
community

19. Patient Care
Goals:
• Comprehensive assessment of every patient enables the planning
and delivery of patient care
• The health care team develops in partnership with the patients a
coordinated plan of care with goals
• Care is delivered to ensure the best possible outcomes for the
patient
Indicator:
• Policies and procedures regarding preoperative and pre anesthetic
assessment
• Quality control of the diagnostic examination

20. Patient Care
Goals:
• The health care team routinely and systematically evaluates and
improves the effectiveness and efficiency of care delivered to
patients
• Care is coordinated between the organization and other health
care providers in the community to ensure that the needs of the
patient are continuously met (Discharge)
Indicator:
• Multidisciplinary team in the formulation of adopted clinical
protocols

21. Leadership & Management
Goals:
• The organization is effectively and efficiently governed and
managed according to its values and goals to ensure that care
produces the desired health outcomes, and is responsive to
patients’ and community needs
• The organization ensures that services provided by external
contractors meet appropriate standards
Indicators:
• Presence of staff satisfaction survey
• Policies and procedures are known to all levels of the work force.

22. Human Resource Management
Goals:
• The organization provides the right number and mix of
competent staff to meet the needs of its internal and external
customers and to achieve its goals (Planning)
Indicators:
• Policies and procedures to orient new employees and hospital
policies
• New personnel are adequately supervised

23. Human Resource Management
Goals:
• Recruitment , selection and appointment of staff comply with
statutory requirements and are consistent with the organization’s
human resource policies
• A comprehensive program of staff training and development
meets individual and organizational needs
Indicator:
• Recruitment and selections are consistent with organizational
policies

24. Information Management
Goals:
• Collection and aggregation of data are done for
patient care, management of services, education and
research
• Integrity, safety, access and security of records are
maintained and statutory requirements are met
(Records management
Indicator:
• Proof that charts are checked for completeness and
accuracyPolicy on record storage, safekeeping,
retention and disposal

25. Safe Practice & Environment
Goals:
• Patients, staff and other individuals within the organization are
provided a safe, functional and effective environment of care
• A comprehensive maintenance program ensures a clean and
safe environment
Indicator:
• Safe and efficient use of medical equipment according to
specifications.

26. Safe Practice & Environment
Goals:
• Risks of acquisition and transmission of infections among
patients, employees, physicians and other personnel, visitors
and trainees are identified and reduced
• The provision of equipment and supplies supports the
organization’s role
Indicators:
• Presence of an infection control program
• Procedure of isolation of nosocomial infections

27. Safe Practice & Environment
Goals:
• The organization demonstrates its commitment to
environmental issues by considering and implementing
strategies to achieve environmental sustainability
(Energy and waste management)
Indicator:
• Procedures on waste disposal involving the reuse,
reduction and recycling

28. Improving Performance
Goals:
• The organization continuously and systematically
improves its performance by invariably doing the right
thing the right way the first time and meeting the
needs of its internal and external clients
Indicators:
• Presence of quality improvement programs
• CPGs

29. Benchbook Self-Assessment
Process & Accreditation
29

30. Minimum Requirement for Accreditation
Compliance to 100% of CORE indicators
AND
Center 60% Compliance to each of the following:
• Patient’s Rights and Organizational
of Ethics
Safety • Patient Care
• Safe Practice and Environment
30

31. Compliance to 100% of CORE indicators
AND
75% Compliance to each of the following:
•Patient’s Rights and Organizational Ethics
Center •Patient Care
of •Safe Practice and Environment
•Leadership and Management
Quality •Human Resource Management
•Information Management
31

32. Compliance to 100% of CORE indicators
AND
Center of
90% Compliance to each of the 7
Excellence
performance
areas
32

33. What if we cannot meet the minimum requirements?
Compliance to 70% of CORE indicators AND
50% Compliance to each of the following:
Provisional • Patient’s Rights and Organizational Ethics,
Accreditation • Safe Practice and Environment
• Patient Care
Failure to meet cut off for provisional
Denial accreditation
33

34. Frequently hard to comply indicators/ evidences
1. Patient’s Rights and Organizational Ethics
• Per validation, patients are seldom informed of their rights and
responsibilities
• Policy on patient and family education and their involvement in care
decision-making
• Monitoring reports related to patient or family education program/policy
• Policies and procedures that address patients' needs for communication
• Provision of mechanisms to respect privacy (e.g. partition between
patient beds especially in government hospitals)
34

35. Frequently hard to comply indicators/ evidences
1. Patient’s Rights and Organizational Ethics
• Policies and procedures on codes of professional conduct. Some have
copies of statutory standards such as the following but have no issuance
adopting them:
– Codes of professional standards (PRC, PMA, PNA, PAMET, CSC, DOLE, etc)
– Patient detention (RA 9434) and
– Anti-deposit law (RA 8344)
– Sexual harassment law (RA 7877)
• Presence of programs on improving staff awareness on codes of
professional conduct and other statutory standards
• Policies and procedures on monitoring compliance to codes of
professional conduct relevant to their respective discipline
• Presence of an Ethics Committee
35

36. Frequently hard to comply indicators/ evidences
1. Patient Care
• Policies and procedures on patient waiting time
• Monitoring and evaluation reports on patient waiting time
• Policies and procedures on informing patients for any cause of delay in
the delivery of services
• Some patients admitted or their families are not appropriately informed by
authorized qualified personnel of their disease, condition or disability, its
severity, likely prognosis, benefits and possible adverse effects of various
treatment options and the likely costs of treatment
• Patients and/or their families are seldom informed of the need and
availability of resources to continue care after discharge
36

37. Frequently hard to comply indicators/ evidences
1. Patient Care
• Comprehensive history and PE within 24 hours from admission
• Doctors’ progress notes done regularly
• Policies and procedures for the standard performance, monitoring and
quality control of diagnostic examinations
• Adopted/developed protocols, CPGs or pathways containing:
– goals to be achieved
– services to be provided
– patient education strategies to be implemented
– time frames to be met
– resources to be used
37

38. Frequently hard to comply indicators/ evidences
1. Patient Care
• Policies and procedures on implementation/compliance to clinical
pathways
• Charts with clinical pathway-covered conditions.
• Policies and procedures on duplicate assessments and treatments
performed by trainees
• Monitoring reports in compliance to policies and procedures on duplicate
assessments and treatments
• Policies and procedures promoting interactive, appropriate and relevant
educational programs for patients
38

39. Frequently hard to comply indicators/ evidences
1. Patient Care
• Policies and procedures regarding selection and procurement of medical
devices and equipment based on organization’s case mix, staff expertise,
service capability, scientific evidence and government policies
• Patient chart from medical records, look at the discharge orders. It should
contain all of the following:
– May go home order
– Home medications (if applicable)
– Follow up visits/schedule
– Home care/advise
39

40. Frequently hard to comply indicators/ evidences
1. Leadership and Management
• Analysis, conclusion and recommendation based on staff satisfaction
survey
• Proof that policies and procedures are reviewed and revised as
necessary
5. Human Resource Management
• Training needs assessment system
• End-of-training assessment report
9. Information Management
• Lack of qualified staff involved in data definition, generation, collection
and aggregation (no training on medical record management)
• Charts are often incomplete
40

41. Frequently hard to comply indicators/ evidences
1. Safe Practice and Environment
• Not all operating manuals of equipment are present
• Existence of safety programs and/or management plans for hospital
safety
• Proper waste segregation and labeling of waste receptacles
• Policies and procedures on risk identification, assessment and control,
security risks, use of personal protective equipment, etc.
• Risk assessment reports
• Preventive and corrective maintenance logbook for equipment
41

42. Frequently hard to comply indicators/ evidences
1. Safe Practice and Environment
• Procurement policy and plan for equipment which considers the following:
– intended use
– cost benefits
– infection control
– safety
– waste creation and disposal
– Storage
• Late issuance of pertinent licenses/permits by respective agencies (e.g.
ECC, Fire safety permit, including PNRI)
42

43. Frequently hard to comply indicators/ evidences
1. Improving Performance
• Presence, Implementation and evaluation of quality improvement
programs
• Implementation of CPGs (development or adoption)
• Proof of better services and patient outcomes
• Implementation of patient satisfaction survey (including analysis)
43

44. Feedback and Experiences during hospital survey
Positive
• Hospitals appreciate standards set by Benchbook, standards are for the
benefit of their facility
• Hospitals find implementation of quality framework helpful
• Although compliance to Benchbook requires exertion of much effort by
hospitals, in the end, they recognize that the things they have done are
actually needed to improve their hospital operations
• Many hospital administrators claim that the process of crafting policies
and procedures and documentation of monitoring and evaluation, among
others, helps them in their work as hospital administrators
• Surveyors appreciate it more if hospitals tag their documents based on
the indicators of the Benchbook
• Once the preliminary results are presented to the hospital management,
the latter is very much eager to comply with their deficiencies the soonest
time possible
44

45. Accreditation Reforms
• Third Party Accreditation
– Delegate accreditation functions exclusive of the decision-
making function to duly recognized third party
accreditation agencies
• On-line Application for Accreditation
• Preferred Provider Scheme/ Contracting
– No out of pocket payment for PHIC members, provider
will be granted faster claims processing

46. New Accreditation Schemes
• Strong collaboration with Licensing of the DOH
- Core indicators to be adopted by licensing
- Licensed hospitals shall be automatically accredited
as Center of Safety but has to sign a performance
commitment with Philhealth
• All government hospitals to be automatically accredited

47. “Excellent firms don’t believe in
excellence- only in constant
improvement and constant
change.”
Tom Peters

48. 48

49. WARRANTIES OF ACCREDITATION
Representation of eligibilities
Compliance to pertinent laws/rules &
regulations/policies/administrative orders and issues
Clinical services
Conduct of clinical services, records, preparations of
claims and undertakings of participation in the NHIP
Management Information System
Administrative investigations/regular
surveys.domiciliary visitations on the conduct of op-
erations in the exercise of the privilege of
accreditation.
49

50. Benchbook Indicators
• Developed through consultative meetings
• Stakeholders suggested indicators for each standard
and criteria
• Stakeholders agreed to set some indicators as CORE
indicators
• Survey tool which contains CORE indicators pilot tested
in 2008
• Revision of some indicators and listing/delisting of CORE
indicators

51. How does Benchbook measure against the
principles underlying ISQua Standards?
• Leadership through effective planning, governance and management
• Customer focus to meet the needs of internal and external
customers, both existing and potential
• Organizational performance through the management of processes
and outcomes and the transparency of decision-making
• Continuous quality improvement based on innovation, evidence, best
practice and evaluation to better meet the needs of customers
• Valuing people by appropriately selecting, training and appraising
personnel and maintaining good relationships
• Safety by providing safe work environments and complying with
statutory requirements.
Source: http://www.isqua.org/Accreditations.aspx?men=29

52. Trends of Health Expenditure
by Source of Funds
100,000
90,000
National
80,000
70,000 Local
In Million Pesos
60,000 Social health
insurance
50,000 Out-of-Pocket
40,000
Other private
30,000
20,000
10,000
0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Years
Source: Philippine National Health Account

53. Quality Dimensions
• Safety
• Efficiency
• Appropriateness
• Accessibility
• Effectiveness
• Consumer Participation

54. Warranties of Accreditation, Institutions
 they recognize the authority of PhilHealth to any inspection or
investigation
 accept the program of quality assurance, payment mechanism and
utilization review of the NHIP
 shall guarantee safe, adequate, and standard medical care
 its personnel shall adhere to a strict Code of Ethics
 they agree to adhere to practice guidelines or protocols, peer
reviews and other QA activities

55. The Quality Problem is Large
U.S. Healthcare Is
DANGEROUS REGULATED ULTRA-SAFE Hazardous:
(>1/1000) (<1/100K)
100,000 HealthCare • 7% of patients
Driving suffer a
medication error
10,000
Total lives lost per year
• Every patient
1,000 admitted to an ICU
Scheduled suffers adverse
Airlines event
100
Mountain Chemical European
• 44,000- 98,000
Climbing Manufacturing Railroads
10 deaths
Bungee Chartered Nuclear
Jumping Flights Power
1 • $50 billion in total
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 costs
Number of encounters for each fatality
Back
Source: Leape, Lucian

57. Legal Mandate
• IRR Rule IX, PhilHealth shall…
– Implement a Quality Assurance Program applicable
to all Health Care Providers for delivery of health
services
– Ensure that health services are of quality necessary
to achieve the desired health outcomes and
member satisfaction

58. PhilHealth’s Mission
To ensure adequate financial access of
every Filipino to QUALITY HEALTH
SERVICES through the effective and
efficient administration of the National
Health Insurance Program

59. Minimal threshold standards
Inspection - “find what’s wrong”
Focus on inputs
Improvement of Process and Outcomes
Continuous quality improvement
Self-assessment and demonstrating
achievements

60. Calls for improvement of
systems and processes,
focuses on customer
orientation, collection and
assessment of relevant
performance data, and
timely action on the results
of these data.

61. History of the Benchbook
Standards
Benchbook Requirement Full 2nd year of
on of CQI Program Implementation implementation
Performance for of Benchbook as Review of
Improvement accreditation Standard for standards,
of Health of hospitals Accreditation indicators and
Services was -PC 12 s 2006 evidences
published
2011
2010
2007
2004

62. 7 Areas of Benchbook Standards
• Patient Rights and Organizational Ethics
• Patient Care
• Leadership and Management
• Human Resource Management
• Information Management
• Safe Practice and Environment
• Improving Performance

63. Commitment to Quality
Begins with management …
• ensures support for the deployment of
activities
• it is up to the hospital leadership to allow,
let alone encourage, the development of a
CQI culture in their hospital.

64. Benchbook Awards

65. Relative Performance of Government and Private
Government Hospitals Private
Leadership and Management
Most could present an assessment of their Difficulty identifying proof of assessment of
performance. Annual activities and targets are their performance/ not always documented
well documented
Patient Care
Procurement policies for drugs are not readily Procurement policies for drugs are readily
available (local government) available
Human Resource Management
Recruitment, selection, and hiring policies are Most have these policies
usually not available (local government)
Safe Practice and Environment
Preventive and corrective maintenance services L3 and hospitals usually have good safety
are not readily available which may be a result of programs compared to government
delayed procurement of services as these hospitals. Personnel responsible of
services were not assured from vendor when the maintaining security and conduct of
equipment was purchased. preventive and corrective maintenance of
equipment are always available

66. Government vs Private

67. National Performance

70. “Excellent firms don’t believe in
excellence- only in constant
improvement and constant
change.”
Tom Peters

71. Background:
Universal Health Bawat Pilipino miyembro,
Care Bawat miyembro protektado,
Kalusugan natin segurado.
General • Automatic accreditation of all gov’t
Appropriations health care providers effective April 1,
Act of 2012 (RA 2012
10155) • Subject to the guidelines to be issued
by DBM, DOH and PhilHealth
DOH AO • Automatic accreditation of all licensed
2011-0020: hospitals as Centers of Safety
Streamlining of • Benchbook core indicators
Licensure and incorporated in DOH licensing
Accreditation of standards 71
Hospitals • Subject to “appropriate rules and

72. Streamlining of Licensure and
Accreditation
• Published January 14, 2012, Philippine
Star
• Effective January 29, 2012
• But will only apply to licensed hospitals
if the licensure standards already
incorporated the 51 core indicators of the
Benchbook standards for hospitals
• Status: DOH is still finalizing the survey
tool

73. Third Party Accreditation:COQ/
COE
Directions Implementation
Recognition of • Recognize • No pre-
Accreditation of accreditation accreditation
Hospitals granted issued by ISQua survey of hospitals
by International accredited accredited by
organizations for international
Accrediting
Centers of Quality organizations
Organizations
and Excellence
•Non-withholding of necessary/essential services to patients
applicable to licensed service capability.
•Compliance to policies on the implementation of case rate and/or
“no balance billing” (if applicable).
•No Writ of Execution issued against the applicant provider by
PhilHealth three (3) years prior to application of accreditation.
•No negative monitoring findings, e.g., irrational drug use,
over/underutilization of services, etc, that remain uncorrected for the
year preceding the applicable period.

74. Automatic Accreditation of Government
• HCPs
Primary Care Benefit Provider (PCB): health units, outpatient
clinics of Levels 2, 3, and 4 DOH licensed hospitals, L1 hospitals
with a L2 laboratory and licensed radiology service referral facilities
with physician as certified by PHIC or CHDs
• MCP + NCP Provider: facilities certified BEmONC with NS
• Anti-TB DOTS Providers: health units/DOH-licensed hospitals that
are certified as DOTS Facilities
• Outpatient Malaria Package (OMP) Provider: certified by DOH
• Outpatient Animal Bite Benefit (OABB) Provider: certified by
DOH
• Other facilities: such as, but not limited to, Ambulatory Surgical
Clinics, Free-standing Dialysis Clinics, etc.
• Other service providers as identified by the Corporation
• All government – employed health care providers, duly licensed by
the Professional Regulatory Commission shall be deemed
accredited, if applicable as a professional provider of applicable
PHIC benefit.

75. “Automatic Accreditation”
• No more pre-accreditation survey will be
conducted by PHIC
• Automatic accreditation is only for entry, all
HCPs shall be subject to Corporate rules and
regulations
• Exclusion:
– Hospitals applying as Centers of Quality and
Excellence
– Some Outpatient Benefit Package Providers:
mostly private

76. Regular Process
Eligible
Registration Survey Deliberation PC to
Participat
e
•Submit
PDR Issue
SC/A Sign
•Pay Fee PAS Notice/I
C PC
D
Subject to
Corporate
Rules and
Regulations

77. Thank you!