The document discusses best practices in quality and excellence in healthcare. It begins with definitions of key terms like quality, performance excellence, and best practice. It then outlines the main topics to be covered: aiming for best practices in hospitals, how to develop best practices, and examples. Specific strategies are provided for developing a comprehensive set of best practices, including leadership commitment and clear communication. The goal is for hospitals to document numerous best practices to demonstrate the highest levels of quality and performance excellence.

1. Quality and Excellence in Healthcare:
Best Practices
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
LUZON REGIONAL MANAGEMENT SEMINAR
Private Hospitals Association of the Philippines
September 19, 2014
Baguio Country Club

2. Quality and Excellence in Healthcare: Best Practices
Greetings and Salutations
From
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

3. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
Main Contents
• Aiming for best practices in quality and
performance excellence in hospitals
• How to aim for best practices in quality and
performance excellence in hospitals
• Examples of best practices in quality and
performance excellence in hospitals

4. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
Main Contents
Delimitations
Specifications
Operational definitions
• Aiming for best practices in quality and
performance excellence in hospitals
• How to aim for best practices in quality and
performance excellence in hospitals
• Examples of best practices in quality and
performance excellence in hospitals

5. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Quality” - “degree to which a set of inherent
characteristics fulfils requirements.” [ISO]
• Degree: refers to a level to which a product
or service satisfies.
~depending upon level of satisfaction,
excellent
good
poor

6. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Quality” - “degree to which a set of inherent
characteristics fulfils requirements.” [ISO]
• Inherent characteristics: those features that
are a part of the product or service and are
responsible to achieve satisfaction.

7. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Quality” - “degree to which a set of inherent
characteristics fulfils requirements.” [ISO]
• Requirements: refer to needs of customer,
organization and other interested parties
(e.g. regulatory bodies, suppliers,
employees, community & environment).
– expectations may be stated, generally
implied or obligatory.

8. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Performance Excellence” - an integrated approach
to organizational performance management that
results in
(1)delivery of ever-improving value to customers
and stakeholders, contributing to organizational
sustainability;
(2)improvement of overall organizational
effectiveness and capabilities; and
(3)organizational and personal learning.
[Baldrige / PQA Criteria for Performance Excellence]

9. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Best Practice” –
a formally documented method or technique
that has been institutionalized in the hospital and
that has consistently shown performance
excellence results at least if not yet proven
superior to those achieved with other means and
which can be or is being used as a benchmark by
other hospitals.
[ROJoson]

10. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Aiming for best practices in quality and
performance excellence in hospitals

11. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Setting the Bar of Excellence in Healthcare or
Hospitals,”
theoretically means putting standards of
excellence in hospitals at a certain level in
the continuum of excellence
or
defining the standards or criteria of
excellence.

12. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
Setting the bar may either be raising or
lowering, it but usually raising, when one is
talking of bar of excellence.

13. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Various levels of excellence
• Rating scale or categorization varies from
one evaluating organization to another.

14. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Categorization:
–low, medium, high, and highest levels of
excellence.

15. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Categorization:
–gold, platinum, and diamond levels with
diamond being the highest level being
used by Accreditation Canada
International.

16. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Categorization:
–Center of Safety, Center of Quality, and
Center of Excellence previously used by
PhilHealth.

17. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Categorization by the Philippine Quality Awards:
– Level 1, Recognition for Commitment to Quality
Management (just beginning quality journey; planted
seeds of quality and productivity);
– Level 2, Recognition for Proficiency in Quality
Management (achieved significant progress in building
sound process);
– Level 3, Recognition for Mastery in Quality
Management (demonstrated superior results; role
model in the Philippines);
– Level 4, Philippine Quality Award for Performance
Excellence (highest level of excellence; national and
global role model).

18. Aiming for best practices in quality and performance
excellence in hospitals
All hospitals should continually aim for the
highest level of quality and performance
excellence.

19. Aiming for best practices in quality and performance
excellence in hospitals
If a hospital has a documented “Journey
towards Excellence” program with at least
some positive evaluation results, then that
hospital can say or boost that it has one
“Best Practice” and this “Best Practice” is
considered to be the Parent, either Mother
or Father, Best Practice.

20. Aiming for best practices in quality and performance excellence in
hospitals
Programmed Journey of Excellence
Parent Best Practice

21. Aiming for best practices in quality and performance excellence in
hospitals
Programmed Journey of Excellence
Parent Best Practice

22. Aiming for best practices in quality and performance excellence in
hospitals
MDH and CMZ have set the bar of quality and
performance excellence
and
they are still continually aiming for the highest level.

23. Aiming for best practices in quality and performance excellence in
hospitals
Aiming for highest level of quality and performance
excellence does not just mean getting more
certificates from external reputable standard-bodies
but more importantly, strategy should be
to have more documented specific best practices
aside from the Parent Best Practice.

24. Aiming for best practices in quality and performance excellence in
hospitals
Presence of a documented comprehensive set
of “Best Practices” (as I have defined it)
- ultimate single criterion to say that
- a hospital has achieved the highest bar or
level of quality and performance
excellence!!!

25. Aiming for best practices in quality and performance excellence in
hospitals
Presence should be validated and affirmed by
a Level 4 PQA and a reputable external
hospital standard accrediting body that puts
emphasis on documented best practices and
benchmarking.
ROJ’s message in: “Aiming for Best Practices in
Quality and Performance Excellence in
Hospitals.”

26. Quality and Excellence in Healthcare: Best Practices
Welcome feedback and queries
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

27. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• How to aim for best practices in quality and
performance excellence in hospitals

28. How to aim for best practices in quality and performance excellence in
hospitals
Subtopics
• Processes of developing a “Best Practice”
• Comprehensive set of “Best Practices” in a
Hospital
• Strategies to have a documented
comprehensive set of “Best Practices” in a
hospital

29. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
• Decide on a management system that will be
developed into a “Best Practice.”
One can choose from the list that I will provide
later.
For examples, communication management
system and strategic planning management
system.

30. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
• Formulate a design and development plan or
blueprint
– systematic approach in planning of
management system
– deployment and implementation
– evaluation, review, and continual improvement
–management review and independent audit

31. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
In the management system plan, adopt / adapt
with innovations best practices from other
institutions if there are.

32. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
Use
systems approach (looking at and managing
the hospital as a whole)
alignment (promoting consistency of all plans,
processes, evaluations, actions of
component systems to support whole
hospital’s goals)
integration (making all components function
as an interconnected unit)

33. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
In the evaluation, always include timelines and
measurements with key performance
indicators.

34. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
• Track the implementation of the
management system plan.

35. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
• Evaluate results of implementation for at
least 3 years in terms of
– level (current level of performance based on
formulated key performance indicators)
– trends (rates of performance improvements and
sustainability of good performance)
– comparison (performance relative to
appropriate comparisons such as other similar
hospitals and benchmarks or hospital industry
leaders)

36. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
All the above must be formally and completely
and accurately documented!!!

37. How to aim for best practices in quality and performance excellence in
hospitals
Processes of developing a “Best Practice”
If management system plan has been
implemented for at least 3 years and has
consistently shown performance excellence
results, then it can be considered as a “Best
Practice” for the hospital.
Once publicized, can be used as a benchmark
by other hospitals.

38. Quality and Excellence in Healthcare: Best Practices
Welcome feedback and queries
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

39. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
Aside from developing “Journey towards Excellence”
program as the Parent Best Practice, hospital should
develop other specific “Best Practices.”

40. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
List of “Best Practices”
- comprehensive
- all hospitals should develop as part of the
“Journey towards Excellence.”
- at least 25

41. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
I formulated this list using as references
• PQA Criteria for Performance Excellence
• international hospital health care standards
particularly on patient-care
• ROJ’s steadfast strategic objectives for
hospitals
• Others

42. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
Using PQA Criteria for Performance Excellence as
Reference:
• Leadership
• Strategic Planning
• Customer Focus
• Measurement, Analysis, Knowledge
Management
• Workforce Focus
• Operations Focus
Develop One Best Practice per Category

43. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
Using international hospital patient care standards as
reference:
• Patient Safety
• Access to Care and Continuity of Care
• Patient and Family Rights
• Assessment of Patients
• Care of Patients
• Anesthesia and Surgical Care
• Medication Management
• Patient and Family Education
• Hospital Infection Control
Develop One Best Practice per Category

44. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
ROJ’s Recommended Steadfast Strategic Objectives for Hospitals
Systems perspective in governance
Integrated value-based health care service
Physician engagement (patronage and loyalty)
Maximal utilization of services with controlled expenses and
losses
Customer delight
Full compliance with the quality and performance standards
(local and international)
Integrated IT-enabled operations system
Staff engagement
Learning organization
CSR program with tangible social impact
Develop one Best Practice per Category

45. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
ROJ Additional Recommended Must-Have
Management System or Program for Hospitals:
• Communication Management System

46. How to aim for best practices in quality and performance excellence in
hospitals
Comprehensive set of “Best Practices” in a Hospital
ROJoson’s Recommendation:
At least 25 documented “Best Practices”
which all hospitals should develop as part of
“Journey towards Excellence” Program

47. Quality and Excellence in Healthcare: Best Practices
Welcome feedback and queries
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

48. How to aim for best practices in quality and performance excellence in
hospitals
Strategies to have a documented comprehensive set
of “Best Practices” in a hospital
What top management and senior leaders
should do?
• Leadership strategy
• Management strategy
• Communication strategy
• Education strategy

49. How to aim for best practices in quality and performance excellence in
hospitals
Strategies to have a documented comprehensive set
of “Best Practices” in a hospital
• Leadership Strategy
–Commitment
–Motivation
–Support
–Role model

50. How to aim for best practices in quality and performance excellence in
hospitals
Strategies to have a documented comprehensive set
of “Best Practices” in a hospital
• Management Strategy
–Technical competence in the processes of
developing “Best Practice”

51. How to aim for best practices in quality and performance excellence in
hospitals
Strategies to have a documented comprehensive set
of “Best Practices” in a hospital
• Communication Strategy
– Clear communication
– Close-loop communication
– Information
– Alignment and integration
– Engagement of staff to the project “Best
Practices”

52. How to aim for best practices in quality and performance excellence in
hospitals
Strategies to have a documented comprehensive set
of “Best Practices” in a hospital
• Education Strategy
– Education, coaching, mentoring on developing
“Best Practices” to all hospital staff

53. How to aim for best practices in quality and performance excellence in
hospitals
Subtopics
• Processes of developing a “Best Practice”
• Comprehensive set of “Best Practices” in a
Hospital
• Strategies to have a documented
comprehensive set of “Best Practices” in a
hospital
ROJ messages: “How to Aim for Best Practices
in Quality and Performance Excellence in
Hospitals.”

54. Quality and Excellence in Healthcare: Best Practices
Welcome feedback and queries
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

55. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
• Examples of best practices in quality and
performance excellence in hospitals

56. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
“Best Practice” –
a formally documented method or technique
that has been institutionalized in the hospital and
that has consistently shown performance
excellence results at least if not yet proven
superior to those achieved with other means and
which can be or is being used as a benchmark by
other hospitals.
[ROJoson]

57. Examples of best practices in quality and performance excellence in
hospitals
Disclosure:
• Not fully matured
• Being implemented for at least 3 years
(institutionalized) – level of commitment at least,
proficiency at most (not yet mastery)

58. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
Examples of best practices in quality and
performance excellence in hospitals
• Governance and Leadership
• Strategic Planning
• Balanced Scorecard
• Safety Promotion and Disaster Preparedness
• Financial Management
• Continual Improvement Program (MDH)
• Corporate Social Responsibility Program (MDH)

59. Examples of best practices in quality and performance excellence in
hospitals
• Strategic Planning
• Balanced Scorecard

60. TPOR1: Journey towards performance
Strategic Planning Conferences
excellence of MDH and CMZ
Every 3 years since 1999
With a structured framework
With Annual Planning Conferences

65. Strategic Planning Conferences
Every 3 years since 2009
With a structured framework
Using Baldrige / PQA Criteria

66. TPOR1: Balanced Journey Scorecard
towards performance
excellence Since 2004
of MDH and CMZ
Performance management and
evaluation tool

67. Balanced Scorecard
Since 2009
Performance management and
evaluation tool

71. Quality and Excellence in Healthcare: Best Practices
Welcome requests for more info
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com

72. Quality and Excellence in Healthcare: Best Practices
“Setting the Bar of Excellence in Healthcare”
Main Contents
• Aiming for best practices in quality and
performance excellence in hospitals
• How to aim for best practices in quality and
performance excellence in hospitals
• Examples of best practices in quality and
performance excellence in hospitals

73. Aiming for best practices in quality and performance excellence in
hospitals
Presence of a documented comprehensive set
of “Best Practices” (as I have defined it)
- ultimate single criterion to say that
- a hospital has achieved the highest bar or
level of quality and performance
excellence!!!

74. Quality and Excellence in Healthcare: Best Practices
Thank you for your attention
Welcome feedback, queries, and requests for info and assistance
REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg
0918-804-03-04
rjoson2001@yahoo.com