Benchbook Complete

(C G H)
Benchbook
On Performance Improvement of Health Services
Philippine Health Insurance Corporation

Quality Assurance Research and Policy Development Group
2004
Benchbook
on performance improvement of health services

Published by the Philippine Health Insurance Corporation (PhilHealth)
Copyright 2004 PhilHealth
All rights reserved. No part of this book may be reproduced or used in any form or by any
means, electronic or mechanical, including photocopying, recording, scanning or by any
information storage or retrieval system, without permission in writing from the publisher.
Editor: Wystan de la Pea
Book and cover design: Arnulfo Aquino
Technical Consultant: Mary Ann Evangelista, M.D.
Table of Contents
From the President and CEO ................................................................................ i
From the Quality Assurance Research
and Policy Development Group (QARPDG) ..................................................... iii
Part I: Introduction ............................................................................................. 1
PhilHealth and the Health Sector Reform Agenda....................................... 5
e Focus of the Quality Assurance Framework .......................................... 8
Dimensions of Quality Health Care........................................................ 9
Cross-Dimensional Issues........................................................................ 11
Implementing the New Quality Assurance Framework ................................ 15
What is Quality of Care? ............................................................................. 20
Why is Quality of Care Important? ............................................................. 22
Where Quality of Care Starts....................................................................... 26
Assessing Quality of Health Care ................................................................. 26
Improving Quality of Health Care............................................................... 28
Part II: PhilHealth Quality Standards for Health Provider Organizations ....... 35
1. Patient Rights and Organizational Ethics .............................................. 39
2. Patient Care Standards .......................................................................... 43
2.1 Access.............................................................................................. 43
2.2 Entry............................................................................................... 44
2.3 Assessment ...................................................................................... 46
2.4 Care Planning ................................................................................. 49
2.5 Implementation of Care .................................................................. 50
2.6 Evaluation of Care........................................................................... 53
2.7 Discharge ........................................................................................ 54
3. Leadership and Management................................................................. 57
3.1 e Management Team ................................................................... 57
3.2 External Services ............................................................................. 58
4. Human Resource Management ............................................................. 60
4.1 Human Resources Planning ............................................................ 60
4.2 Staff Recruitment, Selection, Appointment
and Responsibilities ......................................................................... 61
4.3 Staff Training and Development ...................................................... 62
5. Information Management ..................................................................... 65

5.1 Data Collection, Aggregation and Use............................................. 65
5.2 Records Management...................................................................... 66
6. Safe Practice and Environment.............................................................. 68
6.1 Patient and Staff Safety.................................................................... 68
6.2 Maintenance of the Environment of Care ....................................... 69
6.3 Infection Control ............................................................................ 70
6.4 Equipment and Supplies ................................................................. 71
6.5 Energy and Waste Management ...................................................... 72
7. Improving Performance......................................................................... 74
Part III: Implementing a Performance Improvement Program......................... 77
Rationale and Steps for Performance Improvement ................................... 80
TQM Program Implementation Steps ....................................................... 81
e Documentation-Evaluation-Action Triad............................................ 83
e Plan-Do-Check-Act (PDCA) Cycle.................................................... 86
Quality Improvement Tools ...................................................................... 86
Problem Identification Tools
Affinity Diagram ......................................................................... 89
Brainstorming ............................................................................. 91
Flowchart .................................................................................... 93
Nominal Group Technique.......................................................... 96
Problem Description Tools
Bar Graph ................................................................................... 98
Check Sheet ................................................................................ 99
Force Field Analysis ..................................................................... 101
Line Graph.................................................................................. 103
Pareto Chart................................................................................ 105
Pie Chart..................................................................................... 108
Problem Analysis Tools
Fishbone Diagram ...................................................................... 109
Matrix Diagram .......................................................................... 111
Scatterplot Diagram .................................................................... 114
Solution Development Tools
Prioritization Matrix.................................................................... 116
Process Decision Program Chart (PDPC).................................... 120
Tree Diagram............................................................................... 122
Quality Monitoring Tools

Control Chart ............................................................................. 124
Histogram ................................................................................... 127
Radar Chart ................................................................................ 129
Quality Circles and Quality Teams............................................................ 131
Quality Improvement Activities ................................................................ 134
Clinical Practice Guidelines......................................................... 134
Clinical Pathways ........................................................................ 137
Medical Audits ............................................................................ 148
Utilization Review ....................................................................... 153
Complaints Analysis.................................................................... 154
Expanded Incident Monitoring ................................................... 155
Morbidity and Mortality Meetings .............................................. 158
Sentinel Event Monitoring .......................................................... 159
Credentialing and Clinical Privileging.......................................... 161
Variance Reporting and Analysis .................................................. 162
Part IV: References .............................................................................................. 165
Glossary .................................................................................................... 167
List of Works Cited................................................................................... 179
Appendix .................................................................................................. 187
Participants in the 2001 Workshops to Develop the PhilHealth
Quality Standards for Health Provider Organizations..................... 188
Participants in the 2004 Focused Group Discussions to Copytest
the PhilHealth Benchbook ............................................................ 190
World Medical Association Declaration on the Rights of the Patient ... 192
List of Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.
Figure 9.
Figure 10.
Figure 11.
Figure 12.
Figure 13.
Figure 14.
Figure 15.
Figure 16.
Figure 17.
Figure 18.
Figure 19.
Figure 20.
Figure 21.
Figure 22.
Figure 23.
Figure 24.
Figure 25.
Figure 26.
Relationship between PhilHealth,

its accredited health care providers and PhilHealth members.......... 8
Assessment focus points of PhilHealths
new Quality Assurance framework .................................................... 9
Implementation activities for PhilHealths
Quality Assurance framework......................................................... 15
Quality Care Dynamics: Dimensions and Cross-Dimensional Issues. 20
Donabedian Model of Quality of Care Assessment............................ 27
Evolution in quality thinking in industry and in the health service.... 28
PhilHealth Quality Standards for Health Care ................................. 39
e Documentation-Evaluation-Action Triad
and the PDCA Cycle in Performance Improvement Programs........ 80
e Plan-Do-Check-Act Cycle .......................................................... 87
Sample Affinity Diagram................................................................... 90
Sample flowchart .............................................................................. 95
Bar graph showing the estimated number of beneficiaries
of the NHIP for the period 2000-June 2002 .................................. 98
Bar graph showing PhilHealth claims payment
for the period 1998-June 2002....................................................... 98
Sample Force Field Analysis ............................................................. 102
Average Value Per Claim Filed With PhilHealth, 1999-June 2002..... 103
Sample line graph.............................................................................. 104
Sample Pareto chart........................................................................... 107
Pie chart showing percentage of different kinds
of accredited health care institutions as of June 2002...................... 108
Pie chart showing PhilHealth payments by sector, Jan-Jun 2002 ....... 108
Pie chart showing regional distribution
of NHIP members as of June 2002 ................................................ 108
Sample of a fishbone diagram............................................................ 110
Sample L-shaped matrix comparing personnel tasks
in patient orientation ..................................................................... 113
Sample T-shaped matrix comparing personnel tasks
in patient orientation ..................................................................... 113
Sample scatterplot diagram ............................................................... 114
Sample PDPC showing contingency measures for the persistent
high turn-over of staff following employee training ........................ 121
Template of a tree diagram ................................................................ 123
Figure 27.
Figure 28.
Figure 29.
Figure 30.
Figure 31.
Figure 32.
Figure 33.
Sample control chart showing an out of control process

from October to December ............................................................ 126
Sample histogram showing the number of claims compared to
average lengths of stay in a hypothetical hospital ............................ 128
Sample radar chart showing the performance rating
of a hypothetical organization ........................................................ 130
Flowchart for the development, dissemination and implementation
phases in the creation of a clinical practice guideline ...................... 136
Types of Medical Audit ..................................................................... 151
Flowchart for Peer Review Processes .................................................. 152
Flowchart of activities in case of a sentinel event ............................... 160
List of Tables
Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Tools for the different stages of PDCA .............................................. 88

Accreditation Check Sheet for Medical Professionals......................... 100
Computation of cumulative percentages ........................................... 106
Evaluation Points for QC Members .................................................. 132
Matrix of Aspects Useful for Complaints Analysis ............................. 154
Sample Output Form for Variance Analysis....................................... 162
Matrix of Quality Improvement Activities......................................... 163
Preface
From the President and CEO

This Benchbook aims to show how PhilHealth providers can serve
Filipinos with high quality health care. It is a systematic overview of
the accreditation process, policies and standards, and how they relate
to PhilHealths mission as an insurance company and as an agent for
reforming the Philippine health system.
The Benchbook is not an all-encompassing and exhaustive textbook
on quality of care. Nor is it meant to be a permanent code of conduct.
Readers should refer to many excellent resources on quality of care,
attend training seminars or formal courses, and network with as many
experts as possible.
Envisioned to serve as a yardstick for measuring and assessing the
quality of health care rendered by PhilHealth and its accredited health
providers and professionals, the Benchbook lays out basic concepts on
the value of quality assurance in health care and how the accreditation
process supports continuous quality improvement.
Also included is an updated list of standards and criteria which
health care provider organizations and professionals can use for
self-assessment prior to applying for accreditation and even after
obtaining it. Both accredited providers and professionals and
accreditation applicants should refer to the Benchbook during and
after the accreditation process in order to have a common ground for
discussion and partnership. The Benchbook should also be consulted
in cases when accreditation has been denied, appealed or reinstated.
Production of this Benchbook has been made possible through a
grant from the AusAID, through the PhilippinesAustralia Governance
Facility, and the Deutsche Gesellschaft fr Technische Zusammenarbeit
(GTZ), or the German Development Cooporation.
Finally, I commend Dr. Madeleine R. Valera, PhilHealth Vice President
for Quality Assurance Research and Policy Development, for her vision
of quality assurance in health care in the Philippines, her determined
efforts in realizing it despite Herculean obstacles, and her endless
patience and dedication in managing the team of in-house Quality
Assurance specialists in the writing of this Benchbook.
Francisco T. Duque, M.D., MSc

President and CEO
BENCHBOOK
ii
From the Quality Assurance Research

and Policy Development Group (QARPDG)
The provision of quality health care has always been in the agenda of
the Philippine Health Insurance Corporation.
Realizing that deficiencies in processes would not be corrected by
focusing only on improving the quality of inputs, we decided to move
beyond the traditional accountability framework and work towards
helping our providers aim for continuing improvement.
In the past couple of years since PhilHealth assumed the role
of national health insurance administrator, we have made only
incremental improvements in elevating the quality standards of our
providers. Even as we wanted to focus more on improving processes,
particularly outcomes, we have continued to emphasize mostly
structure standards.
Avedis Donabedian, a pioneer in quality assurance in health care,
states we should focus on all three componentsstructure, process and
outcomeif we want to improve quality. We at PhilHealth have also
recognized that the presence of quality inputs alone will not guarantee
good process and consequently good outcomes.
The Benchbook features a concise list of best possible conditions that
should exist in the organization. It goes beyond the usual emphasis
on structuressuch as facilities and equipmentby providing
process standards as well, such as waiting time and turnaround time
for procedures and treatments. We hope this guidebook will serve as
a useful reference for providers, and for PhilHealth as well, in carrying
out data collection regarding performance and in making appropriate
decisions and actions based on the data.
As writing the Benchbook involved different kinds of input from
different people, we feel we should give credit where it is due,
especially to those individuals who bore the brunt of the Benchbook
production. Those who participated in the Stakeholders Meeting for
Standards Development in 2001 and in the Focused Group Discussion
in copytesting the Benchbook in 2004, are named in a list which
appears in the appendix.
Acknowledgement
iii
For starters, the writing of this Benchbook needed financial allies: the
AusAID, through the Philippines-Australia Governance Facility, and the
Deutsche Gesellschaft fr Technische Zusammernarbeit (GTZ) GmbH.
These two foreign agencies provided the financial lifeline for the
initial writing of the draft and its final editing to make the Benchbook
publication ready. For their administrative support at the start of
the project, Ms. Christine McMahon and Mr. Carlos Mendoza, of the
Philippines-Australia Governance facility deserve our thanks. So do Dr.
Claude Bodart, health program manager; Dr. Matthew Jowett, advisor;
and Mr. Manolito Novales, senior technical coordinator, of the GTZ for
similar assistance in the completion of the Benchbook.
Mr. Karl Karol and Ms. Brenda Ballantyne of the Australian Health
Insurance Commission facilitated the participation of two of their
consultants, Dr. Denis Smith and Dr. Jose Acuin. These two doctors,
joined by Prof. Don Hindle, a PhilHealth consultant, assisted in the
creation of the PhilHealth Quality Standards, the conceptualization
of quality improvement in the context of the Philippine health
system. They also led the brainstorming for a new quality assurance
framework for PhilHealth. Dr. Acuin concretized everything in black
and white by producing the original manuscript. Dr. Hindle wrote
the PhilHealth drafts for the clinical pathways for Outpatient Cataract
Surgery and Low Risk Maternity Care featured in Part III of the
Benchbook.
Reviewing and rewriting Part II (PhilHealth Quality Standards for
Health Provider Organizations) fell on the shoulders of the division
chiefs of the Quality Assurance Research and Policy Development
Group: Dr. Francisco Soria (Utilization Review Division), Dr. Clementine
Almario-Bautista (Health Technology Assessment Division), Dr.
Mary Ann Evangelista (Medical Informatics Division). Dr. Ma.
Theresa Bonoan and Dr. Errol Ciano, quality assurance officers, also
participated in the review and rewriting sessions.
In the final production phase of the Benchbook, Dr. Evangelista acted
as technical consultant from PhilHealth, and working closely with the
editor, did additional research to expand the text and bibliography
where needed, adding information from selected 2000-2003
published titles to ensure that the Benchbook carries state-of-the-art
Quality Assurance ideas. She also executed the various figures and
illustrations.
BENCHBOOK
iv
As editor, Prof. Wystan de la Pea of the University of the Philippines

Diliman designed the methodology for the Focused Group
Discussions/Copytesting sessions, and drafted the accompanying
survey instrument. In the end, he crafted a cohesive yet engaging
and easy-to-read final version, and even enriched the concept of
the Benchbook by fashioning it for a three-fold purpose: as a handy
Quality Assurance reference manual for health care professionals, a
document for PhilHealths institutional memory, and literature for local
discourse on quality care.
Arnold Aquino executed the cover design and most of the layouting.
His wife, Bituin Acebron-Aquino, assisted in the layout work and
proofreading.
Thanks are also in order for the entire QARPDG staff, for their assistance
in all forms.
May this Benchbook serve its purpose of improving the way health
care is delivered to every Filipino.
Madeleine R. Valera, M.D., MScCHHM

Vice-President for Quality Assurance Research and Policy Development
Introduction
Part I
Introduction
PhilHealth and the Health Sector Reform
Agenda
The PhilHealth Quality Assurance
Framework
The Focus of the Quality Assurance
Framework
Implementing the New Quality Assurance
Framework
What is Quality of Care?
Why is Quality of Care Important?
Where Quality of Care Starts
Assessing Quality of Care
Improving Quality of Health Care
BENCHBOOK
2
Introduction
Introduction
PhilHealth is concerned with quality of care because it is more
than just an insurance company. It acts as an instrument of the
government to provide equitable access to the highest feasible
quality of health services for as many Filipinos as possible. Based
on the guiding principles of the National Health Insurance Act of
1995, PhilHealth is committed to:
1. Balance economical use of resources with quality of care;
2. Promote improvement in the quality of health services
through the institutionalization of programs of quality
assurance at all levels of the health service delivery system;
3. Enhance the satisfaction of the community, as well as its
individual beneficiaries;
4. Promote innovation, informed choice among members,
and professional responsibility of health care providers.
PhilHealth-accredited providers are required by law to take part
in quality assurance, utilization review and technology assessment
programs. is is aimed at ensuring that the quality of the services
they deliver comply with a uniform set of standards and that the
acquisition and use of scarce and expensive medical technologies
and equipment are consistent with actual needs and standards of
medical practice.
e Benchbook is divided into three main parts:
Part I explains the context of PhilHealths paradigm shift from
an accountability framework to that of continuous quality
improvement. It provides an overview and brief history
of quality improvement from a global perspective. It also
highlights some of the milestone ideas in quality improvement
in industries and how these were gradually appropriated
for improving quality in health care. Based on these trends,
PhilHealth developed Part II.
BENCHBOOK
Part II contains the benchmark of performance improvement.

It lists seven major groups of standards, to wit:
1.
2.
3.
4.
5.
6.
7.
Patient Rights and Organizational Ethics

Patient Care
Leadership and Management
Human Resource Management
Information Management
Safe Practice and Environment
Performance Improvement
Goals are set to serve as targets for improvement. ese goals

are concretized by standards which delineate the best possible
condition that should exist in the organization for it to attain
quality performance. Finally, one or more criteria flesh out
the standards. ese criteria lay down specific actions that
need to be done to meet standards.
Part III deals with performance improvement. Using as
framework the Plan-Do-Check-Act cycle, it discusses a
Total Quality Management approach to performance
improvement. Highlighting the need for documentation,
evaluation and action in improvement efforts, Part III also
tackles activities and tools needed to attain quality health
care.
Introduction
PhilHealth and the Health Sector Reform Agenda
Origins of Social Health Insurance

Compulsory sickness insurance
started among European countries.
Germany established the first ever
system in 1883. Initially applied to
wage earners, it paid for medical
expenses and provided a cash benefit
for lost wages during sickness. Other
European countries followed in the
decades prior to World War I: Austria
(1888), Hungary and Sweden (1891),
Denmark (1892), Norway (1909),
Serbia (1910), Britain (1911), Russia
(1912) and the Netherlands (1913).
The United States would lag behind
for at least two more decades (Starr
1982).
Social health insurance started in 1969 in the Philippines

with the passage of Republic Act 6111, which established the
Philippine Medical Care Plan or Medicare Program. It provided
for a health insurance scheme under the Government Service
Insurance System (GSIS) and the Social Security System
(SSS) for public and private sector employees, respectively.
Implementation, however, started only three years later with the
creation of the Philippine Medical Care Commission. Benefits
and coverage were expanded through the issuance of several
presidential decrees and executive orders.
In 1978, medical and dental practitioners and health care
facilities were required to secure accreditation from the
Commission, a measure aimed at ensuring quality care for
Medicare patients. e compulsory Medicare program expanded
coverage to the self-employed in 1983 and retirees in 1974 (for
GSIS beneficiaries) and 1990 (for SSS beneficiaries).
But the Medicare programs failure to expand coverage to
acceptable levels especially in the informal sector prompted
the passage of Republic Act 7875 in 1995. Also known as the
National Health Insurance Act, it established the Philippine
Health Insurance Corporation (PHIC) as its implementing
agency with a mission to attain universal social health insurance
coverage within 15 years, with special focus on the indigent
population. In 2002, the government launched Plan 500, a
fast-track enrollment program to give coverage to half a million
indigent families. NHIP coverage is currently estimated at 54%
of the total population. As a financial intermediary, PHIC is also
mandated by law to ensure the quality of services delivered to
its members by developing and implementing quality assurance
standards for its accredited providers. (ASSA 2004; PHIC 1996;
Gamboa, Bautista, Beringuela 1993).
Expanding the coverage of the NHIP is one of the five major
strategies of the Health Sector Reform Agenda (HSRA),
conceived in 1999 by the Department of Health (DOH). e
expansion effort is premised on the operationalization of the
BENCHBOOK
concept of Quality Assurance (QA). According to this concept,

if more Filipinos obtain health care from Philhealth-accredited
providers, the government would be in a better position to ensure
quality through regulation, accreditation, technology assessment,
clinical practice guidelines and organization-wide quality assurance
programs.
Envisioned to be support instruments for other HSRA strategies,
QA programs, which aim to provide high quality diagnostic and
therapeutic services, constitute good business practice for hospitals.
e case is most palpable among government hospitals, as QA
programs can attract investments from diverse sources, promote
fiscal autonomy and secure funding for priority public health
programs. Furthermore, QA programs, with its advocacy for the
use of practice guidelines and technology assessments, ensure
sustained delivery of quality services by local health systems.
e New PhilHealth
Quality Assurance
Framework
e current PhilHealth quality assurance framework is primarily

an accountability framework. As a condition for accreditation with
PhilHealth, health care providers are accountable to PhilHealth for
the range, quality and quantity of services that they provide. e
accountability process requires the inspection and accreditation
of provider facilities and the collection and analysis of data on the
range, quality and quantity of services provided to ensure safe,
effective, appropriate and efficient services.
However, many providers view the current framework as an
application of controls and sanctions. is thinking does
not support a culture of quality improvement within service
provider organizations. Such thinking, which considers quality
improvement as an external administrative function, excludes
clinicians, the very people most able to affect the quality of care.
A new approach is required.
e success of any new PhilHealth quality assurance framework
will depend on its ability to support and be perceived to support a
quality improvement framework for health care providers. While
the need for accountability remains, the focus must move from
accountability methodologies to measures that support continuous
quality improvement.
Introduction
e new quality assurance framework aims to foster an environment of

continuous improvement. Effectiveness of care must be demonstrated
by data on achievements, improvements and outcomes. Data used
by provider organizations to regularly review and improve their
performance shall be the same data which PhilHealth will use to
monitor the quality of services provided by these organizations. is
approach ensures efficiency and effectiveness of the QA framework.
While this new approach will be more demanding because it requires
specific clinical and non-clinical information, it will support provider
organizations in their quality improvement endeavors. More
importantly, this new approach will help create a culture that embodies
quality initiatives as part of the usual everyday practices of health care
organizations.
Critical to the success of the new QA framework is the establishment
of a partnership between PhilHealth and its accredited health care
organizations. rough this partnership, the latter work to improve their
delivery of services and enjoy PhilHealth support.
e PhilHealth member is at the center of the new QA framework.
Providers of health care services are responsible to the patient for
treatment and other health-related services. PhilHealth purchases
the services on behalf of the member, and consequently is primarily
concerned with the value of the services purchased. A primary
determinant of value is the quality of the service. As consumers of
health services are rarely in a position to critically assess the multiple
dimensions of quality, PhilHealth must act on behalf of its members
by encouraging and assisting service providers to continuously assess the
quality of the services they provide.
PhilHealths QA framework focuses on the assessment of six key
dimensions of quality health care and six cross-dimensional issues. is
approach is founded on the principle that if a service provider renders
adequate performance in these dimensions, and rates high on the crossdimensional issues, the result is appropriate quality of care. PhilHealth
shall establish routine quality assessment processes for the various
dimensions of quality and to encourage and assist service providers to
use them for the improvement of patient care.
BENCHBOOK
Accreditation
Payment
Pre
miu
ms
alth
He
e
c ar
Cov
era
ge
Figure 1. Relationship between PhilHealth, its accredited health care providers and
PhilHealth members.
The Focus of the Quality Assurance Framework

PhilHealths QA framework focuses on the assessment of six key
dimensions of quality health care and six cross-dimensional issues.
is approach is founded on the principle that if a service provider
renders adequate performance in these dimensions, and rates high
on the cross-dimensional issues, the result is appropriate quality
of care. PhilHealth shall establish routine quality assessment
processes for the various dimensions of quality. It shall also
encourage and assist service providers to use these same QA
processes to improve patient care.
Introduction
9
Safety
Effectiveness
Appropriateness
Consumer
Participation
Accessibility
Efficiency
Education &
Traning
Accreditation
Dimensions of Quality
Health Care
Quality of Care
Cross-Dimensional
Issues
Competence
Information
Management
Continuity of
Care
Evidence-Based
Medicine
Figure 2. Assessment focus points of PhilHealths new Quality Assurance framework
Dimensions of Quality Health Care1

PhilHealths new QA framework will focus on the following key
dimensions of quality health care:
Safety
New PhilHealth accreditation standards and performance

measures will cover safety issues in phenomena like adverse
events, complications and sentinel events as a major objective
of any health service provider should be the safety of patients.
Harm from care, whether by omission or commission, as well
as from the environment in which it is carried out, must be
avoided. Likewise, risk in care delivery processes should be
minimized. e safety of staff and visitors to the health care
organization must also be ensured.
1
For a more detailed discussion, refer to Chapter 1 (The Components of Quality in Health
Care) of health care quality guru Avedis Donabedians last book before his death, An
Introduction to Quality Assurance in Health Care (2003).
BENCHBOOK
10
Effectiveness
PhilHealth members should expect that the treatment they receive

will produce measurable benefit. e effectiveness of health care is
related to the extent to which a treatment, intervention or service
achieves the desired outcome. PhilHealth will develop outcome
performance measures for all high-volume services.
Appropriateness
PhilHealth shall develop measures to ensure appropriateness of

key medical interventions, including compliance with selected
clinical pathways. Appropriateness of health care is about using
evidence to do the right thing to the right patient in a timely
fashion. Interventions for the treatment of a particular condition
should be selected based on the likelihood of a desired outcome.
Select utilization reviews can act as a surrogate in assessing
appropriateness.
Consumer participation
As patients have a fundamental right to be involved in health care

decisions and delivery, PhilHealth will develop mechanisms for
gathering members input and assessing their satisfaction level with
service providers and PhilHealth. ese mechanisms will provide
patients opportunities to participate in health service planning,
delivery, monitoring and evaluation.
Accessibility
PhilHealth supports equitable access to health services on the

basis of patient need, irrespective of geography, payment group
(indigent, individually paying, etc), ethnicity, age or gender. e
benefit packages should be designed to support equitable access to
health services on the basis of patient need.
Efficiency
PhilHealth shall ensure cost-efficiency through the implementation

of case payment, select contracting and monitoring of compliance
with clinical pathways. ese measures minimize inappropriate
resource inputs and allocate resources to services which provide the
greatest benefit.
Introduction
11
CrossDimensional Issues
Meanwhile, the following are the cross-dimensional issues which
impact on the above dimensions of quality:
Competence
As a major priority for review and action by PhilHealth, there are

three levels of competence to be addressed:
Organizational Competence the facilitys ability to assess
its capacity to perform particular functions or procedures,
or to supply a particular service. e competence of the
organization will be tested by the PhilHealth accreditation
process;
Multidisciplinary Care Team Competence the teams ability
to deliver optimum outcomes for patients. As health services
are characterized by multiple boundaries and barriers among
various disciplines, quality health care delivery requires a team
performance. PhilHealth will encourage a multidisciplinary
team approach to health care delivery through clinical
pathways and accreditation standards;
Individual Competence the individual health care providers
skills, knowledge and attitudes. While there is currently no
system which guarantees individual competence, the best
available evidence suggests that an appropriate mix of quality
improvement tools related to producing individual competence
(selection and recruitment of appropriate staff, credentialing,
peer review, skills assessment, clinical supervision, recertification and continuing education) should be employed.
No one tool is a guarantee, but when used in combination
with others can improve levels of competence. PhilHealth
accreditation standards and process for both individual
practitioners and provider organizations shall support the use
of various approaches to ensuring individual competence.
Information
Management
PhilHealth is committed to improving the accuracy,

appropriateness, completeness and analysis of health care data if
judgments about clinical quality are to be made. is will become
BENCHBOOK
12
increasingly important as PhilHealth makes allocation decisions

based on available health care information. Health service
providers should be encouraged to prioritize the development
of information systems to promote and support appropriate use
of data for health care quality improvement. PhilHealth shall
disseminate comparative information on the quality of service
of different providers to PhilHealth members. Information
provided to service providers shall be de-identified aggregate data
to assist performance comparisons. PhilHealth shall decide what
data about specific providers are to be made available. Members
will need to be informed about the use and limits of such data in
making health care decisions.
Data collection for purposes of accountability, and even for
evaluation, entails costs. ere is the risk that if the cost of
getting good data is too high, organizations will content
themselves with poor ones. e solution is to use data which
provider organizations collect themselves for their own purposes.
Such a strategy provides a stronger guarantee of accuracy and
reliability since the data has utilitarian value in the running of
the organization (World Bank Institute and World Bank 2000).
From the perspective of the new QA framework, collected data
shall be used to gain valuable information for improvement of
services provided by health service organizations.
Continuity of care
is refers to the extent to which an individual episode of

care is coordinated and integrated into overall care provision.
PhilHealth care packages and clinical pathways shall ensure this
important aspect of quality care. Continuity of care is achieved
through admission and discharge planning, communication
and coordination among health care professionals, and linkages
between hospital and community care providers. Health
promotion and preventative programs are also important in
minimizing the demand on curative and palliative services.
Improved delivery of health care can reduce the average length of
stay in acute care facilities and increase utilization of communitybased and primary care services.
Effective care planning allows appropriate linkages with
community-based resources, for instance, the Botika Binhi
Introduction
13
Program (Seed Pharmacy Program). Properly coordinated care

processes provide opportunities to make drugs more accessible to
marginalized patients (Venida, Jovero, Mendoza 2002).
Evidencebased medicine,
clinical practice guidelines
and clinical pathways
In implementing this new framework, PhilHealth emphasizes

the use of evidence-based medicine in making decisions relevant
to care provision. Evidence-based medicine, defined as the
conscientious, explicit and judicious use of current best evidence
in making decisions about the care of individual patients (Tan
Torres 2001: 183), attempts to attain care improvement and
savings in health financing through the elimination of unnecessary
diagnosis or treatment (World Bank Institute and World Bank
2000).
Concrete applications of evidence-based medicine include the
development and routine use of clinical practice guidelines and
clinical pathways. A clinical practice guideline is a statement
systematically developed to aid practitioner and patient in
making appropriate health care decisions for specific clinical
circumstances (Institute of Medicine, 1990). A clinical pathway
is a document that describes the usual sequential way of providing
multidisciplinary clinical care for a particular type of patient,
and allows for annotation of deviations from the norm aimed at
continuous evaluation and improvement.
e judicious use of evidence-based medicine and clinical
epidemiology impact on clinical economicswhich is the use
of cost evaluations to compare different interventions in clinical
careby (Tan Torres 2001):
Increasing the availability and appreciation for good quality
information;
Formulating clinically relevant research questions;
Reviewing and synthesizing data systematically through metaanalyses;
Simplifying reporting of clinical outcomes with resource
implications;
BENCHBOOK
14
Improving the collection of cost-data thereby improving

the cost component of economic evaluations of health care
services;
Considering sample size in cost-effectiveness studies thus
improving validity;
Integrating outcomes, costs and preferences with the use of
decision analytic techniques further assisting physicians and
patients make appropriate decisions regarding care.
Education and training
To successfully implement this framework, PhilHealth shall carry

out a well-planned education program for all stakeholders and set
priorities for the development of clinical practice guidelines and
other quality improvement activities.
A discussion of several quality improvement activities can be
found in Part III.
Accreditation
rough accreditation, PhilHealth assesses an organizations

compliance with set standards. As the framework focuses on
the shift from the traditional accountability orientation to one
of continuous improvement, PhilHealth accreditation shall no
longer exclusively zero in on a provider organizations compliance
with standards but shall also evaluate the organizations
commitment to provide quality care and service.
While accreditation in itself can not guarantee quality, it does
provide useful information to PhilHealth on the structure and
processes required to achieve outcomes of adequate quality.
Over time, PhilHealth accreditation is envisioned to also require
provider organizations (and possibly individual practitioners)
to demonstrate the outcomes of care processes. Accreditation
results shall be made available to PhilHealth members, but they
will need to be educated about the value of such information in
making health care decisions.
Introduction
15
Implementing the New Quality Assurance Framework
Implementation of QA Framework
Accreditation
Clinical Practice
Guidelines
Performance
Measurement
Figure 3. Implementation activities for PhilHealths Quality Assurance framework
Implementation of the QA framework involves the following interrelated activities:

PhilHealths
Accreditation Program
Beginnings of Accreditation:
Codman (1918)
The idea of accreditation as a means
to ensure quality care provision
began in 1918 when studies on
post-operative infections by Dr.
Ernest Codman, a surgeon at the
Massachusetts General Hospital,
influenced the American College of
Surgeons to establish the Hospital
Standardization Program, which
was later adopted by the Joint
Commission on Accreditation of
Hospitals.
In PhilHealth, the Accreditation Department takes charge of

accrediting health care providers. Teams of skilled surveyors conduct
two levels of assessments: first, they evaluate compliance with
documentary requirements.; and second, they visit the provider site
to evaluate actual operations.
rough its accreditation program, PhilHealth verifies the
qualifications and capabilities of health care providers to deliver
the desired and expected quality of health care services, prior to
conferring to them the privilege of participating in the NHIP.
e accreditation program is founded on the ideas on assessment
of health care introduced in 1966 by Lebanon-born public health
expert Avedis Donabedian (1919-2000), and which now constitute
the principal paradigm in the evaluation of health care provision
(Frenk 2000). Donabedians ideas describe the relationship between
structures, processes and outcomes and posit that an organization
with the right structures and processes in place will produce better
outcomes.
BENCHBOOK
16
The Donabedian Approach
This approach focuses on standards that require the presence
of structures (buildings, manpower, equipment, organizational
relationships, etc), processes (treatment, committee activities,
performance guidelines, etc), and outcomes (cure, less pain, disability,
death). Donabedian urges that all three measuresstructure, process,
outcomebe used when assessing and monitoring the quality of health
care. He adds that quality assessment aims to determine how successful
providers have been able to do their work, and that quality monitoring
generates constant surveillance which facilitates early detection and
correction of any deviation from standards (Jonas and Rosenberg 1986).
e new quality assurance framework reorients the accreditation

program to focus on improving outcomes with outcome-based
standards and a continuous quality improvement program.
However, as outcomes can not be improved without appropriate
structures and processes, these two factors must be developed
with the improvement of specific outcomes in mind.
PhilHealths accreditation program shall incorporate this new
approach. It shall require organizations to demonstrate a
commitment to quality (and to continuous improvement), and
assessment shall determine whether they are doing what they say
they are doing.
Philip Crosby, quality management expert and author of the
book Quality is Free (1979) wrote that the focus of quality
is conformance. Applied to the health care setting, it means
compliance with standards. An important component of the
accreditation process is determination of compliance with set
standards. ese standards are used to assess a health care
organizations performance in service provision. e focus is on
what the organization actually does, not its capability. Standards
set maximum achievable performance expectations for activities
that affect the quality of care, like compliance with patient
pathways which emphasize the interface between management
units. Since standards aim to improve outcomes, there is no
prescribed manner on how to achieve improvement.
Introduction
17
PhilHealth accreditation standards shall be redeveloped in

consultation with the health care industry. ey should be equally
applicable to all health care organizations regardless of whether
they are a hospital, day surgery unit, community service, or some
other type of health care organization.
As standards underpin the accreditation process, they have to focus
on the dimensions of quality care as well as on the organizational
cross-dimensional support functions essential to the provision of
this care. ey should reflect contemporary best practice principles,
be achievable, easily understood and measurable.
Section 58 of the PhilHealth Implementing Rules and Regulations
(2000) includes the following health care providers as participants
in the NHIP, to wit:
1. Institutional Health Care Providers
Hospitals
Out-patient Clinics
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Community-Based Health Care Organizations
2. Independent Health Care Professionals
Physicians
Dentists
Nurses
Midwives
Pharmacists
Other duly licensed health care professionals
An accredited provider is privileged to participate in the NHIP
for a prescribed duration, subject to renewal. Accreditation
requirements are detailed in the IRR.
To demonstrate compliance with standards and provide practical
advice on how to apply them in different care settings, PhilHealth
shall design appropriate clinical practice guidelines.
BENCHBOOK
18
Clinical Practice Guidelines

and Clinical Pathways
Ever-increasing evidence points to the role of clinical practice

guidelines and clinical pathways in the reduction of variations
in practice and consequently, in outcomes. us, even as
PhilHealth shall continue to identify high volume and high
impact services, it shall also continue its work on designing
appropriate clinical practice guidelines. ese guidelines should
eventually, through education and implementation strategies,
be adopted as operational pathways in health service provider
organizations.
PhilHealth has disseminated CPGs on Hypertension,
Community-acquired Pneumonia and Urinary Tract Infection
nationwide. For further discussion on CPGs and pathways, refer
to Part III.
Performance
Measurements
Monitoring is an important component in the evaluation of

an organizations performance as it allows measurement and
assessment of patient care and other service processes provided by
health care provider organization.
PhilHealth shall develop a limited range of indicators to measure
performance in the abovementioned dimensions of health care
quality and cross-dimensional issues. e main focus shall be
on supporting the evaluation of the effectiveness of select clinical
pathways. PhilHealth shall require all service providers to collect,
report, and, most importantly, provide evidence of action on
results based on the PhilHealth indicator set.
e following few basic issues should be considered:
Can the health care provider organization effectively
monitor all of the measures identified as being relevant
to PhilHealth? If not, PhilHealth shall determine which
measures are priorities in terms of targeted areas for
improvement.
Are the measures manageable using existing resources and
information systems (both within PhilHealth and within
provider organizations)? It may be preferable to monitor
just a few performance measuresbut effectively do so
than monitor all measures.
Introduction
19
Over time, review of monitoring shall highlight areas where

useful information is being generated. If a monitoring
program does not provide meaningful information, then
it may be more appropriate to direct resources to the
monitoring of other performance areas.
Performance targets shall be established and the frequency with
which these targets are met (or not met) shall provide quantitative
evidence on the quality of the service. As PhilHealth aims to foster
the use of data and targets as part of the quality improvement
process within the health service provider organizations, reviewing
the reasons for less-than-expected achievements can facilitate
improvements in outcomes, structures or processes.
Dissemination of
Performance Results
Patients have a fundamental right to participate in health care

decisions and delivery. However, they need to have information
to effectively participate. High quality, dependable information
on the performance of health care organizations is not currently
available to the public in the Philippines.
Disseminating Performance Results: The U.S. Experience

In the United States, several studies have reported increased efforts to
improve quality of care following release of national data on hospital
mortality rates. Despite criticism, large corporations, who make big
health insurance payments for their personnel, are examples of
consumers who have utilized their purchasing clout to collect hospital
performance data and release them to their employees to help them
make informed health care choices. This is in response to the clamor for
evaluations to focus more on data regarding physicians and hospitals,
and not on the different health plans available. As providers have
opposed public release of performance data due partly to the resistance
to being subjected to a public performance evaluation, fears have
been raised about providers refusing to deal with complicated cases to
protect their performance scores. Researchers, however, have failed to
find evidence of this kind of reaction (Galvin and Milstein 2002).
BENCHBOOK
20
PhilHealth shall determine which information it will make

available and to whom. While the ability of PhilHealth
members to properly use and draw appropriate conclusions
from accreditation and other quality performance data remains
debatable, it will be only through the dissemination and use
of the data that health care providers and the community can
appreciate and understand performance data
As PhilHealth shall develop valid and reliable performance
measures, it shall be in a unique position to provide health care
provider organizations with aggregated data for performance
comparisons. is data can be used to further give impetus to
the quality improvement agenda.
What is Quality of Care?
Patients
QUALITY OF CARE
Safe
Efficient
Effective
Appropriate
Accessible
PatientCentered
Individual Competence
Organizational Competence
Continuity of Care
Evidence-Based Medicine
Accreditation
Providers
PhilHealth
Figure 4. Quality Care Dynamics: Dimensions and CrossDimensional Issues.
Introduction
21
Quality caresome experts prefer the term quality of the process

of care (Donabedian 2003)refers to the degree to which health
care increases the likelihood of desire health outcomes, and is
consistent with current professional knowledge (Lohr, Institute of
Medicine 1990). It takes into account three factors:
a) the variability of the achievement of quality each time
care is rendered;
b) health care can not guarantee the attainment of
outcomes that clinicians and patients expect;
c) scientific evidence and professional standards are crucial
to defining care.
High-quality health care is safe, effective, efficient, appropriate,
accessible and patient-centered. To achieve high-quality care,
provider organizations must address the following critical issues:
a) individual and organizational competence;
b) continuity of care;
c) information management;
d) the role of evidence-based medicine and accreditation.
While the end goal and ultimate recipient of any effort towards
quality of health care is the patient, provider organizations and
PhilHealth are its indirect beneficiaries. Provider organization
benefit through the consequent rationalized use of human and
infrastructure resources. PhilHealth benefits through the resulting
cost-effective utilization of benefit packages.
Internal and External
Customers
Staff and employees
While patients and communities are the ultimate customers who

benefit from quality health care, provider organizations have
other internal and external customers, to wit:
e people who run the hospital are not just its most important
resource. ey are the hospital. is is true particularly to
patients. Hospitals and clinics are only as good as the staff
who directly take care of them. Hospitals and clinics owe their
doctors, nurses and other personnel reasonable compensation for
their work, an environment conducive to efficient performance of
their roles, and fulfillment of their professional and social needs.
BENCHBOOK
22
Funders
All hospitals and clinics owe their funders fiscal responsibility.

Private organizations must earn money for their owners and/
or stockholders. Government hospitals must stay within their
budgets even as they try to generate their own income to
augment limited government subsidies. Devolved hospitals
must, in addition, serve the socio-political needs of the local
governments that support them as a return of their investment.
Partnering with local government officials and the local health
boards increases devolved hospitals chances of competing
for revenue allocations. Competitiveness is critical to survival
regardless of hospital ownership.
Payors of health care
External agencies that pay hospitals and clinics for providing

care to its insured members expect good value for their money.
PhilHealth, as a third party payor, funds hospitals that provide
health care to PhilHealth insured members. In return, hospitals
must maintain their accreditation and abide by its warranties.
Contractors
Individuals or external agencies that agree to provide services

or goods to hospitals and clinics expect to be bound by fair
contracts and be paid promptly. ese contractors include
housekeeping and security agencies, laboratory equipment
wholesalers and drug companies.
Why is Quality of Care Important?

Jonas and Rosenberg (1986) have identified four broad categories
which explain the need for quality of care:
e Hippocratic oath principle of primum non nocere
(First do no harm);
e social and humanitarian motivation to use resources
for the good of those in need;
Professionalism;
Survival.
Introduction
23
In the Philippines, the following conditions point to a similar

impetus for this pursuit of quality:
Tougher Competition
Health care providers that are committed to the pursuit of

continuous improvement, innovation and customer satisfaction
are the ones which survive the competition for a greater market
share of consumers and purchasers of care. Hospitals that have
loyal patients, supportive stockholders or local government
boards and enthusiastic staff are the ones with better prospects
of long-term viability.
Frequent Medical Errors
Harrowing tales of patients given wrong medications or

subjected to wrong operations erode public trust in the
health professions. While physicians, nurses and other health
professionals are trained to be highly proficient under stress,
they are not immune from committing errors. Organizations
should provide opportunities for professionals to learn from
medical errors and take system-wide steps to prevent them.
In 1998, the Institute of Medicines Quality of Health Care
in America Committee recommended that safety systems
be created inside health care organizations through the
implementation of safe practices at the delivery level. A
culture of continuous improvement with strong leadership
and interdisciplinary training is critical in implementing safety
programs (Institute of Medicine 2000).
Since then, different organizations led by the health
departments of the United States, Australia, the United
Kingdom, and New Zealand, as well as other private
organizations like the JCAHO and the Institute for Health
Care Improvement, have developed mechanisms to monitor
and report medication errors, device errors, and other sentinel
events.
BENCHBOOK
24
Studying Medical Errors: Bosk, Sharpe and Faden
Two books published in the last few years provide different perspectives
on medical errors. In his now-classic ethnographic-style study of
surgical errors Forgive and Remember: Managing Medical Failure (1979;
2003, 2nd ed.). medical sociologist Charles Bosk categorizes medical
errors into four major types (technical, judgmental, normative and
quasi-normative). By focusing on what he calls the social accounting
system surgeons practice to account for errors, Bosk suggests how safety
recommendations are much easier to make than implement. He adds
that successful error reduction attempts should focus on how personnel
define errors, understand their causes and think how they could be
remedied.
In another work, Medical Harm: Historical, Conceptual and Ethical
Dimensions of Iatrogenic Illness (1998), Virginia Sharpe and Allan Faden
highlight the do-no-harm dictum as central to the practice of the medical
profession. They reveal that 70% of iatrogenic complications in the United
States could have been prevented.
Rising Costs, Limited

Health Expenditures
Health care has become increasingly dependent on new

and expensive technologies. Patients and providers alike
equate high tech care with good care. Health insurance can
encourage patients and providers alike to use high tech care
simply because it has been paid for. Fear of malpractice
suits compel physicians into defensive practice by ordering
multiple diagnostic tests. On the other hand, simply spending
more money for health has been repeatedly demonstrated not
to increase good health outcomes (Donabedian 1992). is
has been proven in the United States (World Development
Report 1993). Ensuring value for money requires optimal
and efficient use of effective health interventions for the
appropriate indications. Quantifying the cost of quality
illustrates why focusing on quality is important. One has to
take into account Crosbys statement that the price of quality
can be measured in terms of what it will cost the company
should things be done wrong in the first place (like cost of
scrap, rework, engineering changes, purchase order changes,
consumer services, software correction). Should the cost of
quality reach 2.5 percent of income, it must be seen as a call
for improvement (Crosby 1979).
Introduction
25
Rising Demands, Limited

Health Resources
A health-conscious post-baby boom generation has produced

a rising demand for health care. However, there are limited
resources to meet rising demand. is has spawned the need
for equitable access, especially for those who are denied health
care--even if they are the ones who need it the most--either
because they do not know about it or do not have money to
purchase it.
Equitable access also means involving and empowering
consumers in making decisions regarding their own health.
Ensuring equitable access is critical to economic growth
because sick populations can never achieve full economic
productivity; in such a case, the state is forced to ration health
care resources to those who really need them.
Concern With Variations

In Health Care Outcomes
and Costs
Medical decision-making is influenced by previous

experience, current knowledge, patient expectations and
other biases. Unjustified variations in care lead to unwanted
variations in processes and outcomes of care. is in turn
leads to unnecessary costs. Using valid scientific evidence
to plan and implement care will prove useless unless
organizations make their professionals behave more rationally
through a system of rewards and sanctions. is requires
routine training, monitoring and partnering with health care
team members so that clinical practice guidelines are seen
as tools for improving care and are thus internalized and
followed.
BENCHBOOK
26
Where Quality of Health Care Starts

Quality health care, whether delivery is seen at the patients end
or from the provider organizations perspective, starts with two
principal actions:
a) selection of the most appropriate health intervention
b) effective, efficient and timely application of the selected
intervention.
e first action, which is a decision-making one, is determined
by the providers (whether this be the professional or the
hospital) level of knowledge, skill, experience, and the kind and
amount of additional information available. e second, which
is a performance action, is influenced by the adequacy of the
processes used in delivering the intervention. Other important
influences in both actions include patients preferences, peer
practice patterns, societal values, professional and legal sanctions
as well as economic rewards.
At the organizational level, management of human and material
resourceswhich should be oriented towards the provision of
quality health carefacilitates implementation of the decisionmaking and performance actions which initiate quality health
care.
Assessing Quality of Health Care

Traditionally, quality of care assessment is an evaluation of
the structural, process and outcome components involved in
the delivery of health care (Donabedian 1992). ese three
components take into account material and human resources
(structural component), medical and non-medical actions
(process component), and the physical, psychological and social
effects of health care (outcome component).
Material and human resources covered in the structural
component include the number and capability of the medical
and paramedical staff, the number and adequacy of diagnostic
and treatment facilities, and the physical environment in which
Introduction
27
care is given. Non-medical actions covered in the process

component include food provision, hospital room/ward
maintenance and regulation of visiting hours.
Quality of Care Assessment
Structure Component
Process Component
Outcomes Component
(material & human resources)
(medical & non-medical actions)
(physical, psychological & social

effects of care)
Figure 5. Donabedian Model of Quality of Care Assessment
In quality assessment, quality is measured against a set of

standards. Typically, criteria are developed which specify the
attributes of structure, process and outcome components of care.
Whether care is good enough depends on the criteria satisfying
the standards.
BENCHBOOK
28
Improving Quality of Health Care
Quality Health Care
Improvement
QUALITY ASSURANCE
Prevention
try
us
nd
A little over a decade later, in 1854,

Florence Nightingale, then serving
as a nurse in the Crimean War,
introduced the idea of quality care
in army hospitals and posited that
adequate nursing care to wounded
soldiers would decrease the mortality
rate among them. This was the first
time that the relationship between
quality of care and positive outcomes
was established (WHO 2001). She
published a book on the matter,
Notes on Matters Affecting the Health,
Efficiency, and Hospital Administration
of the British Army, Founded Chiefly
on the Experience of the Late War
(1858). In 1999, the Joint Commission
on Accreditation of Healthcare
Organizations (U.S.) published
excerpts from this book and another
Nightingale work, Notes on Hospitals
(1859), as Florence Nightingale:
Measuring Hospital Care Outcomes.
QUALITY IMPROVEMENT
I
ice
erv
The original concept of quality

health care can be traced back to the
mid-19th century in England (WHO
2001) In 1842, Dr. Edwin Chadwick,
a public health activist and pioneer,
reported on unsanitary conditions in
communities and the lack of public
health professionals to provide
quality service. He recommended the
creation of guidelines for the training
of public health workers. At about the
same time, in the United States, Dr.
Lemuel Shattuk published a similar
report on sanitary conditions in
Massachusetts.
TQM
Management
hS
alt
He
19 Century Quality of Health Care

Thinking: Chadwick and Nightingale
th
Pro
du
cts
/M
an
ufa
ctu
rin
g
Quality Products
QUALITY CONTROL
Inspection
Figure 6. Evolution in quality thinking in industry and in the health service
Quality Control
e quality movement first took root in the manufacturing
industry. Initial efforts at improvement centered on quality control
which involved inspection of finished products aimed at the
detection of deviations from their predetermined design. ese
deviations were considered errors or defects. Defective products
were either re-worked or discarded.
However, it soon became apparent that quality control was an
expensive and wasteful process. is is very apparent in health care.
Inspection of the finished surgical work would not ensure that
the correct limb had indeed been amputated. Inspection of the
cleanliness of a hospitals premises would not ensure that accidents
like slips and falls from spilt liquids would not occur. Counting
adverse drug events would do no good to patients who have
already developed drug hypersensitivities.
Ideas on quality thus evolved and expanded, leading to concepts
like quality assurance, quality improvement and total quality
management. Applied in the health care industry, the optimum
attainable outcome was called total quality health care.
Introduction
29
e industrial reconstruction activity in post-war Japan

gave birth to the ideas on statistical quality control and
standardization of W. Edwards Deming, an electrical engineer
by training with a doctorate in mathematical physics from Yale.
One of several American production experts recruited by Gen.
Douglas MacArthur to advise Japanese industrialists, Deming
went on to become a renowned quality control guru in Japan,
where that countrys prestigious quality control award, the
Deming Award, is named after him.
Deming is known internationally for his simple yet revolutionary
principle that all processes are vulnerable to loss of quality due
to variation. He forwarded the idea that quality improvement
results from management-oriented reduction of levels of variation
(Kennedy 1991; Peters and Austin 1985).
Quality Assurance
Demings ideas regarding standardization and variance reduction

would later be appropriated in the quality assurance thinking in
health care. is perspective looks at the prescription of a set of
preventive activities to ensure the quality of the finished product.
ese activities evaluate whether the processes of planning,
execution, delivery and maintenance of goods and services are
being performed according to stated design.
Deming Appropriated
In assuring quality, the objective is not elimination but control of
variability (Deming, cited in WHO 2001). Later experts like Kazandjian
would validate the applicability and appropriateness of Demings
insights in quality health care. Kazandjian (1997) states that variability,
rather than uniformity, is the common trait of medicine across health
systems, geographical regions and cultures. He adds that in most
cases, variability may not be due to misuse of medical knowledge by
physicians, but from a system issue that is, the art of medicine may be
influenced, affected, and even dictated by available resources, financial
incentives, patient preferences, or health system organization.
In the effort to limit variance, standards are established. Broadly defined
as statements of expectations for the inputs, processes, behaviors and
outcomes of health systems, they can effectively limit variations by
defining what is expected from the organization in its daily activities.
Through quality improvement techniques, health care staff can
continuously increase their knowledge of and skill in keeping variations
within acceptable limits, further raising the quality of service provision.
BENCHBOOK
30
Along this line, work processes must conform to design, raw

materials must conform to specifications, and finished products
and services must conform to customer requirements (Ishikawa
1985). is customer requirement orientation follows the
thinking of Joseph Juran, a medical doctor and another quality
guru like Deming who earned fame in postwar Japan for his
ideas on improvement of products and services. Juran has defined
quality as fitness to use by the customer (WHO 2001).
The Do-It-Right-The-First-Time
Slogan
An important component behind
the quality movement in health care
provision is the do-it-right-the-firsttime thinking appropriated from the
American Telephone and Telegraph
corporate slogan conceived as
early as the 1920s. This thinking
received contemporary validation
with Philip Crosbys book, Quality
is Free (1979) where he reported
observing that American companies
were using up a fifth of their time,
capital and management resources
in fixing problems. Crosby suggested
that these resources could be rechanneled to more productive use if
procedures were correctly executed
at the start. There is no such thing as
the economics of quality, Crosby said,
adding that it is always cheaper to do
the job right the first time. (Caldwell
1998; Crosby 1979; Barry, Murcko and
Brubaker 2002).
Quality Management
Applied in health care, this thinkingreducing variation and

focusing on customer orientationhas led to the creation of
quality improvement tools like clinical practice guidelines,
clinical pathways, medical chart audits and utilization reviews.
All these are instruments to determine the effectiveness of
diagnostic and treatment modalities in bringing about desired
health outcomes.
Quality Assurance of the NHIP
RA 7875amended in 2003 by RA 9241mandates PhilHealth to have a
quality assurance program which ensures that health services provided
by accredited organizations to members are of the quality necessary
to achieve the desired outcomes. To achieve this, the Corporation
undertakes the following activities, namely:
1. Verify, through accreditation, the qualifications and capabilities
of health providers to render the necessary health care to
members.
2. Monitor, on a periodic basis, the services rendered to members
by health care providers through a process utilization review
and patient satisfaction review.
3. Monitor and review, through outcomes assessment, the results
of the health care service rendered to members.
4. Initiate and impose changes and corrective actions based
on the results on performance monitoring and outcomes
assessment by using feedback and change
5. Formulate and review program policies on health insurance
based on the above data.
Quality management is the organization-wide pursuit of quality.

e name implies managerial oversight of quality of health care
(Donabedian 2003). e commitment to quality begins with
management, and it is also management that ensures support
for the deployment of activities towards this commitment.
When the pursuit of quality includes the perspectives of internal
(staff and funders) and external customers (patients, payors and
Introduction
31
contractors), the process is called total quality management

(TQM). But while TQM is a means to achieve total quality,
total quality goes beyond achieving patient satisfaction. It
seeks to exceed expectations of internal and external customers
and ensure the sustainability of organizations by involving all
levels of management, maintaining continuous improvement,
and generating income, return of investments and staff loyalty
(Kelada 1996).
Managements involvement in achieving quality is an important
component of TQM. is can be seen in how Deming advocates
quality attainment through the use of statistics, in the belief
that such a method leads to self-inspection (or control) by the
very people involved in production. But Deming has cautioned
against too much focus on statistical figures and clarified that
quality is about people, not products (Peters and Austin 1985).
In an apparent effort to show managements responsibility in
attaining quality, Deming once said that 85% of production
faults were due to management, not workers (Kennedy
1991). To attain quality, he has outlined 14 top management
responsibilities.
Demings 14 Management Responsibilities for Attaining Quality

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Create consistency of purpose.

Adopt the new philosophy.
Cease dependence on inspection.
End the practice of awarding business on the basis of price alone.
Improve constantly.
Institute training/ retraining.
Institute leadership.
Drive out fear.
Break down barriers between departments.
Eliminate arbitrary quotas, exhortations and slogans without
providing resources.
Eliminate work standards (quotas) for management.
Remove barrier to pride of workmanship.
Institute programs for education and self-improvement for everyone.
Transform everyones job to transform the organization.
(Deming 1982; Barry, Murcko and Brubaker 2002; Nelson 1995.)
BENCHBOOK
32
Another TQM concept is the shift espoused by Dr. Donald

Berwick, president of the U.S.-based Institute for Health
Care Improvement and principal investigator for the National
Demonstration Project for Quality Improvement in Health Care,
from the bad apple theorya thinking which warns about how
the presence of one bad element will negatively affect the entire
unitto a systems approach to quality improvement (WHO
2001).
James Reason, pioneer and expert on human error and system
safety, talks of the existing blame culture in health care (Reason
2000). He reiterates that errors in health care happen not because
of a single event, or because of a single persons error, but because
a combination of risk factors within the system itself have aligned
and made the error more likely to happen.
In this thinking, known as the swiss cheese model, Reason says
the holes in the system align, and open up opportunities for
errors to happen. He suggests the logical approach is to identify
these holes in the system, fix them, and thus prevent the
trajectory of error from taking a path. is perspective in error
prevention and performance improvement is the current mode of
thinking in the appraisal and improvement of conditions under
which health care professionals work.
Reason (1990) recommends caution in evaluating errors and
identifying culprits. ough it seems easier to pin the blame on
one person or a group of individuals, it is worth remembering that
most people involved in serious accidents are neither stupid or
reckless, and that hindsight bias may cloud judgement.
Instead, he suggests a few ways in which to assess and reduce
human error risks. Originally intended for high-hazard areas such
as nuclear plants and aeronautics, they may find some use in the
provision of health care as well. Although a detailed discussion
is beyond the scope of this material, they are listed below as
reference.
Introduction
33
Assessment
1.
2.
Probabilistic risk
assessment
Human reliability
analysis techniques
Reduction
1.
2.
3.
4.
5.
6.
Eliminating error risks

Intelligent decision support system.
Memory aids
Training
Ecological interface design
Self-knowledge about error types and
mechanisms
Effective health care can only be delivered in a safe and efficient

environment, and because patients expect more than just
medicines or treatments, the quality of hospital management
becomes just as important as the care itself. TQM being clientdriven, participatory, and process- and team-oriented, it calls for
flatter, less hierarchical organizations where managers directly
lead teams built around principal work processes (Milakovich
1995). In a hospital setting, this would mean organizing patient
entry, care and discharge teams with each group composed of
doctors, nurses and support staff.
Other Features of TQM
Decentralized workforce
Integrated data systems
Long-term and quality-oriented relationships with other
stakeholders
Training is integrated with quality and productivity goals
Quality is measured by client needs and process improvement
Quality reflects continuous improvement and client satisfaction
(Milakovich 1995)
e Benchbook, in concretizing PhilHealths paradigm shift in its

quality assurance framework, follows this TQM paradigm. It calls
for improvement of systems and processes focus on customer
orientation, collection and assessment of relevant performance
data, and timely action on the results of these data. Donabedian
(2003) summarizes quality in health care through a five-point
strategy: observation, interpretation, action, assessment and
vigilance.
Parts II and III further flesh out this paradigm shift. Part II
outlines the standards by which performance in the delivery
of health services are to be assessed during accreditation and
monitoring. Part III makes an inventory of tools PhilHealthaccredited provider organizations can use for continuous quality
improvement.
BENCHBOOK
34
Quality Standards
35
Part II
PhilHealth Quality Standards
for Health Provider Organizations
Patient Care Standards
Improving Performance
BENCHBOOK
36
Quality Standards
37
PhilHealth Quality Standards

for Health Provider Organizations 1
Sometime in 2000, PhilHealths Quality Assurance Research
and Policy Development Group (QARPDG), in the wake of its
monitoring of delivery of care practices and facilities of accredited
hospitals and other providers, felt the need to create a document
which laid out basic criteria for quality standards. As PhilHealth
was then using for accreditation purposes standards similar to the
Department of Healths (DOH) structure-based requirements for
hospital licensing, PhilHealth thought it should instead require a
different set of standards that would be more in keeping with its
corporate mission.
us, while DOH standards focus on structure (physical plant,
equipment, manpower, etc.), PhilHealth thought it appropriate
to orient its standards thinking in terms of process and outcomes.
is Quality Standards portion is divided into the following
seven standards groups:
1.
2.
3.
4.
5.
6.
7.

Patient Care
Performance Improvement
Each group has specific goals which serve as targets for

improvement. All but twothe Patient Rights and
Organizational Ethics and Performance Improvement groups
are further subdivided into subgroups which in turn have
separately-listed goals.
While goals picture the desired-for situation targeted by a
performance improvement program, standards delineate the best
possible condition that should exist in the organization for it to
1
Organization from hereon refers to health care organization.
BENCHBOOK
38
attain quality performance. Standards set maximum achievable

performance expectations for activities that affect the quality of
care (like compliance with patient pathways) which emphasize
the interface between management units. Since standards aim
to improve outcomes, there is no prescribed manner on how
to achieve improvement. e focus is on what the organization
actually does, not its capability. Hence, the standards listed herein
are made as general as possible to make them equally applicable
to all health care organizations regardless of whether they are a
hospital, day surgery unit, community service, or some other type
of health care organization.
One or more criteria flesh out the standard. ese criteria lay
down specific actions that need to be done to meet the standard.
ese actions, determined by the organizations themselves, should
reflect contemporary best practice principles, be achievable, easily
understood and measurable.
Assessment of a health care organizations performance in
service provision as reflected in compliance with standards is
measured through indicators. Indicators are measurable variables
or characteristics that can be used to determine the degree of
adherence to a standard or achievement of quality goals. To
illustrate:
Standard 4.2.4
All services are provided by staff members with
appropriate qualifications, experience or training.
Criteria
All doctors, nurses and midwives providing clinical
care have current licenses and documented evidence of
appropriate training and experience.
All administrative, business and technical services staff
have current licenses and documented evidence of
appropriate training and experience.
Indicator
Percentage of staff with current licenses.
A complete listing of indicators will be published separately as an
accompanying reference to this Benchbook.
Quality Standards
39
Performance
Improvement
Patient Rights
& Organizational
Ethics
Safe Practice &

Environment
Patient Care
Information
Management
Leadership &
Management
Human Resource
Management
Figure 7.
PhilHealth Quality Standards for Health Care
1. Patient Rights2 and Organizational Ethics

GOAL
To improve patient outcomes by respecting patients rights and

ethically relating with patients and other organizations.
STANDARDS
1.1
Organizational policies and procedures respect and

support patients right to quality care and their
responsibilities in that care.
Criteria
Informed consent3 is obtained from patients prior to
initiation of care.
A copy of the World Medical Association Declaration on the Rights of the Patient adopted by
the 34th World Medical Assembly in Lisbon in 1981 and amended during the same organizations
47th General Assembly in Bali in 1995 can be found in Part IV (Appendix).
Informed consent is defined in the glossary. Johns Hopkins University professors Debra Roter
and Judith Halls work (1993) on the patient-doctor communication process, links it with issues
regarding informed consent. Also see the University of Washington School of Medicines website
discussion on bioethics.
BENCHBOOK
40
Policies and procedures which identify and address

patients rights and responsibilities are documented
and monitored.
Patients receive written statements of their rights
and responsibilities.
e hospital protects patients and respects their
rights during research involving human subjects.
1.2
e organization encourages and promotes

opportunities to involve patients and their families in
their care.
Criteria
Policies and programs to educate patients and
families on how to take a more pro-active role
in health care decision making are documented,
monitored and evaluated for their effectiveness.
Patients and their families are involved in making
care decisions with ethical issues4, such as
withholding resuscitation, foregoing life-sustaining
treatment, end of life care, etc.
1.3
e organization documents and follows policies

and procedures for addressing patients needs for
confidentiality, privacy, security, religious counseling
and communication.
Criteria
Hospital staff is aware of and follows policies
and procedures in addressing patients needs for
confidentiality, privacy, security, counseling and
communication.
e hospital systematically determines, monitors
and improves the extent to which patients needs
for confidentiality, privacy, security, counseling and
communication are addressed.
Examples of ethical issues may include, but are not limited to, insisting on giving blood transfusion to
a Jehovahs witness patient who refuses transfusion but will most likely save his life in a critical case.
Quality Standards
41
1.4
e organization systematically elicits, monitors and

acts upon feedback from patients, their families, visitors
and communities.
Criteria
Policies and procedures for routinely determining
and improving the level of patient satisfaction with
all relevant aspects of care are documented and
monitored.
Policies and procedures for addressing and resolving
patients complaints are documented and monitored.
1.5
e organizations personnel discharge their functions

according to codes of ethical behavior and other relevant
professional and statutory standards.
Criteria
e organization identifies relevant codes of
professional conduct and other statutory standards
and informs its personnel about these codes and
standards.
e organization identifies and monitors personnel
compliance with the code of ethics relevant to their
respective disciplines.
Procedures for resolving ethical issues related to
professional practice or to conflicts of interest are
based on the relevant code of ethics and other
professional and legal standards.
1.6
e organization documents and follows procedures for

resolving ethical issues as they arise from patient care.
Criteria
Procedures for resolving ethical issues that arise in
the course of providing care are monitored for their
effectiveness.
BENCHBOOK
42
Patient Rights and

Organizational Ethics
STANDARDS
respect and support for patients
rights and responsibilities
opportunities for patients
involvement in care provision
confidentiality and security
of patients information and
communication
feedback to patients
staff code of ethics
resolution of ethical issues
GOAL:
To improve patients outcomes
by respecting patients rights and
ethically relating with patients
and other organizations.
Quality Standards
43
2. Patient Care Standards

2.1 Access
GOAL
e organization is accessible to the community that it aims to serve.
STANDARDS
2.1.1 e organization informs the community about the

services it provides and the hours of their availability.
Criteria
Information detailing the clinical services offered
and hours of their availability is strategically5
distributed and prominently posted.
Clinical services are appropriate to patients needs
and the formers availability is consistent with the
organizations service capability and role in the
community.
e community is aware of clinical services offered
and times of availability.
2.1.2 Physical access to the organization and its services is
facilitated and is appropriate to patients needs.
Criteria
Entrances and exits are clearly and prominently
marked, free of any obstruction and readily
accessible.
Directional signs are prominently posted to help
locate service areas within the organization.
Alternative passageways for patients with special
needs (e.g., ramps) are available, clearly and
prominently marked and free of any obstruction.
Major service areas have nearby waiting facilities
that are clean, well-lit, adequately ventilated and
equipped with appropriate fixtures and furniture.
5
The following example distinguishes prominent from strategic: if a clinic is located far from the
main street, then the signage should be located at the street corner nearest the clinic. Otherwise
it would not be seen. That is strategic. Making the signage big enough to be seen from a block
away is prominent.
BENCHBOOK
44
e organization documents, follows policies and

procedures, and provides resources for the safe and
efficient direction of patients, their families and visitors,
and staff traffic.
Patients, their visitors and staff can efficiently and safely
move within the confines of the organization.
2.2 Entry
GOAL
e entry processes meet patient needs and are supported by

effective systems and a suitable environment.
STANDARDS
2.2.1 Patients receive prompt and timely attention by

qualified professionals upon entry.
Criteria
Patient waiting times are routinely monitored,
evaluated and improved based on standards and
procedures developed by the organization. Depending
on their needs, patients are seen within the planned
waiting period.
Patients are informed of the cause of any delay in the
delivery of services.
Patients are satisfied with the actual waiting time.
2.2.2 e organization documents and follows policies and
procedures, and provides resources to ensure proper
patient triaging.
Criteria
e staff follows policies and procedures in
determining and prioritizing patients clinical needs
and in identifying clinical services that will best
address them.
e staff follows policies and procedures in
determining admissibility of patients or the need for
referral to other organizations.
Patients are correctly and efficiently assigned to the
clinical services appropriate to their needs.
Quality Standards
45
2.2.3 e organization uniquely6 identifies all patients

including newborn infants, and creates a specific
patient chart for each patient that is readily accessible
to authorized personnel7.
Criteria
All patients are correctly identified by their patient
charts.
e patient charts contain identifiers unique to each
patient.
Patient charts are appropriately and systematically
indexed to facilitate retrieval and storage and to
avoid duplication or loss.
2.2.4 e health professional8 responsible for the care of the
patient obtains informed consent for treatment.
Criteria
Prior to admission, patients and/or their families
are 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 demonstrate
knowledge 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.
2.2.5 Planning for discharge begins upon entry into the
organization and ensures a coordinated approach to
discharge and continuing management.
Criteria
Patients and/or their families are informed of the
expected (barring any complications) approximate
6
To uniquely identify a patient may mean making the patient number a lifetime number.
The organization itself determines the limits of who are authorized personnel in any given situation.
Doctors are not the only providers of care within the organization; hence health professional is
preferred to encompass a wider spectrum of health care providers.
BENCHBOOK
46
duration of treatment, the extent or frequency of reassessment, the likely outcomes and their need for
follow-up care after discharge
Patients and/or their families are informed of the
need for and availability of resources to continue care
after discharge.
2.3 Assessment
GOAL
Comprehensive assessment of every patient enables the planning

and delivery of patient care.
STANDARDS
2.3.1 Each patients physical, psychological and social status is

assessed.
Criteria
An appropriately comprehensive history and physical
examination is performed on every patient within 24
hours from admission. e history includes present
illness, past medical, family, social and personal
history.
Whenever appropriate, mental status examinations,
psychological evaluations and nutritional and
functional assessments are performed on the patient.
2.3.2 Appropriate professionals9 perform coordinated and
sequenced patient assessment to reduce waste and
unnecessary repetition.
Criteria
Based on collaboratively developed policies and
procedures, qualified personnel conduct initial
assessments in an efficient and systematic manner to
avoid repetition.
e order of assessment is determined by the patients
prioritized needs.10
9
This is not about determining who is qualified because this should have been done already at
the credentialing process. Rather it is about determining who are appropriate for the roles in
patient care. For example, a qualified radiologist is not appropriate to make a pre-operative
assessment.
10
The optimal order of assessment could be pre-determined through clinical pathways based on
clinical practice guidelines, or other forms of evidence.
Quality Standards
47
Previously obtained information obtained is

reviewed at every stage of the assessment to guide
future assessments.
2.3.3 Assessments are performed regularly and are
determined by patients evolving response to care.
Criteria
During the course of management, qualified
personnel re-assess the patients physical and
psychological conditions according to the patients
needs.
Re-assessment is done whenever the patients
condition take an unexpected turn.
Re-assessment results in a review of the patients
management.
Qualified personnel give patients for surgery preoperative physical and pre-anesthetic assessment.
e status of post-operative patients is assessed
upon admission into, during confinement and upon
discharge from the recovery area.
2.3.4 Assessments are documented and used by the health
care team to ensure effective communication and
continuity of care.
Criteria
Legible written records of the initial and ongoing
assessments are accomplished for each patient and
kept in the patient chart.11
Medical records are stored in an area that is safe and
accessible to all members of the health care team,
and whenever appropriate, to external providers.12
11
Results of re-assessment may be documented as problem-oriented progress notes in SOAP

(subjective complaints/objective findings / assessment / plan) form for each patient and
kept in the medical record.
12
The term external providers includes, but is not limited to, other health care providers to
whom the patient is referred for continuity of care.
BENCHBOOK
48
2.3.5 Diagnostic examinations appropriate to the provider

organizations service capability and usual case mix are
available and are performed by qualified personnel.
Criteria
Policies and procedures for the standard
performance, monitoring and quality control of
diagnostic examinations are documented and
monitored.
Policies and procedures for accessing and referring
patients to approved external providers when
diagnostic services are not available within the
provider organization are documented and
monitored.
2.3.6 Assessments of patients with special needs are
determined by policies and procedures that are
consistent with legal and ethical requirements.
Criteria
Policies and procedures identify patients with
special needs and the specific types of assessment
appropriate to their needs.13
13
Patients with special needs include infants, school-age children, adolescents, the elderly and the
disabled, victims of alleged or suspected sexual abuse or violence, patients with emotional or
behavioral disorders, patients with drug dependencies or alcoholism.
Quality Standards
49
2.4 Care Planning

GOAL
e health care team develops in partnership with the patients a

coordinated plan of care with goals.
STANDARDS
2.4.1 e care plan addresses patients relevant clinical,

social, emotional and religious needs.
Criteria
e plan, aside from delineating responsibilities,
includes goals to be achieved, services to be
provided, patient education strategies to be
implemented, time frames to be met, resources to be
used.14
2.4.2 e care plan is consistent with scientific evidence,
professional standards, cultural values, medico-legal
and statutory requirements.
Criteria
e care plan is developed by a multidisciplinary
team of health professionals within the organization.
e care plan is developed following search and
appraisal of published scientific literature.
Expert judgment, practice standards and patients
values are considered in developing care plans.
2.4.3 e organization ensures that information about the
patients proposed care is clear and readily accessible to
designated multidisciplinary health care providers and
other relevant persons.
Criteria
Care planning is documented in the patient chart.
Clinical pathways, algorithms and problem-oriented
notes15 in SOAP format are incorporated in the
medical record.
14
15
Clinical pathways derived from clinical practice guidelines and other types of clinical evidence
should be developed or implemented for the top 10 cases of admissions and / or consultations.
For more information, refer to Part III.
Problem oriented notes may take other forms aside from SOAP, such as SOAPIE, etc.
BENCHBOOK
50
2.5 Implementation of Care
GOAL
Care is delivered to ensure the best possible outcomes for the

patient.
STANDARDS
2.5.1 Care is delivered in a timely, safe, appropriate and

coordinated manner, according to care plans.
Criteria
In the management of clinical pathway-covered
conditions, the order and timing of treatments follow
the pathway.
Orders for treatments are implemented within time
intervals established by the organization.
Referrals to other specialties are made according to
established pathways or guidelines.
Results of referrals are communicated to relevant
members of the health care team and are considered
in the management.
2.5.2 Rights and needs of patients are considered and
respected by all the staff.
Criteria
Patients receive explanations on the nature of a test or
treatment, the need for it prior to administration, its
likely effects and side effects, and what patients can
do to cope with them.
Patients wish to decline tests or treatments is respected.
2.5.3 Care is coordinated to ensure continuity and to avoid
duplication.
Criteria
Policies and procedures that determine the extent of
duplicate assessments and treatments performed by
trainees respect patients rights, and are documented
and monitored.
Quality Standards
51
2.5.4 Appropriate personnel educate patients and/or their

families to help them understand patients diagnosis,
prognosis, treatment options, health promotion and
illness prevention strategies.
Criteria
.e organization documents and implements
policies and procedures, and provides resources
to promote interactive, appropriate and relevant
educational programs for patients.
Patients are aware of their roles and responsibilities
in their health care.
2.5.5 Drugs are administered in a standardized and
systematic manner in the provider organization.
Criteria
Drugs are administered in a timely, safe, appropriate
and controlled manner.16
e provider organization documents and follows
policies and procedures and allocates resources
for the training, supervision and evaluation of
professionals who administer drugs.17
Only qualified personnel order, prescribe, prepare,
dispense and administer drugs.
Regular review of prescription orders is undertaken
by appropriately trained staff to ensure safe and
appropriate use of drugs.18
Prescriptions or orders are verified and patients are
identified before medications are administered.
Telephone orders are countersigned by the ordering
physicians not later than standards set by the
organization and based on statutory requirements.
Discontinued or recalled drugs are retrieved and
safely disposed of according to established policies
and procedures.
16
The processes of administering drugs should be documented in flowcharts. See Part III (Flow
Chart) for more information.
17
The Generics Act, National Drug Policy and the PhilHealth Positive List of Reimbursable
Drugs are examples of these government policies.
This is to ensure that prescriptions are written correctly (e.g., in generic form), and that
precautions for drug-drug and drug-food interactions have been adequately addressed.
18
BENCHBOOK
52
Drugs are selected and procured based on the

organizations usual case mix and according to policies
and procedures that are consistent with scientific
evidence and government policies.
Drug administration is properly documented in the
patient chart.
Policies and procedures for detecting, reporting
and monitoring adverse effects are documented and
monitored.
2.5.6 Treatment procedures are performed in a standardized
and systematic manner in the provider organization.
Criteria
Treatment procedures are performed in a timely, safe,
appropriate and controlled manner.19
e provider organization documents and reviews
policies and procedures and allocates resources for the
training, supervision and evaluation of professionals
who perform procedures.
Only qualified personnel order, plan, perform and
assist in performing procedures.
Orders are verified, and patients are identified before
treatment procedures are performed.20
Treatment procedures are legibly and accurately
documented in the patient chart by qualified
personnel.21
Medical devices and equipment are used, maintained,
stored and disposed based on technical specifications.
Medical devices and equipment are selected and
procured based on the organizations case mix, staff
expertise, service capability and according to policies
and procedures that are consistent with scientific
evidence and government policies.
19
20
21
The processes of performing the most common treatment procedures should be documented
in flowcharts. See Part III (Flow Chart) for more information.
Armbanding may be one method for identifying patients for surgery. The actual operative site
may be marked indelibly beforehand.
Treatment records should document who did what to whom, when and for what indication.
An appropriately adequate description of the procedure and operative findings should be
included in the records.
Quality Standards
53
2.5.7 e care of patients with special needs is governed by

policies and procedures that are consistent with legal
and ethical requirements.
2.6 Evaluation of Care

GOAL
e health care team routinely and systematically evaluates and

improves the effectiveness and efficiency of care delivered to
patients.
STANDARDS
2.6.1 Data relating to processes and outcomes of patient

care are analyzed to provide information for care
improvement.
Criteria
e organization routinely collects process and
outcomes data from its provision of patient care.
e organization provides resources for the formal
and collaborative evaluation of care using analysis of
process and outcomes data.
Results of evaluation of care are fed back to the
health care providers concerned.
Results of evaluation of care are routinely presented
and discussed in meetings of top management.22
2.6.2 e health care team takes action to address any
improvements required.
Criteria
Evaluation of care leads to formal and collaborative
performance improvement activities that harness the
resources of appropriate services.
22
There are many clinical tools that can be used to evaluate care, including medical audit,
utilization review, sentinel event monitoring and incident reporting. For more information on
how to conduct these routine assessments of care, refer to Part III.
BENCHBOOK
54
2.6.3 Quality improvement activities are documented, enable

continuous quality improvement and incorporate the
following elements:
Monitoring, assessment, analysis and evaluation of
activities
Appropriate and timely action
Evaluation of the effectiveness of any action taken
Feedback of evaluation results
2.7 Discharge
GOAL
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.
STANDARDS
2.7.1 e discharge plan is part of the patients care plan and

is documented in the patient chart.
2.7.2 e organization provides information about the
continuing management plan to the patient and
relevant health care providers in a manner that
maintains patient confidentiality and privacy.
2.7.3 e organization arranges access to other relevant
community health services23 in a timely manner, and
ensures that patients are aware of appropriate services
before discharge.
2.7.4 Patients understand the discharge plans and their
responsibilities for continuing management.
23
Examples of other relevant community health services include, but are not limited to, rural health
units (RHU), Botika sa Barangay, etc.
Introduction
55
Patient Care
ACCESS STANDARDS
information about services
access to services
GOAL:
The organization is accessible to the
community that it aims to serve.
ENTRY STANDARDS
prompt and timely attention
efficient triaging
unique patient identification
informed consent
planning for discharge and
continuing care
GOAL:
The entry processes meet patient
needs and are supported by
effective systems and a suitable
environment.
ASSESSMENT STANDARDS
physical, psychological, social
assessment
coordinated assessment by
professionals
regular assessments
proper documentation of
assessments
GOAL:
Comprehensive assessment of
every patient enables the planning
and delivery of patient care.
appropriate diagnostics
special needs assessments
CARE PLANNING STANDARDS
relevant to patients needs
evidence-based care plan
clear and accessible information
on care n
GOAL:
The health care team develops in
partnership with the patients a
coordinated plan of care with goals.
BENCHBOOK
56
IMPLEMENTATION OF CARE
STANDARDS
timely, safe, appropriate and
coordinated care delivery
respect for patients needs and
rights
coordinated care delivery
among professional
GOAL:
Care is delivered to ensure the best
possible outcomes for the patient.
patient education
standardized drug
administration
standardized treatment
procedures
appropriate care for patients
with special needs
EVALUATION OF CARE STANDARDS

analysis of process and
outcomes data
GOAL:
The health care team routinely
and systematically evaluates and
improves the effectiveness and
efficiency of care delivered to
patients.
actions for improvement

activities
CARE PLANNING STANDARDS

discharge plan
continuing management plan
patient access to community
health services
patient understanding of
discharge plan
GOAL:
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.
Introduction
57
3. Leadership and Management
3.1 e Management Team
GOAL
e 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.
STANDARDS
3.1.1 e provider organizations management team provides

leadership, acts according to the organizations policies
and has overall responsibility for the organizations
operation, and the quality of its services and its
resources.24
3.1.2 e organizations management team ensures the
presence of effective working relationships within the
organization, with the community, and with other
relevant organizations and individuals.
3.1.3 Terms of reference, membership and procedures are
defined for the meetings of all committees within the
organization. Minutes of meetings are recorded and
approved.
3.1.4 e organizations management team regularly assesses
its own performance and the performance of the
organization.
3.1.5 e organization develops and implements policies and
procedures which cover the major services and aspects of
operations.
24
The organizations management team may consist of the hospital director or chief of
hospital or chief health officer together with the administrative officer and / or service
heads.
BENCHBOOK
58
Criteria
e organization develops its mission, vision and
corporate goals based on agreed-upon values.
e organizations by-laws, policies and procedures
support care delivery and are consistent with its
goals, statutory requirements, accepted standards
and its community and regional responsibilities.
Policies and procedures, aside from being complied
with, are reviewed and revised as necessary.
e organization communicates its policies and
procedures to all levels of the workforce.25
3.2 External Services

GOAL
e organization ensures that services provided by external

contractors meet appropriate standards.
STANDARDS
3.2.1 Documented agreements and contracts cover external

service providers and specify that the quality of
services provided must be consistent with appropriate
set standards.
25
Total quality management begins with commitment and tangible support from the
organizations top leadership. Refer to the What is Quality of Care section in Part 1 for a
discussion on its importance to the organizations survival and on how it can be assessed and
improved. Also refer to Part III for step-by-step instructions on how to establish a total quality
management program.
Quality Standards
59
Leadership and
Management
THE MANAGEMENT TEAM STANDARDS

leadership
effective working relationships
committee meetings
GOAL:
The organization is effectively and
efficiently governed and managed
according to its values and goals
to ensure that care produces
the desire health outcomes, and
is responsive to patients and
community needs.
management performance
assessment
policies and procedures for
operations
EXTERNAL SERVICES STANDARDS
contracts
GOAL:
The organization ensures that
services provided by external
contractors meet appropriate
standards.
BENCHBOOK
60
4. Human Resource Management

4.1 Human Resources Planning
GOAL
e 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.
STANDARDS
4.1.1 Planning ensures that appropriately trained and

qualified (and where relevant, credentialed) staff are
available to undertake the type and level of activity
performed by the organization. is includes those who
are consulted26 when suitable expertise is not available
within the organization.
Criteria
e organization defines the qualifications and
competencies of its staff.
e organization documents and follows policies and
procedures for hiring, credentialing and privileging of
its staff.
4.1.2 Workload is monitored and appropriate guidelines
consulted to ensure that appropriate staff numbers and
skill mix are available to achieve desired patient and
organizational outcomes.
Criteria
Staff numbers and skill mix are based on actual
clinical needs.27
Appropriate policies and procedures are monitored
to temporarily compensate for, and to definitively,
address inadequacies in staff numbers or expertise.
26
Those who are consulted include technical as well as medical consultants, such as engineers,
waste disposal experts, accountants, etc.
27
The hospital may document and analyze information, like daily patient loads, utilization rates of
services, turnaround times, to determine staff size and mix.
Quality Standards
61
4.2 Staff Recruitment, Selection, Appointment and Responsibilities
GOAL
Recruitment, selection and appointment of staff comply with

statutory requirements and are consistent with the organizations
human resource policies.28
STANDARDS
4.2.1 Recruitment, selection, appointment and reappointment

procedures ensure appropriate competence, training,
experience, licensing and credentialing of all appointees.
Criteria
e organization defines, disseminates and ensures
compliance with policies and procedures governing
personnel recruitment, selection and appointments.
e recruitment and selection process is open and
transparent, is consistent with legal and ethical
requirements, and allows a fair and unbiased
evaluation of the qualifications and competencies of
all applicants.
Relevant staff members participate in the
development and implementation of personnel
recruitment, selection and appointment.
Selection and appointment and evidence of staff
compliance with selection or appointment standards
are documented
Relevant licenses are routinely monitored for renewal.
Evidence of continuing staff education and training is
routinely monitored and assessed.
4.2.2 Upon appointment, staff members receive a written
statement of their accountabilities and responsibilities
that specifies their role and how it contributes to the
attainment of the goals and maintaining quality of care.
e statements are reviewed when necessary.
28
Staff in this context refers to employees, contractors and other service providers.
BENCHBOOK
62
Criteria
Written job descriptions are given to and discussed
with all newly-appointed staff members.
4.2.3 Staff members are accountable for the care and services
they give and for the discharge of their delineated
responsibilities.29
Criteria
e organization ensures that staff accountabilities
and responsibilities are consistent with their
qualifications, training, experience, registration and
licensure.
4.2.4 All services are provided by staff members with
appropriate qualifications, experience or training.
Criteria
All doctors, nurses and midwives providing clinical
care have current licenses and documented evidence
of appropriate training and experience.
All administrative, business and technical services
staff have current licenses and documented evidence
of appropriate training and experience.
4.3 Staff Training and Development

GOAL
A comprehensive program of staff training and development

meets individual and organizational needs.
STANDARDS
4.3.1 ere are relevant orientation, training and

development programs to meet the educational needs
of management and staff.
29
Logbooks of procedures document the identities of the staff member who did the procedures. All
entries in the patient chart are legibly signed by the originatorsthose who wrote the entry in the
patient chartand dated.
Quality Standards
63
Criteria
e organization assesses the educational needs of
management and staff and identifies and/or provides
resources to meet those needs.
Policies and procedures for orientation of new
management and staff are documented and
monitored.
e organization evaluates the effectiveness of
training and development programs to ensure that
they meet organizational, community and individual
needs.
4.3.2 e organization clearly defines and ensures compliance
with the lines of authority and supervision.
Criteria
New personnelincluding trainees, volunteers, new
graduates and external contractorsare adequately
supervised by qualified staff.
e staff are provided with a documented
job description outlining accountabilities and
responsibilities.
BENCHBOOK
64
Human Resource
Management
HUMAN RESOURCES PLANNING

STANDARDS
HR needs assessment
GOAL:
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.
workload monitoring
STAFF RECRUITMENT,
SELECTION, APPOINTMENT AND
RESPONSIBILITIES STANDARDS
procedures
job descriptions
GOAL:
Recruitment, selection and
appointment of staff comply with
statutory requirements and are
consistent with the organizations
human resource policies.
staff accountabilities
service provision by appropriate
staff
GOAL:
STAFF TRAINING & DEVELOPMENT
STANDARDS
orientation, training and
development programs
supervision
A comprehensive program of
staff training and development
meets individual and
organizational needs.
Introduction
65
5. Information Management
5.1 Data Collection, Aggregation and Use
GOAL
Collection and aggregation of data are done for patient care,

management of services, education and research.
STANDARDS
5.1.1 Relevant, accurate, quantitative and qualitative data are

collected and used in a timely and efficient manner for
delivery of patient care and management of services.
Criteria
e organization defines the relevant aspects of its
operations from which data will be collected.
e organization defines data sets, data generation,
collection and aggregation methods and the qualified
staff who are involved in each stage.
e organization defines policies and procedures to
monitor and improve the accuracy, completeness and
reliability of relevant qualitative and quantitative data
relating to its operations.
e organization provides resources and opportunities
to enable management and staff to use data in their
decision and policymaking activities.
Policies and procedures on record storage, retention
and disposal are documented and monitored.
5.1.2 e collection of data and reporting of information
comply with professional standards, statutory and
PhilHealth requirements.
Criteria
e organization collects and submits reports required
by the Department of Health and PhilHealth.
BENCHBOOK
66
5.1.3 Every patient has a sufficiently detailed patient chart

to facilitate continuity of care, and meet education,
research, evaluation and medico-legal and statutory
requirements.
Criteria
Care providers document management details in the
patient chart. All entries are promptly accomplished,
accurate, legible, dated and duly signed by the care
providers whose designations are clearly indicated.30
Patient charts are routinely checked for
completeness and accuracy, and action is taken to
improve their quality.
5.1.4 Data in the patient charts are coded and indexed to
ensure the timely production of quality patient care
information and reports to PhilHealth.31
Criteria
Data from the patient charts are routinely
collected, aggregated and reported for use in quality
improvement activities, for administrative purposes
and for mandatory reporting to the Department of
Health and PhilHealth.
5.2 Records Management

GOAL
Integrity, safety, access and security of records are maintained and

statutory requirements are met.
30
Documentation in patient charts should be sufficiently detailed to enable any member of the
health care team to understand care plans and care provision. Clinical pathways are excellent
means to achieve this.
31
Data from patient charts are used in peer review, medical audits, variance analysis, quality
circle meetings, etc.
Introduction
67
STANDARDS
5.2.1 Clinical records are readily accessible to facilitate patient
care, are kept confidential and safe, and comply with all
relevant statutory requirements and codes of practice.
Criteria
When patients are admitted or are seen for ambulatory
or emergency care, patient charts documenting any
previous care can be quickly retrieved for review,
updating and concurrent use.
e organization has policies and procedures, and
devotes resources, including infrastructure, to protect
records and patient charts against loss, destruction,
tampering and unauthorized access or use. Only
authorized individuals make entries in the patient chart.
DATA COLLECTION, AGGREGATION AND

USE STANDARDS
timely and efficient data
collection
GOAL:
Collection and aggregation
of data are done for patient
care, management of services,
education and research.
standardized information
detailed medical charts
coding and indexing of data
GOAL:
RECORDS MANAGEMENT STANDARD
Integrity, safety, access

and security of records are
maintained and statutory
requirements are met.
accessible records
BENCHBOOK
68
6. Safe Practice and Environment

6.1 Patient and Staff Safety
GOAL
Patients, staff and other individuals within the organization are

provided a safe, functional and effective environment of care.
STANDARDS
6.1.1 e organization plans a safe and effective

environment of care consistent with its mission,
services, and with laws and regulations.
Criteria
e organizational environment complies with
structural standards and safety codes as prescribed
by law.32
ere are management plans which address safety,
security, disposal and control of hazardous materials
and biological wastes, emergency and disaster
preparedness, fire safety, radiation safety and utility
systems.
ere are management plans for the safe and
efficient use of medical equipment according to
specifications.
6.1.2 e organization provides a safe and effective
environment of care consistent with its mission and
services, and with laws and regulations.
Criteria
Policies and procedures that address safety, security,
control of hazardous materials and biological wastes,
emergency and disaster preparedness, fire safety,
radiation safety and utility systems are documented
and implemented.
32
The organization maintains current licenses and permits that ensure safe and effective
operations. Such permits include, but are not limited to, occupancy, electrical, plumbing,
radiation safety, fire safety, occupational safety, food storage and handling and waste disposal.
Introduction
69
Policies and procedures for the safe and efficient use

of medical equipment according to specifications are
documented and implemented.
e design of patient areas provides sufficient space
for safety, comfort and privacy of the patient and for
emergency care.
All personnel understand and fulfill their role in safe
practice.
Risks are identified, assessed and appropriately
controlled. Where elimination or substitution is not
possible, adequate warning and protection devices are
used.
A coordinated security arrangement in the
organization assures protection of patients, staff, and
visitors.
6.1.3 e organization routinely collects and evaluates
information to improve the safety and adequacy of the
environment of care.
Criteria
e effectiveness of safety procedures and devices are
routinely tested, monitored and improved.33
An incident reporting system identifies potential
harms, evaluates causal and contributing factors for
the necessary corrective and preventive action.
6.2 Maintenance of the Environment of Care

GOAL
A comprehensive maintenance program ensures a clean and safe

environment.
33
Staff compliance with safety procedures, performance in emergency and fire drills, handling
and operation of medical devices are regularly assessed and monitored. Findings of routine
checks of equipment and facilities are documented and appropriately reported.
BENCHBOOK
70
STANDARDS
6.2.1 Emergency light and / or power supply, water and

ventilation systems are provided for, in keeping with
relevant statutory requirements and codes of practice.
6.2.2 Regular maintenance of grounds, facilities and
equipment in keeping with relevant statutory
requirements, codes of practice, or manufacturers
specifications are done to ensure a clean and safe
environment.
6.2.3 Equipment is serviced only by people trained in the
maintenance of that equipment. Registers and records
of equipment and related maintenance are kept.
6.2.4 Current information and scientific data from
manufacturers concerning their products are available
for reference and guidance in the operation and
maintenance of plant and equipment.
6.3 Infection Control

GOAL
Risks of acquisition and transmission of infections among

patients, employees, physicians and other personnel, visitors and
trainees are identified and reduced.
STANDARDS
6.3.1 An interdisciplinary infection control program ensures

the prevention and control of infection in all services.
6.3.2 e organization uses a coordinated system-wide34
approach to reduce the risks of nosocomial infections.
34
System wide refers to the different processes making up the entire system.
Introduction
71
Criteria
e organization undertakes case finding and
identification of nosocomial infections.
e organization takes steps to prevent and control
outbreaks of nosocomial infections.
6.3.3 e organization uses a coordinated system-wide
approach to reduce the risks of infection the staff are
exposed to in the performance of their duties.
Criteria
ere are programs for prevention and treatment of
needlestick injuries, and policies and procedures for
the safe disposal of used needles are documented and
monitored.
ere are programs for the prevention of transmission
of airborne infections, and risks from patients with
signs and symptoms suggestive of tuberculosis or
other communicable diseases are managed according
to established protocols.
6.3.4 Cleaning, disinfecting, drying, packaging and
sterilizing of equipment, and maintenance of
associated environment, conform to relevant statutory
requirements and codes of practice.
6.3.5 When needed, the organization reports information
about infections to personnel and public health
agencies.
6.4 Equipment and Supplies

GOAL
e provision of equipment and supplies supports the

organizations role.
BENCHBOOK
72
STANDARDS
6.4.1 Planning of facilities and selection and acquisition of

equipment and supplies involve input from relevant
staff and are undertaken by appropriately-qualified
personnel.
Criteria
Appropriate equipment and supplies that support
the organizations role and level of service are
provided. Consideration is given to at least:

the intended use

cost benefits

infection control

safety

waste creation and disposal

storage
6.4.2 Specialized equipment is operated according to
specifications and only by appropriately-trained staff.
6.4.3 Items designated by the manufacturer for single use
are not reused unless the organization has specific
policies and guidelines for safe reuse which take into
consideration relevant statutory requirements and
codes of practice.
6.5 Energy and Waste Management

GOAL
e organization demonstrates its commitment to environmental

issues by considering and implementing strategies to achieve
environmental sustainability.
STANDARDS
6.5.1 e handling, collection, and disposal of waste

conform to relevant statutory requirements and codes
of practice.
6.5.2 e organization implements a waste disposal program
which involves reuse, reduction and recycling.
Quality Standards
73
Practice and
6 Safe
Environment
PATIENT AND STAFF SAFETY STANDARDS
plan of safe and effective
environment of care
provision of safe and effective
environment of care
GOAL:
Patients, staff and other individuals
within the organization are
provided a safe, functional and
effective environment of care.
routine evaluation of
environment of care
MAINTENANCE OF THE ENVIRONMENT
OF CARE STANDARDS
emergency light, power supply,
water and ventilation
regular maintenance of facilities
and equipment
GOAL:
A comprehensive maintenance
program ensures a clean and safe
environment.
maintenance of equipment by
qualified personnel
current information on products
are available
INFECTION CONTROL STANDARDS
infection control program
risk reduction of nosocomial
infection
standardized cleaning and
sterilization procedures
GOAL:
Risks of acquisition and transmission
of infections among patients,
employees, physicians and other
personnel, visitors and trainees are
identified and reduced.
internal and external reporting

EQUIPMENT & SUPPLIES STANDARDS
planning and acquisition of
equipment and supplies
specialized equipment operated
by qualified staff
GOAL:
The provision of equipment
and supplies supports the
organizations role.
safe reuse guidelines

ENERGY & WASTE MANAGEMENT
STANDARDS
standardized waste handling and
disposal program
implementation of a waste disposal
program
GOAL:
The organization demonstrates its
commitment to environmental issues
by considering and implementing
strategies to achieve environmental
sustainability.
BENCHBOOK
74
7. Improving Performance
GOAL
e 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.
STANDARDS
7.1
e organization has a planned systematic organizationwide approach to process design and performance
measurement, assessment and improvement.
7.2
New processes of care are designed collaboratively based

on scientific evidence, clinical standards, cultural values
and patient preferences.35
Criteria
ere are resources available for developing or
adopting clinical practice guidelines.
Clinical practice guidelines for the top 10 causes of
admissions and / or consultations and PhilHealthadopted guidelines are disseminated and monitored.
7.3
Management is primarily responsible for developing,

communicating, and implementing a comprehensive
quality improvement program throughout the
organization and delegating responsibilities
to appropriate personnel for its day-to-day
implementation.
7.4
All service units and staff are responsible for, and

demonstrate involvement in, performance improvement
that results in better services for internal and external
clients.
35
Important processes of care include invasive and non-invasive surgical procedures, medication use, and
hospital admissions. Important outcomes include patient and staff satisfaction, lengths of stay, staff
views, and autopsy results.
Quality Standards
75
Improving Performance
STANDARDS
organization-wide approach
collaboration in new processes
of care
management responsibility
service unit and staff
responsibility
evaluation of quality
improvement program
better service and care
confidentiality of data
7.5
Managers and staff evaluate the effectiveness of the

quality improvement program and take action to
address any improvements required.
7.6
e organization provides better care and service as a

result of continuous quality improvement activities.
7.7
Quality improvement activities respect the

confidentiality of data regarding patients, staff and
other care providers.
GOAL:
The organization continuously
and systematically improves its
performance by invariably doing
the right thing the right way the
first time and by meeting the
needs of its internal and external
clients.
BENCHBOOK
76
Performance
Improvement
77
Part III
Implementing a Performance
Improvement Program
Rationale and Steps for Performance
Improvement
TQM Program Implementation Steps
The Documentation-Evaluation-Action Triad
The Plan-Do-Check-Act (PDCA) Cycle
Quality Improvement Tools
Quality Circles and Quality Teams
Quality Improvement Activities
BENCHBOOK
78
Performance
Improvement
79
Implementing a Performance
Improvement Program 1
TQM and quality improvement are concepts that need to

be operationalized, i.e., made tangible in the operations of a
system. With TQM as the underlying philosophy and quality
improvement as its goal, the next challenge calls for conversion
of these abstract concepts into measurable realities. is step
requires an improvement in the performance parameters of an
organization.
is section zooms in on the mechanics of implementing a
performance improvement program. It discusses the needed
perspective and operational scheme for implementation. Aside
from giving a brief description of the Plan-Do-Check-Act
approach, Part III surveys and defines select activities needed to
implement a quality improvement program, and the tools used
to study quantitative and qualitative data regarding performance.
Part III also provides a step-by-step guide for utilization of those
same tools and some application examples.
For a more robust discussion, this section synthesizes relevant information from the
following sources: Institute of Medicine (2001), Joint Commission on Accreditation of
Healthcare Organizations (1998, 2000, 2002), Kelada (1996), Nelson (1995), Sloan (1994), and
WHO (2001) and various internet sources listed in the bibliography. The reader is encouraged
to refer to these sources for further information.
BENCHBOOK
80
Rationale and Steps for Performance Improvement

Achieving total quality is the goal of continuous performance
improvement. is means continuously upgrading performance
targets from previously-accepted minimal standards, a challenge
which demands a management philosophy advocating
continuous quality improvement in all levels of the organization,
and strategies operationalizing such philosophy.
Current literature in health care advocates a systems approach to
quality improvementimprove the system, rather than focus on
the errors of individuals--because errors are built into the system
anyway (De Geyndt 1994). A TQM philosophy guides this
organization-wide pursuit of quality.
Implementing a TQM program involves three steps: first,
awareness of management of the importance of quality
improvement; second, mobilization of a quality improvement
team; and third, launching of organization-wide improvement
activities (Kelada 1996). In carrying out these steps, the
overarching triad of documentation, evaluation and action
should be a primary consideration. Documentation, evaluation
and action are the three building blocks in establishing a
performance improvement program, and the Plan-Do-Check-Act
Cycle should be its work philosophy. e operational scheme is
seen below:
Documentation
Pl
an
Performance
Improvement
Program
Action
Ch
k
ec
ct
Evaluation
Figure 8. The Documentation-Evaluation-Action Triad and the PDCA

Cycle in Performance Improvement Programs
Performance
Improvement
81
TQM Program Implementation Steps

1. Management
Awareness
Management is primarily responsible for any quality improvement

effort in an organization. e choice to achieve quality
improvement is ultimately a management decision; the same
goes for the strategies and activities used to achieve quality
improvement. Management should decide that efforts towards
quality improvement are, in the long run, worth their financial
costs.
A steering committee, composed of top management-picked
senior supervisorswho must be familiar with quality concepts
and should be prepared to participate directly and continually
in improvement activitiesdevelops and promulgates the
organizations quality policy, and ensures that performance
improvement is the overriding agenda in any management
meeting.
Top management appoints a TQM coordinator who is directly
accountable to the CEO, and who takes charge of the planning,
implementation, monitoring and evaluation of the TQM program.
Top management is responsible for familiarizing the staff with TQM
concepts and explaining how they fit into the organizations vision,
mission and goals. Management needs to fire up each staff members
desire to make a personal contribution in achieving total quality.
2. Mobilization
e TQM coordinator spearheads an assessment of organizational

readinessthe capability to meet industry and health practice
expectations and standards. e morale, size and expertise of the
staff as well as the available care processes and services are also
considered. Actual and potential patients, government and nongovernment partners and funders of the organization are identified
and their expectations determined.
As managers and staff must have the necessary knowledge,
attitudes and skills to conduct performance improvement projects,
the TQM coordinator establishes a training program envisioned
to carry out a shift from old to new management paradigms and
bring out the necessary change in organizational culture.
BENCHBOOK
82
e TQM coordinator facilitates the creation of quality circles

and teams in all work areas. Like-minded staff members are
identified as team or circle leaders. Each leader then organizes a
quality team or quality circle.
Quality circles are small groups whose members belong to the same
work area (for example, the dietary section) and they regularly meet
to identify and solve problems within their work area using their own
resources.
Quality teams are bigger groups than quality circles and consist of
employees and managers who belong to different work areas but are
involved in the same care process (for example, departments involved
in discharging a patient).
3. Launching of
Performance
Improvement
Activities
Performance improvement projects are launched in one area

which has the greatest chance of success within a short time.
ese improvement activities are then gradually extended to
the entire organization. Momentum is maintained by quickly
moving on from one area to another.
Continuous evaluation of the projects and their outcomes to
monitor effectiveness of the performance improvement projects
should be regularly done. Managers must regularly report
areas for improvement. A process of rewarding performance
improvement through positive reinforcement must be
established.
Steps in Implementing TQM
1. Management awareness
Build awareness and commitment in
top management
Create a TQM steering committee
Appoint a TQM coordinator
Orient other staff on TQM
2. Mobilization
Assess organizations readiness for TQM
Establish a TQM training program
Organize quality teams in work areas
3. Launching of performance improvement activities
Pilot a quality improvement project in
one area then gradually extend it to
other areas
Continuously evaluate process and
outcome
Continuously reinforce quality
improvement programs
(Kelada 1996)
Performance
Improvement
83
The DocumentationEvaluationAction Triad
1. Documentation
Continuous quality improvement requires decision-making based

on the systematic analysis of data. Health care organizations
operate through systems and processes that depend on interlinked
actions of many disciplines. Operations cover administrative,
financial, housekeeping, technical and health care services. Writing
down policies and procedures that govern the critical systems in
each of these services, and documenting activities, are essential in
achieving total quality care.
The seven PhilHealth standards on performance improvement

emphasize the need for documentation for the following reasons:
Safety Standard Operating Procedures (SOP) provide

a step-by-step guide to clinicians in administering
interventions to patients so that key steps are not missed
or interchanged. Well-written SOPs reduce the risks of
error in the health care environment.
Consistency of purpose Policy manuals enable

both managers and staff to behave in accordance with
organizational goals and codes of conduct and provide
guidance in resolving ethical dilemmas and conflicts.
Standardization Explicit job descriptions provide

standards that allow for uniform staff orientation,
continuing self-assessment and transparent performance
evaluation. In terms of patient care, standardization of
processes for medical, surgical or diagnostic interventions
reduces variations, which, in turn, translates to costefficiency.
Improvement Documented policies and procedures

form the basis for organizational self-assessment. Areas
for improvement can only be identified systematically by
referring to written processes and documented outcomes.
Documentation must cover all important aspects of health

operations. ese aspects are specified in the accreditation
standards. e extent of documentation is directly linked to the
degree of achievement of the standards.
BENCHBOOK
84
2. Evaluation
Delivering high quality health care is about consistently

benefiting patients in the cheapest and most acceptable manner
possible. Because many factors determine the outcomes of
treatment, the quality of care is only as good as the last patient.
Using the exact set of interventions in closely similar cases will
not produce similar outcomes all the time.
e key to improvement is reflection and analysis. Learning
comes from taking stock of the intended benefits and unintended
harms brought on patients. Real learning comes from deducing
guidelines and distilling lessons from all previous cases and
refining future interventions accordingly.
Donabedian (Jonas and Rosenberg 1986) urges that all three
measuresstructure, process, outcomebe used when assessing
and monitoring the quality of health care. In assessing patient
care, for example, the following questions can serve as guide:
Are the right interventions being done? Are they safe and
efficacious? e balance of benefit and harm resulting
from an intervention, or a set of interventions, determines
the level of quality. Treatments should be scientifically
proven to be better than no-treatment, and should be
reasonably free of adverse risks.
Are interventions performed correctly? Once the most
efficacious and safe interventions are selected, the next
step is to deliver them as efficiently as possible and with
an eye towards continuous improvement.
The more beneficial interventions are not necessarily the costlier
ones. There is an optimum level of benefits which any intervention
should deliver. Beyond this level, the costs of additional interventions
outweigh any additional benefit. Efficiency levels increase marginally
and can even decrease.
Performance
Improvement
85
Are the procedures being done the ones that matter?

Health care outcomes are the ultimate test of quality.
ey tend to be more difficult to measure than processes.
Nonetheless, every effort should be expended to evaluate
important clinical outcome of care because even doing the
right things right may still lead to undesired outcomes.
Donabedian (1992) suggests the following classification and
examples of health care outcomes:
Clinical symptoms, morbidity, accuracy, survival
Physiological / biochemical functional change, stress
test performance
Psychological, mental feelings, beliefs, knowledge
Social and psychosocial coping mechanisms, social
role performance
Integrative mortality, longevity
Evaluative satisfaction, quality of life
3. Action
Compliance of health care organizations with standards of

performance is best measured through effective identification of
problems and opportunities for improvement, and on how they
proceed to improve performance based on the information.
BENCHBOOK
86
The Plan-Do-Check-Act (PDCA) Cycle

e Plan-Do-Check-Act cycle (PDCA)2, is one strategy to
operationalize the documentation-evaluation-action triad (Table
1 lists the different tools that may be used to carry out the PDCA
cycle). It can be used at any organizational level but is particularly
effective at the frontliners level. It is a simple but systematic
method for identifying areas for improvement (Plan), and testing
(Do), evaluating (Check) and institutionalizing (Act) solutions.
Documentation is needed in all four stages of the cycle, but it is
critical in the planning stage since no plan can be sensibly drawn if
the problem has not been sufficiently documented and specified.
Evaluation is needed during the planning and checking stages.
Evaluation is particularly important in the checking stage because
the effectiveness of all potential solutions must first be established,
or the organization runs a high risk of institutionalizing faulty
solutions and committing costly errors.
Improvement takes place during the do and act stages. Action
is crucial during the act stage when top management must
summon its administrative capacity to institutionalize beneficial
changes that would otherwise remain temporary and limited
in scope. e ability to institutionalize change is the hallmark
of a learning organization. A learning organization continually
evaluates and improves its performance.
Quality Improvement Tools

e tools discussed here are used to carry out the different steps
of the PDCA cycle. ere are five different groups of tools, each
addressing specific concerns in different phases of a performance
improvement program.
e first two of these five groups identify and describe problems in
the Plan phase of the PDCA.
2
In some literature from the United States, Study is used instead of Check. Hence, the
acronym PDAS in some books.
Performance
Improvement
87
Do
Pl
ct
A
Standardize and
institutionalize
countermeasures
Present the results
to a hospital-wide
forum and get top
management approval
to adopt the solutions
throughout the
hospital
k
ec
an
Ch
Act
Develop and implement

countermeasures
Propose as many
solutions to the vital few
root causes
Narrow down
solutions to the most
effective and practical
countermeasures
Implement
countermeasures
Plan
Identify the problem
Understand the current
situation by clarifying
processes and causes of
variations from standards
Set targets and decide on
what the situation should be
if the problem was solved
Identify indicators of
improvement
Collect relevant data
Analyze the problem
Analyze the root causes
Create a plan for action
Check
Figure 9. The Plan-Do-Check-Act Cycle
Confirm effectiveness of
countermeasures
Monitor implementation of
countermeasures
Document the effectiveness
of the countermeasures by
collecting data
Analyze data
Determine if the problem has
been solved; if targets have
been achieved; if standards
have been reached
Reflect on the lessons learned
from the problem solving steps
BENCHBOOK
88
e third group, the problem analysis tools, aims to determine

the causes of certain problems and to describe how certain factors
impact on their degree of severity. One tool for example, the
fishbone diagram, is very useful in carrying this out. It is used
extensively among quality circles in Japan, though it is employed
less elsewhere because it can be time-consuming and quite tedious.
e fourth group of tools, the solution development tools, assists
in prioritizing solutions or sets of solutions to be tried on a trial
basis in the Do step of the PDCA.
The Japanese and QC Tools
In 1977, after a 5-year study, a
group of Japanese scientists
and engineers came up with
what they called the Seven
Management Tools for Quality
Control. These seven are the
Affinity diagram, Relations
diagram, Tree diagram, Matrix
diagram, Matrix data analysis,
the Process Decision Program
Chart, and the Arrow diagram.
Some time earlier, Japanese
quality control personnel were
made to undergo widespread
training in seven elementary
statistical methods, which have
been called Seven Quality
Control Tools, namely: the
Check sheet, Histogram, Causeand-Effect diagram, Pareto
principle, Control chart, Scatter
diagram, and Graphs. Publicity
given to Japanese quality control
circles led to wide use of those
tools in training courses for
quality control in the United
States (Juran 1992, Ishikawa
1985).
e Check step in the PDCA evaluates the effectiveness of the

trial solution in correcting the problem identified.
e decision to accept or reject a trial solution constitutes the
Action step in the PDCA. If the first solution is not effective,
alternates are tried, one after the other, until an acceptable
solution is identified.
With an acceptable solution found and implemented, its long-term
effect can be monitored using quality monitoring tools.
Table 1. Tools3 for the different stages of PDCA
Purpose
Tools
Problem Identification
1.
2.
3.
4.
Affinity Diagram
Brainstorming
Flowchart
Nominal Group Technique
Problem Description
1.
2.
3.
4.
5.
6.
Bar Graph
Check sheet
Force field analysis
Line Graph
Pareto Chart
Pie chart
Solution Analysis
1. Fishbone/Cause-and-effect
Diagram
2. Matrix Diagram
3. Scatterplot diagram
Problem Development
1. Prioritization matrix
2. Process decision program chart
(PDPC)
3. Tree diagram
Quality Monitoring
1. Control chart
2. Histogram
3. Radar chart
The classification of the tools is based on what the tool is best suited for. The tools may be
used for more than one purpose.
Performance
Improvement
89

Affinity Diagram
What It Is and What It Does
An Affinity Diagram is an organizing technique used to sort

several ideas or issues into meaningful groups. is method
simplifies the analysis process as it narrows down the focus on a
certain issue by identifying important aspects or creating useful
categories.
Used together with flowcharting, it helps to attain agreement on
various issues, processes and results. is technique encourages
the search for non-traditional links among ideas and issues.
How To Do It
1. State the issue under discussion in a clear and concise

sentence.
1.1 e team should agree on the choice of words to be
used.
2. Brainstorm at least 20 ideas or issues.
2.1 Follow procedures used in brainstorming.
3. Record each idea in large print visible to all.
3.1 Avoid using single words.
4. Sort ideas into five to ten categories into which the ideas
are to be grouped.
4.1 During sorting, focus on the connections between the
ideas.
4.2 Let some ideas stand alone, as they may represent
independent groups.
4.3 Once each member feels sufficiently comfortable with
the groupings, sorting slows down.
BENCHBOOK
90
5. Reach a consensus on the labelswhich could either be a

word or a short phrasefor each group of ideas; the labels
will be the main headers in the diagram.
5.1 Each grouping should have a concise sentence
summarizing its central idea and significant subordinate
concepts.
5.2 Divide large groups into subgroups when needed and
create the necessary subheaders.
6. Draw the final Affinity Diagram by connecting all main
headers with their groupings.
Why do 80% of patients in the OPD wait 90 minutes before receiving care?
Wait for MD for
more than 1 hour
No sanctions for
tardiness
MD makes long
rounds of inpatients
MD comes
to clinic late
No signages
displayed
Long queue
at the reception
No SOPs
Receptionist
is absent
Cannot find old
charts of patients
New patients do not know

where to go first
Clinic hours change
very often
Figure 10. Sample Affinity Diagram
Performance
Improvement
91

Brainstorming
Team inking
Brainstorming, or team thinking, is a technique used to generate

multiple perspectives on a given issue by generating as many
ideas as possible from the team. An important characteristic of
this technique is its uninhibited and criticism-free feature which
encourages all members of the group to express their ideas.
is method welcomes new insights and modes of thinking and
encourages involvement of every member of the group,
preventing domination of the discussion by a few people. It can
be structured, in which each member gives ideas at a specific
turn; or unstructured, in which any one can contribute an idea as
it comes.
How To Do It
1. Identify a specific issue or problem for brainstorming.

1.1 e issue is stated, agreed upon and written down for
everyone to see.
1.2 To ascertain if everyone understands the issue or
problem at hand, one or two members are asked to
paraphrase it.
2. Ask all members for ideas, doing so on a rotation basis or
by letting anyone with a new idea to speak up.
2.1 All ideas are welcomed and none is criticized.
2.2 Everyone contributes until the group exhausts all new
ideas.
3. Record all ideas presented, exactly as stated.
3.1 Recording ideas using the exact words used to state
them (the packaging) will allow appreciation of
nuances and differences of seemingly-similar ideas.
3.2 Any member contributing an idea should make sure
that his or her ideas should be recorded accurately, with
no abbreviations that could lead to misinterpretations.
BENCHBOOK
92
4. Review the list of ideas generated and eliminate

redundancies.
4.1 Discard ideas that are practically identical.
4.2 Subtle differences in apparently identical ideas can be
perceived by the use of slightly different wordings.
4.3 Ensure that all the generated ideas are clear.
Performance
Improvement
93

Flowchart
Flow Diagram
A flowchart is a map, or a pictorial representation, of the

elements of a process or a sequence of events. e elements/
events are arranged in such a way to show their chronological
order and interrelationships. It is a management tool used to
understand the intricacies of a process.
Flowcharts are best constructed by people who carry out the
work being mapped out. By analyzing activities which impact on
performance, a team can reach an agreement regarding steps in a
process. It also allows for the use of a common language to name
the different elements of a process.
As a quality improvement tool, it facilitates needed simplification
and standardization by identifying bottlenecks in the process,
missing or redundant steps, and problem areas.
How To Do It
1. Determine the boundaries of the process.

1.1. Clearly define the starting (input) and the terminal
(final output) points of the process being studied.
1.2. Team members should agree on the level of detail to be
shown on the flowchart for process understanding and
problem identification.
BENCHBOOK
94
2. Identify the steps in the process.

2.1. Brainstorm a list of major activities, inputs, outputs and
decisions involved from the beginning to the end of the
process.
3. Arrange the steps in sequential order.
3.1. Unless flowcharting is being done for a new process,
sequencing should follow the actual order of events
employed in the work process. While initially difficult
to do, this allows identification of probable causes of the
problems in the process.
4. Draw the flowchart using the appropriate symbols.

4.1 Use labels that are understandable to the entire team.
Flowcharting symbols
Juran (1992) proposes the following basic
flowcharting symbols:
Arrows show the direction or flow of the process.
Boxes or rectangles indicate a task or activity.
Diamonds indicate a decision point in the process,

usually a yesorno question.
Ovals mark the beginning or end of a process.

A half or torn sheet of paper for a report completed
or filed.
Performance
Improvement
95
Flowchart for Admission:
Patient arrives at the E.R.
Old patient
YES
Chart Retrieval
NO
Chart Issuance
Assessment:
(Nurse: Medical History)
Diagnostics
Assessment
Confinement
necessary?
NO
YES
Inpatient
Figure 11. Sample flowchart
Outpatient
BENCHBOOK
96

Nominal Group Technique
Team inking
><
^
><
^
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:;
:;
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e Nominal Group Technique is a team brainstorming method

useful for balancing member participation and reaching consensus
on the relative importance of issues, problems or solutions. By
giving each team member equal chance to rank issues without
pressure from other members who may tend to dominate
discussions, this method allows the team to see major causes of
disagreements.
By starting from individual rankings to reach a consensus, this tool
instills ownership of ideas and commitment to the teams choice.
How To Do It
1. Generate a list of statements on issues, problems or

solutions to be prioritized.
1.1 Silent or individual brainstormingwriting ideas
in sheets of paperis preferable in generating ideas,
particularly if team members are still unfamiliar or
uncomfortable with each other.
1.2 Record the statements on a board or flipchart where
everyone can read them.
Performance
Improvement
97
2. Eliminate duplicates, group together related ideas and/or

clarify meanings of the statements.
2.1 e facilitator/group leader should always ensure
that there is team consensus in the rephrasing and
elimination of any statement and grouping of ideas.
3. Finalize the list of statements.
3.1 Each statement should be represented by a letter.
4. Rank the statements in order of importance.
4.1 e highest number may be used to indicate the highest
rank, the smallest number the lowest rank.
4.2 Add the resulting individual rankings and show the
total scores for each statement.
5. Select the statements with the highest total scores as the
teams group decision.
5.1 e group decides on the final number of statements to
be selected.
5.2 Repeat the selection process for the statements if there
are many statements to choose from or the total scores
are very close to each other.
5.3 Each member may briefly make clarifications or
comments on the statements.
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Bar Graph
Bar Chart
Figure 12. Bar graph showing the estimated number

of beneficiaries of the NHIP for the period
2000June 2002.
Figure 13. Bar graph showing PhilHealth claims

payments for the period 1998June 2002.
A bar graph plots the frequency of occurrence of different kinds

of events during set time intervals. It shows differences in data
collected during different time periods.
How To Do It
1. Assign frequency of events to the vertical axis.

1.1 Assign one bar per event.
2. Assign the time intervals to the horizontal axis.
2.1 Uniform time intervals should be marked on the
horizontal axis.
3. Plot the data according to the time intervals.
3.1 e height of each bar should correspond to the
frequency of the event assigned to it.
Performance
Improvement
99

Check Sheet
A check sheet is a data-organization tool for the systematic

recording and compilation of historical data or qualitative or
quantitative observations on a certain phenomenon aimed at
detection of patterns and trends.
A check sheet forces agreement within the team, for purposes of
data uniformity, to come up with a common definition or set of
characteristics of conditions or events to be observed. is will
ensure easy detection of patterns emerging from the collected
data
How To Do It
1. Agree on the definition of the events or conditions being

observed.
1.1 If the list of events or conditions are to be constructed
while observations are being made, agreement must
be reached on the overall definition of the project and
terms used in defining project goals.
2. Collect data over a sufficient period to ensure it represents
typical results.
2.1 Collect data consistently and accurately.
2.2 Look out for the need to stratify datathe subgrouping
of data to accommodate important differences in the
population (where the data was obtained)as reflected
in the sampling (the portion of the population being
studied).
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Table 2. Accreditation Check Sheet for Medical Professionals
Accreditation Requirement
1.
Application form
2.
Old accreditation ID
3.
ID picture
4.
Accreditation fee
5. Validated MI5 / RF 1
6.
PRC ID
7.
PMA card
8.
Certificate of good standing
9. TIN card / W2
10. PhilHealth ID card / Form M1b
11. Specialty Board Certificate
Medical Specialist
Initial
Renewal
P 1,500.00
P 1,500.00
Performance
Improvement
101

Force Field Analysis
Force field analysis is used to identify and enhance factors (also

called driving forces) which facilitate organization objectives and
pinpoint and minimize those that act as obstacles (also known
as restraining forces). Weighing the pros and cons of a given
problem and proposed solutions encourages serious team reflection
on all concerned issues.
Essentially a change analysis tool, this method allows a team to
see what is needed to solve a certain problem (or designated as
current situation). Only when driving forceswhich may be
external or internal to the organizationare stronger, will change
be possible; if not, they should be strengthened or restraining
forces minimized. However, simply pushing the positive factors for
a change can produce the opposite effect. It is better to work on
removing barriers.
A key element in this analysis method is data collection. Whether
data is primary (prospectively collected) or secondary (obtained
from existing records), it is needed for evaluation of the issues.
Secondary data may be convenient but could prove inaccurate. On
the other hand, while primary data collection takes time and effort
to carry out, it may be more valid.
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1. Identify a certain problem situation and state the desired

situation, which shall be considered as the solution.
1.1 Draw a large T on the board or flipchart.
1.2 Write down the problema specific, measurable
situation that represents the gap between what is and
what should beand the desired situation above the
horizontal line of the large T.
1.3 Write down the positive and negative sides of the
situation on opposite sides of the vertical line of the T.
How To Do It
2. Describe the desired situation.

2.1 Identify the driving forces that would lead to the desired
situation.
2.2 Identify the restraining forces that impede the
realization of the desired situation.
3. Identify needed actions to either strengthen driving forces
or minimize restraining forces.
3.1 Prioritizethrough open discussion or by ranking
methods like the nominal group techniquethe driving
forces to be strengthened and the restraining forces to
be minimized.
Problem Statement: Implementation of quality improvement activities for the year

is only 25% of target.
Current Situation:
Only 25% of planned quality improvement
activities are being implemented.
Ideal Situation:
100% of planned quality improvement
activities are implemented.
Driving Forces:
1.
2.
3.
Management recognizes the need to carry out

quality improvement projects.
The nurses are very eager to do the quality
improvement projects.
Improved services mean more return business.
Restraining Forces:
1.
2.
3.
Doctors are not interested in quality

activities.
Some team members do not like to work
on projects after office hours.
There is no budget allocation for quality
improvement projects.
Figure 14. Sample Force Field Analysis
Performance
Improvement
103

Line Graph
Figure 15. Average Value Per Claim filed with PhilHealth, 1999-June 2002.
A line graph is a data analysis tool which shows the evolution of a

process or its output over a period of time. As a performance
tool, it measures certain parameters of a process observed over a
given time frame. It is also used to spot trends and other patterns
occurring in a process as it shows the peaks and lows reflected in
the quantitative data.
By plotting the developing of a process, a line graph indicates
whether the process is working, whether a certain target level has
been reached, and which areas need or have undergone
improvement.
e line graph is useful in spotting trends at the early stages of
data collection.
How To Do It
1. Decide the kind of data to be collected and how long the

collection should be.
1.1 e data gathering period should be long enough to
show a trend.
1.2 Establish even intervals of time over which the data are
to be arranged.
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104
2. Plot quantitative data and time intervals on their respective

axes.
2.1 Assign the quantitative data to the vertical axis (X-axis).
2.2 Assign the time intervals to the horizontal axis (Y-axis).
3. Connect the data points.
Figure 16. Sample line graph
Performance
Improvement
105

Pareto Chart
Pareto Diagram
Pareto Graph
Vilfredo Frederigo Samaso Pareto (1848-1923)

French-born Italian economist and sociologist who developed the
theory on the rise and fall of the governing elite. His early work
resulted in the formulation of the Pareto Law, which stipulated that the
distribution of incomes could be determined by mathematical formulas.
A simpler version of this law says that 80 percent of the wealth of an
economy is owned by 20 percent of the population. It would later be
popularized as the 80-20 rule and appropriated by quality expert Joseph
Juran, who rephrased it to mean that 80 percent of the problems are a
result of 20 percent of the causes. Using the Pareto concept, Juran also
conceived of the vital few and the trivial many.
A Pareto chart is an analysis tool useful in identifying problems

that require further studydue to the frequency of incidence
and in prioritizing the search for solutions. A Pareto chart
analysis can show which of the several causes of a problem are the
most significant and which have less bearing in the occurrence of
the problem.
Used in studying problems with multiple causes, a Pareto chart
displays the significance of problems in a simple, easilyinterpreted visual format. It shows in an easy-to-read bar graph
the frequency of problems, arranged in descending order, which
affect a given process. e graph also shows the percentages of
various factors in order of size.
How To Do It
1. Decide on a topic.
1.1 e topic may be a general one or a specific problem.
2. List the specific problems or causes of the problems to be
compared and rank ordered.
2.1 Compare and rank order the listed problems either by
cause-and-effect analysis (Fishbone diagram),
brainstorming or review of existing data.
BENCHBOOK
106
3. Choose the most meaningful and feasible unit of

measurement to compare, such as frequency or cost.
4. Choose a time period for the study.
5. Gather the necessary data on each problem category or
cause either prospectively, or by reviewing existing data.
6. Construct a table listing the problem or causes, and their
respective frequencies.
6.1 Calculate the percentages and cumulative percentages
(the cumulative percentage is the first percentage plus the
second percentage, plus the third, and so on).
Table 3. Computation of cumulative percentages.
Causes
Percentage of
Total
Computation
Cumulative
Percent
20%
0%+20%=20%
20%
18%
20%+18%=38%
38%
15%
38%+15%=53%
53%
11%
53%+11%=64%
64%
7. Construct a graph, listing the problems or causes in

decreasing order of frequency or size.
7.1 Assign the problems or causes on the horizontal (X) axis.
7.2 Assign the percentages from 0 to 100% on the vertical (Y)
axis.
8. Draw the cumulative percentage line showing the portion of
the total that each problem or cause category represents.
8.1 On the vertical line opposite the raw data, write 100%
opposite the total frequency of causes and mark the
subdivisions accordingly.
8.2 Starting with the highest problem category, draw a dot or
mark an x at the upper right hand corner of the bar.
8.3 Add the total of the next problem category to the first
and draw a dot above that bar. Do the same for the next
problem categories and connect the dots with straight lines
until 100% is reached.
Performance
Improvement
107
150
100%
120
80%
90
60%
60
40%
30
20%
Cause 1
Cause 2
Cause 3
Cause 4
Cause 5
0%
Figure 17. Sample Pareto chart
9. Interpret the results and identify the vital few causes (8020 rule).
9.1 Generally, the tallest bars indicate the biggest contributors
to the overall problem.
9.2 Dealing with these problem categories will impact the
most in solving the general problem.
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Pie Chart
Figure 18. Pie chart showing percentage of different kinds of accredited

health care institutions as of June 2002.
A pie chart is a pictorial representation of an entire unit as

constituted by its different parts. e proportion of these different
components are displayed and the interrelationships between the
different parts are seen.
How To Do It
1. Determine proportion of the whole that can be assigned to

each of the items.
1.1 e proportion of the component items are expressed in
percentages.
2. Divide the circle, assigning the slices to each item.
2.1 e sizes of the slices representing specific items
correspond to the percentage they occupy in the entire
unit.
Figure 19. Pie chart showing PhilHealth

payments by sector, Jan-Jun 2002.
Figure 20. Pie chart showing regional

distribution of NHIP
members as of June 2002.
Performance
Improvement
109

Fishbone Diagram
Ishikawa Diagram
Cause-and-Effect Diagram
Kaoru Ishikawa
According to Ishikawa, a professor of engineering in two Japanese
universities and winner of the Deming Prize, the ideal state of quality
control is where the level of quality is so high that inspection is no longer
needed. He believed that quality assurance is attained by eliminating the
root cause of error. He created a diagram to illustrate causes and effects. It
has come to be known as the fishbone diagram, or the Ishikawa diagram
A fishbone diagram is a management tool used to show the many

possible causes of a problem and the possible actions to solve it. It
identifies and graphically displays in increasing detail all possible
causes to a problem or condition to get to its root cause or causes.
In doing so, ideas for possible solutions are generated.
Designed to look like a fish skeleton, the head of the fish
represents the effect, or the problem being studied. e bones
connecting to the spineor the problems which create the
effectare then identified and labeled. e causes of these
problems are then identified until a complete cause-and-effect
picture emerges.
How To Do It
1. Identify the problem to be solved.

1.1 e problem is labeled as the effect and represented in
the diagram as the head of the fish located at the righthand end of a horizontal line.
1.2 Write the statement of the problem in a box on the right
side (head-of-the-fish side) of the diagram.
1.3 Everyone should agree on the statement of the problem,
which should include as much information (what, where,
when, why, how much) as possible.
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110
2. Brainstorm causes of the problem.

2.1 e possible causes (major cause categories) of the
effect should be grouped together (represented as
bones connected to the spine).
2.2 Connect the major cause categories to the spine.
3. Label the major cause categories.
3.1 In the health care industry, major cause categories
include: policies (higher-level decision rules),
procedures (steps in a task), plant (equipment and
space), and people (manpower).
3.2 Other frequently-used cause categories include:
environment (buildings, logistics and space) and
measurement (calibration and data collection).
4. Study the results.
4.1 Search for the causes behind the causes until there is a
complete picture.
4.2 Revise the diagram based on the results of data
collection and analysis.
Cause 4
Cause 2
Effect
80% OPD
patients wait 90
minutes
Long rounds
Emergency consults
Doctors come to clinic late
Cause 3
Patients wait for

doctors for more
than 1 hour
Cause 1
Figure 21. Sample of a fishbone diagram.
Performance
Improvement
111
Matrix Diagram
A matrix diagram is used to show a graphic representation of

the presence and strength of relationships between two sets of
information or activities. In terms of service improvement, it is
used to compare the relationship between certain requirements and
the work processes that deliver those requirements.
A matrix diagram, by making patterns of responsibilities visible
and clear to the team, promotes even and appropriate distribution
of work activities.
How To Do It
1. Determine the factors needed to make a correct selection or

assignment.
1.1 List the most important resources or responsibilities
involved in performing a specific task.
1.2 Select the key factors affecting successful implementation.
1.3 Assemble the right team, selecting individuals who are
knowledgeable on key factors and can realistically assess
the relative importance of each.
BENCHBOOK
112
Other Matrices:
1. Y-shaped matrix compares three sets of items. It bends a T-shaped
matrix to allow comparisons between items on the
vertical axes.
2. X-shaped matrix compares four sets of items. This is essentially two
T-shaped matrices placed back to back.
3. C-shaped matrix this is a three-dimensional matrix as it simultaneously
shows the relationships among three sets of data.
2. Select the type of matrix to be used

2.1 L-shaped matrices are for 2-factor comparisons; Tshaped ones are for 3-factor comparisons; Y-shaped
matrices are for 3-factor comparisons showing direct
relationships.
3. Select relationship symbols to be used.
3.1 Make sure that the team clearly understands the
meaning of the symbols.
3.2 Create a legend section by choosing and defining
relationship symbols.
3.3 Rate the strength of relationships (i.e. high, moderate or
low).
4. Complete the matrix by using the appropriate factors and
symbols.
4.1 In identifying the persons responsible for specific
components of a task, include those who are directly
involved in implementing and/or evaluating the task.
4.2 In assigning responsibilities, choose only one person to
exercise the primary responsibility. Assign secondary
responsibilities to all other identified persons.
5. Examine the matrix and draw the appropriate conclusion.
Performance
Improvement
113
LEGEND:
For personnel:
primary responsibility
provide assistance
provide resources
Task
Personnel
Secure
Informed
Consent
Discuss Rights and

Responsibilities
Explain
Financial
Obligations
Tour
Facility
Attending
physicians
Nurses
Billing and
collections
Figure 22. Sample Lshaped matrix comparing personnel tasks in patient orientation
For goals:
high impact
moderate impact
low impact
Facilitate
patient
autonomy
Communicate
hospital
policies
Resolve practical concerns
Allay patients
anxieties
Encourage
patient
involvement
Goals
Task
Personnel
Secure
informed
consent
Discuss
rights and
responsibilities
Explain
financial
obligations
Tour Facility
Attending
phycisians
Nurses
Billing and
collections
Figure 23. Sample Tshaped matrix comparing personnel tasks in patient orientation
BENCHBOOK
114

Scatterplot Diagram
Scatter Diagram
Dot chart
Scatter chart
Figure 24. Sample scatterplot diagram
A scatterplot diagram is one graphical representation of data

which shows the relationship between two variables. But while
patterns appearing in the diagram allow for visual estimation of
how changes in one affects the other, the scatterplot diagram only
indicates a relationship and does not signal a causation.
Plotting this diagram demands a big data set, or at least 30 data
points.
How To Do It
1. Collect data on several variables in the process being

studied.
1.1 Choose two variables which are suspected to have a
relationship.
1.2 For a value of one variable, determine the value of the
other.
2. Plot each observation based on its two coordinates from
each of the 2 data sets.
2.1 Both axes should be of the same length.
Performance
Improvement
115
3. Determine the existence of a correlation between the

variables.
3.1 If the resulting graph resembles a nearly-horizontal or
nearly-vertical line, or random points appear in no
apparent order, there is no correlation between the
variables.
3.2 If the graph resembles a slanting line, there is a positive
(if upward slant) or a negative (if downward slant)
correlation; the more the pattern resembles a line, the
stronger the relationship.
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Prioritization Matrix
Selection Grid
A prioritization matrix is a screening tool used to narrow down

options through a systematic comparison of choices using a set of
criteria. is is particularly useful when there are limited resources
available for implementation of a certain activity.
e prioritization matrix allows basic disagreements on issues to
surface for their prompt resolution. It focuses on increasing a
teams chances of success by identifying the best actions that can be
done and not losing time in pondering all possible ones that could
be done. As all options are considered, this activity builds
consensus, instills team ownership of the decision and enhances
follow through of group decisions.
is is best used with a small team (3-8 people), when there are
few options (5-10) and criteria (3-6), and when complete
consensus is needed and serious consequences are at staken should
the plain fails.
How To Do It
1. Agree on the ultimate goal to be achieved and state it in a

clear, brief sentence.
2. Create the list of criteria and a scoring system.
2.1 Reach a consensus on the final set of criteria and their
meanings.
2.2 Use either a yes/no system or a point system to indicate
fulfillment of a criterion.
3. Create a list of options.
3.1 Reach a consensus on the final set of options and their
meanings.
Performance
Improvement
117
4. Create an L-shaped criteria matrix to weigh criteria

against each other.
4.1 List all the criteria on the vertical and the horizontal
axes.
4.2 Read across each row and weigh the row criterion
against each of the column criteria.
4.3 Each time a weight is recorded in a row cell, its
reciprocal value must be assigned to the corresponding
column cell.
4.4 Total the weights in each row to get the criterion weight
for each row criterion.
For example:
Criteria
Income
generating
Expense
reduction
Consistent
with
mission
Increase in
patient
load
Total
Relative
decimal
value
1/10
1/5
5.3
0.14
1/10
1/5
0.5
0.01
21
0.56
11
0.29
Criteria
Income
generating
Expense
reduction
1/5
Consistent with
mission
10
10
Increase in
patient load
Grand total
Legend: 10
5
1
1/5
1/10
37.8
row item is much more important than column item

row item is more important than column item
row item is just as important as column item
row item is less important than column item
row item is much less important than column item
5. Create an L-shaped criteria matrix to weigh options

against each other.
5.1 List all the options on the vertical and the horizontal
axes.
5.2 Read across each row and weigh the row criterion
against each of the column criteria.
5.3 Each time a weight is recorded in a row cell, its
reciprocal value must be assigned to the corresponding
column cell.
5.4 Total the weights in each row to get the option rating
for each row criterion.
BENCHBOOK
118
For example:
Options
Options
Solicit
funds
Solicit funds
Charge
fees
Economize
Improve
quality
Total
Relative
decimal
value
1/5
6.2
0.16
1/10
1/10
0.4
0.01
1/5
11.2
0.30
20
0.53
Charge fees
1/5
Economize
10
Improve quality
10
Grand total 37.8

Legend: 10
5
1
1/5
1/10
row item is much more important than column item

row item is more important than column item
row item is just as important as column item
row item is less important than column item
row item is much less important than column item
6. Create an L-shaped summary matrix to compare each

option based on all the criteria combined.
6.1 List all criteria on the horizontal axis and all options on
the vertical axis.
6.2 For each matrix cell, compute the option scores by
multiplying the criterion weight of each criterion by the
option rating of each option. For each option, add all the
option scores horizontally for a row total.
6.3 Divide the row totals by the grand total. is creates
option ranks for each option.
For example:
Income
generating
(0.14)
Expense
reduction
(0.01)
Consistent
with
mission
(0.56)
Patient
load (0.29)
Total
Relative
decimal
value
Solicit funds (0.18)
0.025
0.002
0.101
0.052
0.18
0.18
Charge fees (0.01)
0.001
0.000
0.006
0.003
0.01
0.01
Economize (0.30)
0.042
0.003
0.168
0.087
0.30
0.29
Improve quality
(0.53)
0.074
0.005
0.297
0.154
0.53
0.52
Criteria
Options
Grand total
1.02
7. Choose the highest ranking option or options (in the

example above, improving quality is seen as the best option).
7.1 Use common sense as wellas prioritization matrices do
not constitute an exact science, the team should be open to
alternative conclusions, particularly when option ranks are
very close or defy logic.
Performance
Improvement
119
Simplified Prioritization Matrix

1. Conduct a team brainstorming session on problems being experienced.
1.1 Identify the problems and their frequency of occurrence.
2. Using a short number scoring system, rank the problems, evaluating
them according to impact on the entire system/operations if they
remain uncorrected, and the possibility of a solution being within
reach.
3. Fill out the Prioritization Matrix chart with the group.
3.1 In the first column, write down the problems that were mentioned
during the brainstorming session.
3.2 In the second to fourth columns, define the criteria.
3.2.1 Examples of criteria are frequency, importance, and
feasibility.
Problem
Frequency
Importance
Feasibility
4. Add up the total number of points for each problem.
Total Points
BENCHBOOK
120

Process Decision Program Chart (PDPC)
A PDPC chart is used to graphically illustrate contingency

planning. Possible problems and difficulties in implementation
are determined and strategies for dealing with them are
determined in advance. e PDPC is useful in the following
situations:
1. Implementation of a new or untried plan that has risks
involved;
2. Implemention of complex plans and the consequences of
failure are serious;
3. Implemention of a plan with time constraints, when there
is no sufficient time available to deal with contingent
problems as they occur.
How To Do It
1. Create a team that is familiar with the process under study

this usually involves the people directly in charge of the
work process.
2. e actual work flow of the activities is clarified and the
team constructs a tree diagram, placing prerequisite
activities in a time sequence.
3. All possible contingencies are identified for each step by
asking, what could go wrong here?
Performance
Improvement
121
4. Contingency plans are placed on the chart.

5. e most feasible countermeasure to each problem
identified is chosen and built into a revised plan.
Process Decision Program Chart for Implementing

Evidence-based Participatory Quality Improvement
Category
Objective
Activity
Possible
outcome
Familiarity with
QI tools
Longevity bonuses
Employee training
Capability buiding
Contigency Plan
Competence in QI
projects
High turn-over
of staff
Job enrichment
Opportunities for
exposure
Advocacy
Figure 25.
Sample PDPC showing contingency measures for the persistent high turn-over of staff
following employee training.
BENCHBOOK
122

Tree Diagram
A tree diagram is a graphic tool used to map out detailed groups of

tasks marked for implementation. It breaks down a goal expressed
in broad terms into increasing levels of detailed actions (called
stratification) that should or may be done to achieve stated goals.
e tree diagram aims to partition a big idea or problem into its
smaller components, to make the idea easier to understand, or the
problem easier to solve.
While the tree diagram makes the entire team check all of the
logical links and the completeness of details at every level of a plan,
it helps make a potentially overwhelming project manageable by
showing the real level of complexity of actions involved in the
achievement of any goal.
How To Do It
1. Choose the tree diagram goal statement that is clear and

action-oriented.
2. Assemble a team which consists of 4-6 action planners with
detailed knowledge of the goal.
2.1 e team should take the tree diagram only to the level of
detail that the teams knowledge will allow.
3. Generate the major headings, which represent the major
task areas.
3.1 Keep the first level of detail broad.
3.2 Avoid jumping to the lowest level of task.
Performance
Improvement
123
4. Break each major heading into greater detail.

4.1 Asking what needs to be done to accomplish this task?
can lead to successively detailed levels.
5. Stop the breakdown of each level up to the point where
there are assignable tasks, or the team reaches the limit to
its own expertise.
Assignable
task
Major Task
Subtask
Assignable
task
Subtask
Assignable
task
Subtask
Assignable
task
Assignable
task
Objective
Subtask
Assignable
task
Subtask
Assignable
task
Subtask
Assignable
task
Major Task
Assignable
task
Subtask
Assignable
task
Major Task
Assignable
task
Subtask
Assignable
task
Subtask
Figure 26. Template of a tree diagram.
Assignable
task
BENCHBOOK
124

Control Chart
A control chart is a tool used to monitor developments in a

process over time. Statistically based in pinpointing process
variations, it is most useful in long-term studies as it indicates the
times when a process registers values outside acceptable limits,
times when improvement efforts are needed in a process.
Control Chart History
e control chart is also used to determine whether changes in

a process are due to random variability (also called common
causes), or to the unpredictable and occasional causes better
known as special causes.
Walter Shewhart first developed

control charts in the 1920s at
Bell Labs as a quality control tool
in manufacturing. Shewhart
would later create the process
improvement approach known
as the Plan-Do-Check-Act cycle,
to be used with control charts.
The health care industry would
appropriate control charts as a
quality improvement tool only in
the 1980s (Nelson 1995).
Common causes are flaws inherent in the design of the

process. They can be measured and monitored but not entirely
eliminated.
Special causes are variations from standards caused by
employees or by unusual circumstances or events. Special causes
produce variations that affect quality and must be monitored,
analyzed and eliminated.
The distinction between the two causes is important as most
variations in processes are caused by system or process flaws rather
than employee errors. When management realizes this, changes in
the system can take place, as the implantation of a culture of blame is
prevented.
Performance
Improvement
125
ere are two types of control charts: variable data control charts,
or measurements charts, which measure quantifiable events
(such as weight, volume, speed, time, length); and attribute
data control charts, which measure the presence or absence of a
quality.
How To Do It
1. Select the kind of data to be collected, whether variable or

attribute.
2. Select the kind of control chart to use.
2.1 Variable data control charts are used to determine the
extent of the statistical control of a process.
2.1.1 XmR control charts (also known as I-chart,
X-Rm, x-R or X-m ) plot individual data
measurements and the range between present and
past data values.
2.1.2 X-S control charts (or the sigma chart) plot the
mean and the standard deviation.
2.2 Attribute data control charts generally examine flawed
products as a fraction of a whole.
2.2.1 e p chart measures the fraction of defective
items in a sample of either varying or constant
size.
2.2.2 e c chart measures the count of defective items
for a constant sample size.
2.2.3 e u chart measures the count of defective items
for a sample of either varying or constant size.
3. Collect data.
3.1 Record the data on the appropriate control graph.
4. Calculate upper and lower control limits, and data mean
and standard deviation, if needed.
5. Plot the data points and control limit.
5.1 e control graph is divided into the following three
zones: upper control limit (UCL), standard (average),
and lower control limit (LCL).
BENCHBOOK
126
6. Interpret the graph.

6.1 e process is out of control if:
One or more data points fall above the UCL or below
the LCL;
ere are at least eight consecutive data points on one
side of the average line (center line);
At least six consecutive data points steadily increase or
decrease, thus signaling a trend.
Data Reminders
If the data fluctuates within the limits, it is the result of common
causes within the process (flaws inherent in the process) and can
only be changed if the system is improved.
If the data falls outside of the limits, it is the result of special causes
(in human service organizations, special causes can include bad
instruction, lack of training, ineffective processes, or inadequate
support systems). These special causes must be eliminated before
the control chart can be used as a monitoring tool. In a health
setting, for example, staff may need better instruction or training, or
processes may need to be improved, before the process becomes
under control. Once the process is under control, samples can
be taken at regular intervals to assure that the process does not
fundamentally change.
14
UCL
12
Average
Occurence
10
8
LCL
6
4
2
0
Jan Feb Mar Apr May Jun Jul
Figure 27.
Aug Sep Oct Nov Dec
Sample control chart showing an out of control

process from October to December.
Performance
Improvement
127

Histogram
Bar Chart
Frequency Distribution Chart
A histogram is a bar graph which displays the frequency

of occurrence of data values and shows the spread of data
distribution. As a graphic summary of data, the horizontal axis
shows data size and the vertical axis displays frequency.
is tool enables a team to be more familiar with how a process
works, as a histogram allows team members to see patterns of
variation occurring in a process. It helps compare current and
previous performances as well as predict future performance.
How To Do It
Histogram history
One of the earliest tools in
statistical analysis, William Playfair
first published this kind of bar
chart in 1786. Histogram as
a word was introduced by Karl
Pearson in 1895 (JCAHO 2002).
1. Gather data about a variable to be studied.

1.1 Determine data categories and time intervals to be used
1.2 Collect enough data points (at least 50 to 100) to be able
to detect patterns of occurrence and calculate the data
centering (like the mean) and data spread (like standard
deviation).
1.3 Use historical data to find patterns or to provide baseline
measure of past performance.
1.4 Collect data prospectively for current process
information.
1.5 To compare previous and current process performances,
the two data sets (current data and historical data) should
have uniform variables.
BENCHBOOK
128
2. Construct a frequency table.

2.1 Each time interval should have its corresponding
frequency value.
3. Draw a histogram based on the frequency table.
3.1 Mark the vertical bar o Y-axis from 0 to the highest
frequency value.
3.2 Mark the horizontal bar o X-axis with the lower and
upper limits of the time intervals.
4. Interpret the histogram.
4.1 Centering is that spot in the graph where most data
points cluster, as indicated by the tallest vertical bars.
4.2 Variability, or spread is the distance between the point of
centering to the farthest class intervals on either side.
4.3 If a histogram is symmetrically centered or bell-shaped,
the data points are said to be normally distributed
4.4 A histogram result that leans toward one side is skewed.
Number of Claims
600
500
400
300
200
100
0
10
12
14
Average Length of Stay

(Days)
Figure 28.
Sample histogram showing the number of

claims compared to average lengths of stay in a
hypothetical hospital
Performance
Improvement
129

Radar Chart
Spider Chart
Spider web Chart
A radar chart is a graphical display of the differences between

actual and ideal performance. It is useful for defining
performance and identifying relative strengths and weaknesses of
activities.
How To Do It
1. Determine the area to study.

2. Assemble a team with members coming from different
areas of the organization to get varied perspectives and
avoid blind spots.
3. Select and define rating dimensions.
4. Collect data on actual performance.
5. Rate all performance dimensions.
6. Draw the chart by tracing a large wheel with a spoke for
each category.
6.1 Label each spoke properly.
6.2 Plot the rating against ideal values.
7. Connect all the dots, the ratings, for each dimension and
highlight as needed.
8. Calculate a gap score for each dimension by subtracting
the team rating from the maximum rating.
9. Interpret and use the results.
BENCHBOOK
130
Patient rights and organizational ethics
10
8
Improving performance
Patient care
6
4
2
0
Safe practice and environment
Leadership and
management
Information management
Figure 29.
Human resource management
Sample radar chart showing the performance rating

of a hypothetical organization
Performance
Improvement
131
Quality Circles and Quality Teams
Quality Circle History

The Quality Circle, as conceived
by Japanese quality expert Kaoru
Ishikawa, is a small group, with
a maximum of ten members
belonging to the same work
section. They meet voluntarily
at least twice a month, and elect
a leader. Among their activities
are identification of qualityrelated problems, understanding
of their causes, formulation and
implementation of corrective
actions. By promoting
involvement of workers in a
particular section, quality circles
enhance personnel self-image
and status. In the manufacturing
industrys experience, QCs
have been highly useful in the
elimination of low-incidence
defects and making processes
error-proof.
The United States tried to
implement its own version of
quality circle activitiescalled
the Zero Defect (ZD) movement-in the 1960s. It was adopted by
the Pentagon for its contractors
but the movement did not catch
on. Part of the problems with
ZD, according to its critics, is the
focus on the output and not on
the process that could produce
the desired output (Donabedian
2003, Juran 1992, Ishikawa 1985,
Walton 1986).
Quality improvement may be operationalized through

small-scale quality projects in particular work areas through
quality circles, or though organization-wide activities such as
incident monitoring, morbidity and mortality conference, and
implementation of clinical practice guidelines.
A quality circle (QC) is a group of 5 to 10 workers, the
frontliners, from one work area of the hospital who meet
regularly to identify and solve problems in their work area
using their own resources. Doctors, nurses, other paramedical
personnel and support staff can belong to one quality circle.
e quality circle approach to problem solving is data-based,
participatory and action-oriented. Problems are identified after
systematically collecting information from the work place.
Quality circle members are directly involved in all steps of the
problem-identification and problem-solving processes. Solutions
are feasible, practical, and doable within several months and may
be incorporated into hospital-wide routine or policy.
A quality team, on the other hand, is a quality circle with a
bigger scope in at least two respects:
it involves managers as well as front-liners
it involves more than one area or process of work and
often tackles cross-functional issues.
Quality Team at Work
More efficient discharge of patients is best done by a quality team
that includes different members of the clinical team from the
wards, accounting and billing sections, dietary, rehabilitation and
housekeeping departments.
BENCHBOOK
132
e first step in initiating a quality circle/quality team activity is

the selection of a person, a QC leader, who will be responsible
for facilitating and promoting QC activities in the health
care facility. is person should have training on basic quality
assurance, statistical process control and other QC tools. QC
leaders are supposed to recruit members into the quality circle.
QC promotion consists of planning and implementing companywide education programs, overseeing and coordinating activities
of quality circles, facilitating QC meetings and activities
(especially when the circle is new), holding QC conferences,
establishing an award-giving system to top performing
circles, and ensuring a mechanism for the adoption of QC
recommendations in company policies.
Quality circles and teams evaluate performance through selfevaluation and management evaluation.
Table 4. Evaluation Points for QC Members
SelfEvaluation
achievement of set
targets
meeting schedules
attendance in QC
activities
extent of involvement
in QC work
familiarity with and
utilization of QC tools
Managements Evaluation
meeting annual targets
demonstration of the
effectiveness of QC
activities
cooperation among
members
management satisfaction
with outcomes of QC
activities
Performance
Improvement
133
Quality Circle /Quality Team Approach to Problem Solving
Select a theme
Identify a problem or issue

Evaluate and narrow down a problem or issue
Clarify the reasons why a problem or issue must be
addressed
Understand the current

situation and set targets
Document the presence of the problem by collecting data

Decide on what the situation would be if the problem were
solved
Create a plan of action
Schedule the problemsolving activities of the

quality circle
Enumerate as many causes of the problem as

possible, group them together to discover root causes
and narrow down the list to a vital few
Propose as many solutions to the vital few root causes

Narrow down solutions to the most effective and
practical countermeasures
Implement countermeasures in quality circle work area
Analyze the root causes
Develop and Implement

countermeasures
Confirm effectiveness
of countermeasures
Standardize and
institutionalize
countermeasures
Document the effectiveness of the countermeasures by

collecting data on the problem level
Reflect on the lessons learned from the problemsolving process
Present the results to a hospitalwide forum to get top

management approval
Check the solution if it stays effective
BENCHBOOK
134
Quality Improvement Activities

Clinical Practice
Guidelines
Clinical Practice Guidelines are systematically developed

statements which assist in formulating practitioner and patient
decisions about appropriate health care for specific clinical
circumstances (Institute of Medicine 1990). Properly-designed
guidelines are based on scientific evidence and on judgments and
values obtained from consensus among care providers, patients
and other stakeholders. ese guidelines aid decision-making
regarding the aims, benefits, harms and costs of management
alternatives. Properly-used guidelines may be effective in
reducing the rate of unjustified or unwanted variations, and thus
the extent of inappropriate care.
Guidelines have been proven to improve both the processes and
outcomes of health care, increasing efficiency and educating
patients and providers alike through the use of guideline-derived
measurement tools (for example, a guideline-derived clinical
pathway addressing a specific diagnosis).
As guidelines are only as good as the current best practice
available or as good as the evidence on which they are based,
methods used in searching, appraising, and synthesizing
the evidence should be explicit, unbiased, reliable and welldocumented. is calls for a systematic and comprehensive
review of the medical literature for the best available and
current evidence on a given topic. Formal methods of building
consensus are then used to incorporate the judgments and values
of professionals and the preferences of patients. e resulting
recommendations are therefore based on a transparent process
that can be replicated.
Once the guidelines are constructed, external reviewers examine
them for validity, applicability and relevance. Independent
reviewers conduct a reality check during dissemination and
implementation to evaluate the feasibility, acceptability and
flexibility of the guidelines. ey also monitor the effectiveness of
the dissemination and implementation methods in encouraging
compliance.
Performance
Improvement
135
Characteristics of Good Guidelines
Valid
Clear
Reliable
A multidisciplinary process
Clinically applicable
Clinically flexible
Has documentation
Undergoes a scheduled review
Methodological Standards on Guideline Development and
Format
Purpose of the guideline is specified.
Rationale and importance of the guideline are explained.
Participants in the guideline development process and
their areas of expertise are specified.
Targeted health problem or technology is clearly
defined.
Target patient population is specified.
Intended audience or users of the guideline are
specified.
Principal preventive, diagnostic and therapeutic options
available to clinicians and patients are specified.
Health outcomes are specified.
The method by which the guideline underwent external
review is specified.
An expiration date or date of scheduled review is
specified.
Methodological Standards on the Formulation of
Recommendations
The role of value judgment used by the guideline
developers in making recommendations is discussed.
The role of patient preferences is discussed.
Recommendations are specific and apply to the stated
goals of the guideline.
Recommendations are graded according to the strength
of the evidence.
Flexibility in the recommendations is specified.
(Shaneyfelt TM, Mayo-Smith MF, Rothwangl J 1999).
BENCHBOOK
136
Choose a guideline topic
Frame specific condition and

patient type to be addressed by
the guideline.
Identify type of experts needed
in guideline development.
Review scientific literature
Build consensus among

stake holders
Write the guideline
Disseminate the guideline
Guideline review to
assess effectiveness
Pilot test the guideline
Institutionalize the guideline
Figure 30.
Flowchart for the development, dissemination and

implementation phases in the creation of a clinical
practice guideline.
Performance
Improvement
137
Clinical Pathways
To Interdisciplinary Plan of Care
A clinical pathway is an interdisciplinary plan of care that outlines

the optimal sequencing and timing of interventions and expected
outcomes for patients with a particular diagnosis, procedure or
symptom.
Major Features of a Clinical Pathway:

1.
Patient outcomes.
Expected patient outcomes at specific time points are listed.
2.
Timeline.
Timelines for sequencing interventions are specified.
3.
Collaboration.
All members of the health care team develop the pathway.
4.
Comprehensive aspects of care.

Nutrition, tests, treatments, drugs, activity, patient teaching
and discharge planning are specified and sequenced.
Clinical pathways are effective educational and communication

tools that benefit both patient and care provider. Routine use of
clinical pathways is expected to result in more satisfied patients
because they will know what care to expect and what the goals
of treatment are. Pathways will also benefit health professionals
by facilitating coordinated care plans. is way, physicians can
visualize current care, and anticipate future care and outcomes.
BENCHBOOK
138
Drawbacks:
Developing Clinical
Pathways
1.
Doctors who view pathways as cookbook medicine may not

use them.
2.
Filling up pathways add paperwork.
3.
Evidence that pathways are worth the extra effort is

insufficient.
4.
Pathways may be used by a plaintiff s attorneys if they are

mistaken for rules and not tools.
1. A multidisciplinary pathway team is organized.

2. A disease, procedure or symptom is selected as pathway
target.
3. Clinical practice guidelines that cover the disease are
searched and critically appraised.
4. e scientific literature is also searched for high-quality
evidence on the effectiveness of procedures.
4.1 e search includes systematic reviews, meta-analyses
and technology assessments to supplement the
information obtained from clinical practice guidelines.
5. Sample pathways are reviewed.
5.1 In the absence of high-quality studies, existing
pathways may be reviewed and appraised for validity
and feasibility.
6. Evidence obtained from steps 3, 4 and 5 are used to
determine the choice, combination and order of tests and
treatments in the pathway.
7. Team members select which aspects of care are to be
included in the pathway.
8. Evidence-based tests and treatments are plugged into
appropriate places in the pathway.
8.1 Interventions with strong supporting evidence are
included in the pathway; interventions with weak
supporting evidence or with strong non-supporting
evidence are deleted.
Performance
Improvement
139
9. Team members review the pathway to assess agreement

with their respective routine activities.
10. e pathway undergoes revision and modification until
team members agree on the best compromise between
what is evidence-based and what is feasible, given local
resources.
10.1. Other sources of information that may modify the
pathway are routine hospital data, hospital resources,
professional judgment, patient values and other
professional standards of care.
10.2. Patient outcomes that directly result from following the
pathway are specified.
11. e pathway is reviewed and tested to determine its
efficiency, feasibility and consistency with legal and
regulatory requirements.
12. e pathway is placed in the patients medical record, the
nursing Kardex or in a separate folder.
13. A non-technical version may be shared with the patient.
13.1. All caregivers review the pathway at the start of each
shift and throughout the patients stay to evaluate
patients progress toward the days expected outcomes.
13.2. All caregivers document that the planned care activities
are accomplished and that the expected outcomes are
achieved. e if-it-is-not-written-down-it-was-notdone-rule applies here.
14. Deviation or variance from the days care or outcomes is
also documented.
15. e health care team develops an action plan to solve
problems and improve care.
16. e pathway may be reviewed for modification after 3 to 6
months of use.
It should be possible to develop four to six pathways at the same
time, and have them ready for pilot testing within 3 or 4 months.
BENCHBOOK
140
Clinical Pathway Samples
1st 30 min
Assessment
Ascertained dyspnea,
at least 1 of 3: cough,
wheeze,prior attacks
AND
No history suggestive of
other diseases
Age<50
Smoking <10 packs / yr
Assessed severity
Diagnostics
PEFR taken
Treatments
Oxygen
Asthmatics in imminent
failure intubated and
ventilated
Medications
Teaching
Clinical Pathway for Bronchial Asthma in Acute Exacerbation

De La Salle University Medical Center (Provider Version)
2nd 30 min
Risk factors assessed
3rd 30 min
4th 30 min
Response to treatment
assessed
ABG, CXR for all patients

with poor response or with
risk factors
Imminent asthmatics
admitted to ICU
Mild asthmatic with good

response discharged
All patients with

incomplete or poor
response admitted
Oxygenation continued
Nebulization with beta2

agonist Systemic steroids
AND / OR
ipatropium bromide for
moderate asthmatics or
worse
Parenteral beta2 agonists
and aminophylline for
imminent asthmatics
Mild asthmatic sent

home with inhaled beta2
agonists
Oral or inhaled steroids
Antibiotics
Antihistamines
Nebulization with beta2

agonist Systemic
steroids
AND / OR
ipatropium bromide for
moderate asthmatics or
worse continued
Patients on proper
nebulization technique
Mild asthmatic instructed

on proper administration
of beta 2 agonists, steroids
and their side effects
Mild asthmatic instructed
on avoidance / reduction of
risk factors
is clinical pathway was developed following release of the

Philippine Consensus Report on Bronchial Asthma by the Philippine
College of Chest Physicians. PhilHealth has incorporated the report
in an in-house document, Clinical Practice Guidelines Adopted by
Philhealth (c2000).
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e following recommendations were excerpted from that report:

e cardinal symptoms of asthma, either alone or in combination,
are cough, dyspnea or breathlessness, wheezing, chest discomfort or
chest pain/tightness.
Functional assessments like PEFR should be determined
Oxygen should be administered by nasal cannula or mask in
adults
For mild to moderate exacerbations, inhaled short acting beta 2
agonist is administered. Either an oral short acting beta 2 agonist
or short acting theophylline may be considered as an alternative.
During more severe exacerbations, higher than usual does of short
acting beta 2 agonist are often needed If there is incomplete
response within 4 hours, the patient may be having a moderate
to severe episode. Treatment is immediately started, consisting of
nebulized or inhaled beta 2 agonist, ipatropium bromide, high
dose systemic corticosteroids, oral or IV, aminophylline IV bolus plus
continuous infusion
Criteria for admission: inadequate response to therapy within 1 to
2 hours, persistent PEF<50% 1 hour after treatment, presence of
risk factors as previously defined
Criteria for ICU admission: lack of response to initial therapy,
confusion, drowsiness and other signs of impending respiratory
arrest.
Patients with a good response to emergency treatment require
at least 60-minute period of observation after the last dose of
bronchodilator to ensure stability of response.
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PhilHealths Draft of Clinical Pathway for Outpatient Cataract Surgery
Case Type: OPD Cataract Surgery
Name of hospital:
Name of Doctor:
Accreditation No.
Name of Member:
PhilHealth No:
Name of Patient:
Age/Sex:
Home Address:
Date of Operation:
Part I. Consultation prior to Surgery

Activities
Remarks
Clinical History
Patients complaints of visual problems
Patients desire for improved visual function
Patients desire for prevention of progression
Patients preference for surgery
Concomitant ocular problems
Concomitant medical problem
Physical Examination
External Eye exam
Pinhole Test
Sit lamp exam
Tonometry
Dilated Fundoscopy
Contrast Sensitivity (for px w/VA better than 20/40 but
needs further eval.)
Medical evaluation/Pre-anesthetic CP evaluation
Procedures
Keratometry
Biometry
LAI (Lacrimal Irrigation Test)
Patient Education and Orientation
Availment of Cataract package
Documentary requirements
Explanation of procedure
Clarify pre-admission issues
Post-op expectations reinforced
Advise NPO >= 6 hrs prior to surgery
Part II. 1 Hour prior to Surgery
Activities
Nursing Care
Check for documentary requirements
Prepare patient for surgery
Remarks
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Establish baseline vital sign values and continuous
monitoring thereafter
Fasting state confirmed
Allergies recorded
Obtain consent for operation
Obtain consent for anesthesia
Medications
Mydriatics and/or cycolplegics to dilate the pupil
Other medications
Physiologic Outcomes
Changes in vision
Glare
Sedation
Pupils dilated
Vital Signs: Changes
Part III. Hour of Surgery
Activities
Remarks
Pre-Anesthetic: Preparation
Oxygen
IVF
Pulse Oximeter
Cardiac monitor (if indicated)
Preparation of Cataract Set
Administration of anesthesia
Purely local - Topical
Local with sedation (IV)
General (if indicated) with ET tube
Surgical Preparation
Surgical Options
Extracapsular cataract extraction or
Phaco-emulsification
-
with Intraocular Lens implantation (IOL)
Others
Part IV. Post Surgery
Activities
Assess for immediate complication
Continue nursing care
Continuous vital signs monitoring
Post-op (Antibiotics/Steroids)
Miscellaneous
Eye Shield/Goggles/Pad
Remarks
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Part V. Remainder of Outpatient Stay
Activities
Remarks
Anesthetic
Full Diet when fully awake (if under sedation/GA) 8 hrs.
after
Patient Education
Reinforce patient education and ensure thorough
knowledge of continuing eye care and lifestyle
adjustment
Nursing care
Prepare patient for home
Discharge Planning
Documentary requirements for billing, follow-up visits,
home eye care, medications, and activities
Home medications
Follow-up check up
within 24 hrs.
after 1 week
on the 3rd week
6th week w/ refraction
Disallowed activities
avoid lifting heavy > 5 kgs.

avoid bending
avoid chemical eye contact
Discharge if fit
PhilHealths Draft of Clinical Pathway for the Low Risk Maternity Care Package
Name of Provider:
Accreditation No:
Name of Outpatient Clinic:
Accreditation No:
Address of Clinic:
Date:
Name & Signature of Patient:
Address:
Age:
Civil Status:
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Part 1: Initial Prenatal Consultation
Date: ____/____/____
A. Perform Risk Assessment: Clinical History and Physical
Examination
DONE
REMARKS
DONE
REMARKS
DONE
REMARKS
DONE
REMARKS
DONE
REMARKS
1. Ascertain vital signs are normal

2. Obtain menstrual history
LMP :
3. Determine AOG and EDC
AOG:
EDC:
4. Obtain obstetric history
G__ P__ (__, __, __, __)
5. Ascertain present pregnancy is the second low-risk pregnancy
6. Rule out presence of risk factors from past pregnancy
7. Rule out risk factors related to previous infants
8. Rule out medical/surgical risk factors
9. Obtain personal social history
10. Obtain immunization history
11. Perform complete physical examination
12. Determine pertinent abdominal examinations
FHT:
fht:
13. Give complete diagnosis
Dx:
B. Give pregnancy counseling and education on:
1. Maternal nutrition
2. Prevention of infection
3. Preparation for motherhood
4. Family planning
5. Breast feeding
C. Write Delivery Plan indicating:
1. Schedule of prenatal examination
Date: ___/___/___
2. Expected date and venue of delivery
Date: ___/___/___
Place:
3. Orientation for LRMC Package/Availment of Benefits
D. Request routine prenatal laboratory examinations
1. Complete Blood Count
2. Urinalysis
E. Administer Tetanus Toxoid if not yet immunized
Date T1:
___/___/___
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Date T2:
___/___/___
Date T3:
___/___/___
F. Ascertain results are normal
DONE
REMARKS
DONE
REMARKS
DONE
REMARKS
1. Complete Blood Count

Hgb:
Hct:
WBC:
Platelet:
2. Urinalysis
Protein:
Sugar:
Bacteria:
WBC:
RBC:
Part 2: Follow-up Prenatal Consultation
Date: ____/____/____
A. Determine AOG in weeks
B. Obtain vital signs
C. Determine pertinent abdominal examinations
D. Rule out presence of pregnancy danger signs
E. Schedule date of next visit
F. Patient education and counselling
Part 3: Normal Birth
Date: ____/____/____
A. Perform complete History and Physical Examination (VS)
Determine AOG
Obtain vital signs
Determine patient abdominal examination
Perform IE
B. Ascertain that patient is in true active labor
C. Admit and obtain informed consent
D. Monitor course of labor, accomplish partogram
E. Prepare Delivery Room
F. Attend to delivery of baby
G. Get apgar score of newborn
H. Routine newborn care
I. Provide delivery of placenta
J. Check if placenta is complete
K. Ensure good uterine contraction
L. Inspect for perineal and vaginal lacerations
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M. Explain the procedure to the patient
N. Suture perineal laceration under local anesthesia
O. Check repair and ensure hemostasis
P. Transfer patient to recovery area
Q. Monitor during immediate postpartum period
R. Discharge clearance (D/C IE)
Give complete diagnosis
S. Accomplish documents for PHIC reimbursement
T. Schedule postpartum and newborn care follow-up
consult - 1 week after delivery
Part 4. Routine Newborn Care
Date: ____/____/____
DONE
REMARKS
DONE
REMARKS
A. Ensure patent airway

B. Wipe and dry newborn, keep the newborn warm
C. Do cord dressing using sterile cord clamp, Vitamin K
D. Give Vitamin K IM injection
E. Apply eye prophylaxis
F. Perform complete birth history and physical examination
G. Fill out the birth certificate
H. Fill out babys chart
I. Give complete diagnosis
J. Clearance for D/C
Part 5. Post-partum Care
Date: ____/____/____
A. Check for postpartum complication in mother and baby
B. Check perineal wound healing
C. Check for signs of postpartum complications
D. Check for signs of newborn complications
E. Counselling and education
1. Newborn care
2. Breastfeeding and nutrition
3. Newborn immunization
4. Family planning
F. Provide family planning service to patient if requested
G. Schedule postpartum visit 6 weeks postpartum
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Medical Audits
A Medical Audit is used to identify opportunities to improve

procedures used in the diagnosis, treatment and care of specific
patients, and the associated use of resources and resulting
outcomes.
Medical audits provide a comprehensive and step-by-step
analysis of quality of care. It can demonstrate variations in
clinical practice and their possible causes. Because it allows for
investigation, demonstration and correction of clinical error, it
provides a way to manage the moral, legal and financial risks of
clinical errors.
Implementing
a Medical Audit
1. Determine criteria for selecting the subjects for audit.

1.1 Criteria may include high-risk, high-volume, or
problem-prone patients or clinicians who have a high
proportion of these types of patients.
1.2 Examples of auditable cases are all deaths, patients who
extend their usual length of stay (based on their illness),
all nosocomial infections, all-readmissions, all patient
falls, etc.
2. Screen subjects for audit by routinely applying the
selection criteria to all patients or clinicians.
3. Determine criteria for selecting the subjects for audit.
3.1 Criteria may include high-risk, high-volume, or
problem-prone patients or clinicians who have a high
proportion of these types of patients.
3.2 Examples of auditable cases are all deaths, patients who
extend their usual length of stay (based on their illness),
all nosocomial infections, all-readmissions, all patient
falls, etc.
4. Screen subjects for audit by routinely applying the
selection criteria to all patients or clinicians.
5. Develop medical review criteriastatements used to assess
specific health care decisions, services and outcomes (U.S.
Department of Health and Human Services 1995)for
evaluating performance.
5.1 Select a guideline or pathway that covers the disease or
condition being audited.
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5.2 Identify guideline recommendations and draft the

medical review criteria.
5.3 Level of performance is evaluated by measuring the extent
of conformance to guidelines or pathways.
6. Identify standardsstatements of minimum-maximum
range of acceptable resultsagainst which to compare level
of performance.
Standards Development Methods
Benchmarking
process of measuring an organizations performance on
certain processes or procedures by comparing identified
centers or practices of excellence in order to improve
performance.
Comparative method
standards are derived from comparison with rate of
compliance to common performance measures.
Prescriptive method
standards are derived from medical literature and expert
opinions on what should be achieved.
7. Determine what kinds of patient-specific data are to be

collected and how collection is to be done.
7.1 Patient-specific data include the particular diagnostic
and treatment interventions and the resulting health
outcomes.
7.2 Data is collected from the review of medical charts either
retrospectively (after care has been given) or concurrently
(while care is still being given).
8. Identify clinicians and sites of care.
9. Define case sample and case sampling period.
9.1 Identify data source.
9.2 Write medical review criteria, specifying acceptable
alternatives and time window.
9.3 Specify data items and data rules.
9.4 Draft data collection forms and procedures.
9.5 Devise analysis procedures.
9.6 Pilot test and revise criteria, forms and procedures, if
necessary.
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10. Assemble a peer review team.

11. Conduct review on each medical chart and determine
performance level for each review criterion.
12. Compare performance levels with quality standards and
interpret the results.
13. Report review findings.
13.1 Report the entire review process.
13.2 e main findings are structured around an analysis
using the six dimensions of quality.
13.3 Recommendations include actions required to improve
the quality of care.
14. Act on review findings.
15. Conduct review again to re-evaluate performance.
15.1 Analyze the effectiveness of the action recommended to
improve performance.
15.2 Examine the relevance of the audit and the resulting
performance improvement program to other clinical
departments, facilities or clinical groupings.
e Four Kinds
of Medical Audit
1. Nursing Audit. is is a patient-focused audit process

of nursing care as defined according to the following
dimensions (Miller and Knapp 1979):
application and execution of physicians legal orders
observation of symptoms and reactions
supervision of the patient
supervision of other members of the clinical team
other than physicians
reporting and recording of facts, including evaluation
results
application and execution of nursing procedures and
techniques
promotion of physical and emotional health by
direction and teaching
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Types of Medical Audit
Nursing Audit
Clinical Audit
Risk Management
Peer Review
Figure 31. Types of Medical Audit
2. Clinical Audit. is is a patient-focused audit process

involving doctors, nurses and other clinicians who comprise
the clinical care team.
3. Risk Management. is is a process for identifying risks-which may have moral, financial or legal consequences--and
which adversely affect the quality of care and the safety of
patients, staff and visitors. Risk management evaluates those
risks and takes positive action to eliminate or reduce them
(Miles and Lugon 1996).
4. Peer Review. Evaluation or review of a health professionals
clinical management by ones equals according to some explicit
or implicit criteria thought to represent desirable practice is
called peer review (Kelada 1996). e practice of peer review
reflects the variety of clinical and non-clinical staff members
who use it as a tool for quality improvement.
Essential Components of Peer Review
discussion of adverse events
quantitative indices of the clinical units performance
identification of systematic deficiencies
follow-up of previously identified matters
consensus on interpretation of findings and recommended
action
recognition of serious concern about an individuals
performance (rarely done)
Typically, three or more clinicians (e.g., doctors, nurses and

allied health professionals) agree to meet regularly to discuss
recent events and outcomes (individual or collective) of
patients under their groups care.
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Peer review meetings may be prompted by the identification

of medical cases that satisfy a set of screening criteria. ese
criteria are indicators of possible adverse patient events
during hospitalization. If an adverse event is noted in the
medical records, events that are regarded as serious breaches
in the standard of a care or could reasonably be regarded as
preventable, are forwarded to the appropriate peer group. e
group then deliberates on whether or not a standard of care
has been achieved or if the adverse event could be regarded
as reasonably preventable. Actions to prevent a recurrence are
then proposed.
A peer review report is generated and forwarded to an
appropriate authority within the organization for collating
over time. is authority then acts upon the recommendations
that require system-wide involvement, follow-up of unresolved
issues and oversight. Confidentiality is strictly upheld and no
patient or clinician is identified in any part of the report.
Identification of medical case

with possible adverse event
Subject to screening
Nature of Error
Serious breach in
standard of care
Preventable adverse
Prevent
Generate Report
Figure 32.
Flowchart for Peer Review Processes.
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Utilization Review
Utilization review assesses the appropriateness and efficiency

of the use of resources. It focuses on the cost-effectiveness of
interventions used; identifies providers who need to attain a more
efficient resource use; improves overall quality of care through
cost-efficient use of resources; and explicitly shows the necessary
trade-offs between health care outcomes and its costs.
Utilization review of cases may be done:
Retrospectively cases are accumulated over time before they
are screened and audited for appropriateness and efficiency of
care.
Concurrently cases are accumulated over time while
ongoing screening and audit are performed.
Audit of pathways and guideline use quality of care is
audited against practice standards defined by pathways and
guidelines.
Criteria used for reviewing cases may be:
Implicit A clinician reviewer applies his/her own judgment
to quality and/or appropriateness of the care provided.
Validity depends entirely on knowledge, skills and judgment
of the reviewer.
Explicit and independent of diagnosis is is a level-ofcare audit. Using criteria that reflect severity of illness and
intensity of service needed, medical charts are screened to
determine if each hospital admission was justified. ese
criteria define levels of medical and nursing services and nondisease specific patient conditions that require continuing
acute hospital inpatient stay. Cases identified by the screening
criteria are then reviewed in detail by clinicians.
Explicit and specific to diagnosis is is a diagnostic
criteria audit. Clinical practice guidelines that are specific to
patient types and diseases are developed. Review criteria are
then derived from the guidelines and are used to evaluate the
appropriateness of care for each individual patient.
Length of stay (LOS) profiles Region-, hospital- or
department- specific average LOS are calculated and used
as a standard against which average LOS of different
regions, hospitals or departments are compared. Outliers
(i.e., those with average LOS that fall beyond two standard
deviations from the mean) are identified for detailed review of
appropriateness and efficiency of care.
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Complaints Analysis
While a complaint is defined as any expression of dissatisfaction by

a customer, complaints data are considered welcome opportunities
to learn from dissatisfied patients, and identify areas for
improvement.
Table 5. Matrix of Aspects Useful for Complaints Analysis
Complaints
Category
Complainant
Complaint form
Complaint period
Quality care
provided
Person affected
Written
Prior to an
episode of care
Health care
provided to an
individual
Third party on
behalf of the
person affected
Verbal, over the

phone
During an
episode of care
General health
care issues
Staff
Verbal, face-toface
Following an
episode of care
Non-health
care services
Any person
concerned
about health
care
Anonymous
complainant
Concerned
agency
An effective complaint handling process results in the

identification of key areas for improvement by:
1. Addressing varying patterns of practice;
2. Highlighting deficiencies in protocols, guidelines and
procedure;
3. Highlighting areas requiring further training and
development;
4. Providing critical clinical information to concerned
individuals and units;
5. Providing an objective mechanism for monitoring clinical
outcomes as an alternative to reliance on peer review and
self-regulation; and
6. Providing the opportunity for complainants to achieve
satisfaction by:
Demonstrating commitment to providing quality
service;
Recognizing and acknowledging the consumers
right to complain;
Restoring trust and support for the service
provider;
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155
Legitimizing the value of consumer input into

quality improvement; and
Improving communication in patient care.
Handling Complaints
and Conducting Complaints
Analysis
Often, the service or clinician subject of a complaint may

disagree with the complainant about the circumstance that
led to the complaint, or may not feel that the complaint is
justified. is is only secondarily significant. What is principally
important is that there is a perception of problematic or
substandard quality of care or service e incident should be
investigated and considered for its value in improving the quality
of the care or service provided.
Due process must be observed and the following principles taken
into account:
Both the complainant and the person against whom the
complaint is lodged must be allowed to freely and openly
express their versions of the event which is the subject of
the complaint.
Assignment of blame to either party should be avoided
except in very serious complaints.
Mediation should be done between the parties in conflict.
Actions should focus on implementing corrective
measures in the system to avoid the recurrence of the
adverse event.
Expanded Incident
Monitoring
An incident monitoring system is used to routinely identify,

process, analyze and report incidents to prevent their recurrence.
An incident is an event that occurs in connection with patient
care that merits reporting, or is reported because of a deviation
from expected or standard practice. is deviation could have or
actually have adversely affected a patients health status.
Expanded incident monitoring follows conventional incident
reporting mechanisms, but it is enhanced by greater opportunity
to identify a bigger range of incidents than can be expected from
current voluntary reporting methodology. It is limited only by
the staffs capacity to conduct routine monitoring. It may
uncover deeper and more systemic problems with the use of
problem-solving tools. Incidents covered include clinical and
non-clinical events.
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It facilitates performance improvement by providing information

derived from reports. It clearly delineates events as starting points
for quality improvement. It enables a team-based, multidisciplinary
approach that involves both senior and junior staff in detecting
and preventing incidents.
Effective incident monitoring is dependent on a commitment to
act upon information that arises from improvement activities. is
also involves the reporting of incidents or processes that require
action at the facility level.
Implementing Expanded
Incident Monitoring
1. A clinical team or ward-based unit identifies an appropriate

time to discuss incidents that have occurred in the clinical
area for a specific time period.
2. Voluntarily-reported incidents are basic topics for
discussion.
2.1 Other incidents identified based on replies to screening
questions are also included.
3. e set of questions are based on a knowledge of those
incidents which could occur in that clinical setting, and
which reflect on the six dimensions of qualitysafety,
effectiveness, appropriateness, consumer participation,
access and efficiency.
Sample Questions for Expanded Incident Monitoring
In the past week, have there been
any drug errors?
any intravenous line infections?
any unanticipated admissions to ICU?
any falls, any wound infections?
non-compliance with (identified) guidelines?
inappropriate admissions/treatments?
unreported results?
reports not acted upon in timely fashion?
delayed discharges/transfer?
complaints?
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157
3.1 e questions and incidents under study may vary for

each clinical team.
3.2 Such incidents should be identified and an appropriate
person nominated to follow up on relevant details of the
incident prior to discussion at the ward/team meeting.
4. A team member should present and discuss the facts about
the incident:
4.1 Patient and provider information should, when possible,
be de-identified;
4.2 Discussion should be robust, but the approach should
always be educational rather than fault-finding;
4.3 Discussion should be focused around identifying the
system issues of the care delivered.
Suggested issues for discussions:
What did we do or what did we forget to do that

contributed to these incidents? (Errors of omission are far
more common that errors of commission).
What needs to be done at this level to prevent this incident

from occurring again?
Who is responsible for follow-up action?

Who else needs to know about this? Does this have to
be reported to the TQM committee, either for action or
information?
5. If there is no sufficient information available regarding an

incident, a person should be assigned to conduct a followup and re-present the issue in the following meeting.
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Morbidity and
Mortality Meetings
(M&Ms)
Morbidity and mortality meetings review deaths and adverse

outcomes among patients of a specified clinical group or
specialty. Recommended as a core activity for all clinicians,
M&Ms provide a venue to critically analyze the circumstances
surrounding the outcomes of care provided by an individual or
a multidisciplinary group of clinicians. ese outcomes include
deaths, adverse outcomes and significant deviations from regular
clinical practice.
M&Ms should not be used only to review the exotic cases that
may be of greater interest to clinicians. M&Ms also provide an
ideal forum for the regular review of the clinical indicators relevant
to a given specialty or field of practice.
Recommendations for improving the processes of care given to a
particular group of patients are made following M&Ms.
Conducting M&M
Meetings
1. All meetings should be multidisciplinary and should

include all clinicians, technicians, and managers involved in
the care of the concerned group of patients.
1.1 All levels of staff involved in the care of these patients
both junior or senior should be involved.
2. Meetings should be held on a regular basis, and at least once a
month.
3. All deaths should be identified and if appropriate (e.g.
among renal patients) should include deaths that occurred
outside of the acute care setting.
3.1 Focus should be placed on identifying the issues related
to the processes or system of care that led to the death or
incident, and not on the individuals who provided the
care.
4. Discussion should be used for instructional purposes, and
not for putting blame to individuals.
4.1 Discussions should focus on measures that can be
recommended or implemented to prevent a similar
incident or adverse outcome.
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159
5. A brief report should be compiled after each meeting,

which identifies the actions that must be taken following
the discussions and review.
5.1 If there are no recommendations for action, that should
be so recorded.
5.2 If action cannot be taken at the clinical level, a
report should be sent to the senior managers of the
organization identifying the issues that should be
addressed at that level.
6. All action items should be placed on the agenda for the
next meeting.
7. Feedback must always be present.
8. Everyone who is associated with the care being reviewed
should have the opportunity to report.
9. Case reviews should be conducted in a timely manner,
within recent memory of the people involved in the case.
Sentinel Event
Monitoring
Sentinel event monitoring identifies potentially serious breaches

in practice standards. ese breaches are unexpected variations
which may have resulted in either death or serious physical or
psychological injury. Serious injury, specifically loss of limb or
function, represents a significant adverse event that warrants
immediate investigation.
Sentinel events also include any process variation for which
recurrence would carry a significant chance of a serious adverse
outcome (JCAHO 1998).
But sentinel events are not always adverse events. Unexpected
successful outcomes in health care, which are also considered
variations in a process, are also considered sentinel events.
Renewed interest on preventable adverse events have come with
the attention on errors. However, this may be misleading as it
suggests the fault of individual health care practitioners, when
a problem area in the system of care may be the main culprit
(Donabedian 2003).
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Implementing Sentinel
Event Monitoring
Adverse events: United States

In the late 1980s, the Harvard
Medical Practice Study
highlighted the unrecognized
incidence of adverse events in
selected hospitals in the United
States. Deaths, disabilities
and prolonged lengths of stay
resulted from errors in care
provision, yet little was done
to systematically and routinely
identify and correct the sources
of error.
The first sentinel event was
identified in 1995 involving
the death of a woman from
an overdose of chemotherapy
in a famous hospital in
Boston (JCAHO 1998). The
health care industry has since
institutionalized sentinel event
reporting throughout the United
States in order to detect and
reduce serious errors.
1. In monitoring sentinel events, initial strategies should

already be in place for quick response in the event of an
occurrence.
1.1 Appropriate personnel should be available to stabilize the
patient, perform necessary surgery or tests, administer
medications, and take actions to prevent further harm.
1.2 e organization should be ready to contain the risk of
an immediate recurrence of the adverse event.
1.3 Evidence of the events that led to the adverse outcome
should be preserved for critical assessment of what
happened.
1.4 Appropriate parties should be notified.
1.5 Patients and their families should be notified and told
about the adverse event.
2. Reporting of sentinel events and their investigation should
be a routine organization-wide activity involving clinical
and non-clinical staff.
3. Swift investigation of the event and corrective action should
be done.
4. Management should recognize that it is ultimately
responsible for a system that allows such sentinel events to
occur.
4.1 Avoid knee-jerk reactions such as witch hunting and
finger pointing.
5. Focus should be on identifying root causes and developing
real solutions that improve the system.
Sentinel event
Prevent recurrence
Appropriate
patient care
Risk
containment
Preservation of
evidence
Disclosure
Figure 33.
Determine
apparent cause
Core system faults
Determine
root cause
Flowchart of activities in case of a sentinel event
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Credentialing and
Clinical Privileging
Credentialing and clinical privileging match the work

that practitioners wish to perform in a hospital with their
demonstrated competence and professional skill. ese two
processes specify the conditions individual practitioners should
meet before being granted clinical privileges. ey also define the
processes for the review, modification and revocation of clinical
privileges.
e granting of privileges takes into consideration the hospitals
delineated role within the community, its designated service, and
its support capabilities.
Credentialing and clinical privileging facilitate effective risk
management for medico-legal purposes and ensure maintenance
of appropriate high-quality services to guarantee patient safety.
Implementing Credentialing
and Clinical Privileging
1. Assemble a multidisciplinary committee for credentialing

and clinical privileging
2. Ensure that the credentialing process clearly delineates the
range of clinical privileges granted to each individual.
3. Establish a mechanism for individualized and supervised
continuing education.
4. In formulating advice and recommendations, the
following should be considered:
Irregularly undertaken procedures/treatments, even
if these treatments are generally performed by the
clinical group to which the practitioner belongs;
New technology;
Small departments or services;
Maintenance of skills, sufficient caseload and
continuing medical education;
Assessment of the infrastructure supporting the
privileges to be delineated e.g. availability of
nursing staff for certain specialized procedures, or of
equipment for specific pathology service; and
Practice outside of the normal privileges for a
particular discipline.
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Variance Reporting
and Analysis
A variance is a deviation from what has been specified in the

clinical pathway. Variance reporting and analysis is used to
routinely document and identify the most common causes of
deviation from routine care for prioritized problem-solving. is
activity is important because it provides a basis for analysis and
consequent adjustments. Analysis might lead to revision of the
clinical pathway. It might also lead to attempts to revise clinician
behavior or to resolve system weaknesses.
Many quality of care problems are identified by analysis of variance
reports. For example, if there was a missed or delayed diagnostic
test, there should be a record of this variance and its causes.
Implementing Variance
Reporting and Analysis
1. Record the reason for variance, according to a standard

classification.
1.1 is will facilitate the periodic evaluation process, and
comparison of results with those from other provider
organizations.
1.2 Both positive (deviation produced positive results)
and negative (deviation was detrimental in some way)
variances should be recorded.
2. Tabulate the results according to elements of care and cause
or tabulate variances against outcome data.
Table 6. Sample Output Form for Variance Analysis

Element
of care
Cause of variance
Patient
preference
Family or
friends
Patient
condition
Clinician
preference
Admission
Assessment
Discharge plan
Pathology
11
Imaging
Specimens
Observations
Performance
Improvement
163
Table 7. Matrix of Quality Improvement Activities
QI Activity
Assessment Focus
Assessment Procedure
Audit
Process and outcome of

administrative or clinical
care service
Screening
Provideror service
aspectspecific
document review
Utilization review
Process
Routine indicator
monitoring or
screening
Providerspecific audit
Complaints analysis
Input, Process and

Outcome
Document review
Primary data collection
Expanded incident
monitoring
Process and Outcome
Routine event
monitoring
Document review
Mortality and morbility

audit
Process and Outcome
Screening
Conference discussion
Sentinel event monitoring Input, Process and

Outcome
Routine event
monitoring
Document review
Credentialing and
clinical privileging
Input
Document review
Clinical pathway
Causes of variance
Pathway review
BENCHBOOK
164
Part IV
165
Part IV
References
Glossary

List of Works Cited

Appendix
BENCHBOOK
166
Glossary
167
Glossary
Accreditation
verification process of the qualification and capabilities of

health care providers prior to granting of privilege of
participation in the National Health Insurance Program (NHIP),
to ensure that health care services they are to render have the
desired and expected quality.
Accreditation, initial
accreditation given to a health care provider applying for
the first time.
Accreditation, renewal
accreditation given to a health care provider after the
expiration of a previous accreditation.
Accreditation, provisional
accreditation granted to a health care provider applying
for renewal while compliance to standards/ requirements
set by the Corporation are being completed for a period
determined by the same.
Accreditation, reinstatement
restoration of accreditation following a suspension of an
accreditation after compliance with the requirements,
conditions and corrections imposed by the Corporation.
Re-accreditation
accreditation given to a health care provider following the
expiration or denial of a previous accreditation or
following a change of ownership or upgrading of
capability of institutional health care providers or
acquisition of specialty capabilities and skills by
professional health care providers.
Adverse events
injury caused by medical management (and not necessarily the

disease process) that either caused death, prolonged
hospitalization or produced a disability at the time of discharge.
BENCHBOOK
168
Affinity diagram
used to creatively generate a large number of ideas/issues and then

organize and summarize natural groupings among them to
understand the essence of a problem and its breakthrough solutions.
Ambulatory surgical clinic
an institution or entity accredited by the Department of Health to

provide out-patient surgical services.
Audit
a process used to identify opportunities for improvement by

reviewing the procedures used in the diagnosis, treatment and care
of specific patients, as well as the associated use of resources and
the resulting outcomes.
Bar graph
summarizes continuous data by showing the frequency of

occurrence of different kinds of events.
Benchmarking
process of measuring an organizations performance on certain

processes or procedures in comparison with identified centers or
practices of excellence in order to improve performance.
Comparative method
standards are derived from comparison with other
performance rates of compliance to common performance
measures.
Prescriptive method
standards are derived from medical literature and expert
opinions on what should be achieved.
Brainstorming
an activity used to creatively and efficiently generate a high volume

of ideas on any topic by a process.
Case mix
the type and number of patient groups an organization serves.
Case payment
payment based on the condition itself, and not on the specific

medical or surgical intervention used.
Cause-effect analysis
used to identify, explore and graphically display, in increasing

detail, all possible causes related to a problem or condition to
discover its root cause(s).
Glossary
169
Check sheet
used to systematically record and compile data from historical

sources, or observations as they happen, so that patterns and
trends can be clearly detected and shown.
Clinical audit
see Medical audit.
Clinical pathway
an interdisciplinary plan of care that outlines the optimal

sequencing and timing of interventions and expected outcomes
for patients with a particular diagnosis, procedure or symptom.
Clinical practice guidelines
systematically developed statements, built on synthesis of

evidence, which provide formal recommendations about
appropriate and necessary care, intended to assist practitioner
and patient to make decisions about appropriate health care for
specific clinical circumstances.
Competence
required expertise necessary for the performance of a medical

intervention or the delivery of health services.
Complaints analysis
process wherein expressions of dissatisfaction of patients and staff

are analyzed to identify areas for improvement.
Compliance
utilization of performance data to identify problems and

opportunities for improvement, and pave the way for concrete
action to improve performance.
Complications
circumstances that make an event difficult to manage.
Control chart
line graph used to monitor, control and improve performance

over time by studying process variations and their causes.
Credentialing and privileging
a process that matches the work that a practitioner wishes to

perform in a hospital with his or her demonstrated competence
and professional skill.
Criteria
statements that lay down specific actions that need to be done to

meet a standard.
Deming cycle
see Plan-Do-Check-Act cycle.
BENCHBOOK
170
Diagnostic procedure
any procedure employing analysis and examination to identify a

disease or condition.
Document review
inspection or assessment of a document intended to identify

opportunities for improvement.
Emergency
unforeseen combination of circumstances which calls for immediate

life-preserving or quality-of-life preserving actions (to preserve sight
in one or both eyes, hearing in one or both ears, extremities at or
above the ankle or wrist).
Environment of care
surroundings or conditions under which the process of health care

provision occurs.
Equitable access
fair and impartial opportunity to enter a place or to obtain a

particular service.
Evaluation of care
assessment of the process of care provision.
Evidence-based medicine
the use of current best evidence in making medical decisions.
Expanded incident monitoring
routine process of identification, processing, analysis and reporting of

deviations from expected or standard practice to prevent recurrence.
Fee-for-service
reasonable and equitable health care payment system in which

physicians and other health care providers receive payment not
exceeding their billed charge for each unit of service provided.
Fishbone diagram
see Cause-effect analysis.
Flowchart
diagram used to show the actual flow or sequence of events in a

process.
Force field analysis
analysis tool used to identify the forces and factors in place that
support or work against the solution of an issue or problem so that
the positives can be reinforced and/or the negatives eliminated.
Goal
statement describing the desired-for situation targeted by a

performance improvement program.
Glossary
171
Gross negligence
the want of care and diligence expected of a reasonable

individual, which may point to a presumption of indifference to
potential or actual danger of injury to another person or of
damage to property of others.
Guideline
flexible technical references describing what health care providers

should or should not do for a given clinical condition.
Health care provider
any of the following:

Health care institution
duly licensed and/or accredited, devoted primarily to the
maintenance and operation of facilities for health
promotion, prevention, diagnosis, treatment and care of
individuals suffering from illness, disease, injury,
disability or deformity, or in need of obstetrical or other
medical and nursing care. It shall also be construed as
any institution, building, or place where there are
installed beds, cribs, or bassinets for twenty-four hour use
or longer by patients in the treatment of disease, injuries,
deformities, or abnormal physical and mental states,
maternity cases; or infirmaries, nurseries, dispensaries,
and such other similar names by which they may be
designated.
Health care professional
any doctor of medicine, nurse, midwife, dentist or other
health care professional or practitioner duly licensed to
practice in the Philippines and accredited by PhilHealth.
Health maintenance organization
an entity that provides, offers or arranges for coverage of
designated health services needed by plan members for a
fixed pre-paid premium.
Preferred provider organization
a network of providers whose services are available to
enrollees at lower cost than the services of non-network
providers.
BENCHBOOK
172
Community-based health care organization

an association of residents in a community organized for the
improvement of the health status of that community through
preventive, promotive and curative health services.
Health education
any and all information that help patients make informed choices
about personal health, available health services, healthy lifestyles,
disease prevention and early detection of illness.
Health provider organizations
see Health care provider.
High-volume services
frequently-performed services or those which affect a large number

of people.
Histogram
see Bar graph.
Hospital
an institution, building or place, government or private, duly

licensed by the Department of Health and accredited by PhilHealth,
where there are installed beds, cribs or bassinets for 24-hour use or
longer by patients in the treatment of diseases, injuries, deformities,
abnormal physical and mental states, and/or maternity cases.
Indicator
a measurable variable or characteristic that can be used to determine

the degree of adherence to a standard or achievement of quality
goals.
Information
meaningful, interpreted and processed data used to make judgment

on a hypothesis or answer a research question.
Informed consent
Generally understood as the implied or explicit (read: written

permission) given by the patient prior to initiation of care following
provision of sufficient information to make an informed judgement
on medical treatment choices. It, however, refers more to the process
by which patients are made to participate in the decisions involved in
their health care. Informed consent is founded on patients legal and
ethical right to direct what happens to their bodies and from the
doctors ethical duty to involve patients in the treatment process. It
includes a patient-doctor discussion of the following issues: the
nature of the decision or procedure; reasonable alternatives to the
proposed intervention; the relevant risks, benefits, and uncertainties
Glossary
173
related to each alternative; assessment of patient understanding;

and patients acceptance or refusal of the intervention.
Initial accreditation
see Accreditation.
Length of stay
the number of days a patient remains in the hospital.
Line graph
graph showing the number of events through time.
LOS
see Length of stay.
Matrix diagram
diagram used to systematically identify, analyze and rate the

presence and strength of relationships between two sets of
information.
Medical audit
process of identifying opportunities to improve diagnosis

treatment and care of specific patients.
Clinical audit
patient-focused audit process involving doctors, nurses and
other clinicians who comprise the clinical care team.
Nursing audit
patient-focused audit process of nursing care.
Medical intervention
any action of a health care professional aimed at providing life

saving action, relief of pain, prevention or mitigation of disability
using pharmacological, surgical or diagnostic modalities.
Medical review criteria
Medical review criteria are statements used to assess specific

health care decisions, services and outcomes.
Meta-analysis
the statistical synthesis of the results of several studies testing the

same relationship into a single outcome measure, thus increasing
the strength of the conclusion.
National Health Insurance

Program (NHIP)
the compulsory health insurance program of the government as

established in the National Health Insurance Act of 1995 (RA
7875) which shall provide universal health insurance coverage
and ensure affordable, acceptable, available and accessible health
care services for all citizens of the Philippines.
BENCHBOOK
174
Nominal group technique
team brainstorming method used to quickly come to a consensus

on the relative importance of issues, problems or solutions by
combining individual rankings.
Nosocomial infection
infection acquired from the hospital
Nursing audit
see Medical audit.
Organizational ethics
code of moral values that should be present in an organization
Outcome
the effect of care on the health status of patients and populations

seen in less impairment of functions, less pain and suffering,
and/or less illness.
Outcomes assessment
process of monitoring and review of end results of the health

service rendered by providers both from the standpoint of effects
on health and/or member satisfaction.
Outcome-based standard
measure of the quality of care rendered based on the end-result of

health care provision, including the presence or absence of death,
disability, pain, dissatisfaction, or cure.
Pareto chart
data analysis tool which combines analysis of the frequency of a

problem and analysis of its causes by identifying the most
influential cause or causes, also called the vital few, thereby
separating them from the trivial many.
Pathway review
assessment or evaluation of the flow of care provision for a specific

condition.
Patient pathways
see Clinical Pathway.
Patient rights
the moral and legal entitlement of a patient to care.
PDCA
see Plan-Do-Check-Act cycle.
PDPC
see Process Decision Program Chart.
Peer review
process by which the treatment of a patient or the performance of a

health care professional is reviewed by his/her professional
colleagues either within his/her professional organization or
Glossary
175
hospital, when commissioned by the Corporation to undertake

the same, or within the Corporation itself. e result of said
review can be utilized as basis for payment or non-payment of
claims.
Performance measure
a standard used to assess the level of function of a task, activity or

program.
Performance monitoring
ongoing measurement of a variety of indicators of health care

quality to identify opportunities for improvement in health care
delivery.
Philippine Health Insurance

Corporation (PHIC)
the corporation mandated by law to administer the National

Health Insurance Program
Philippine National Drug Formulary
the essential drugs list for the Philippines prepared by the

National Drug Committee of the Department of Health in
consultation with experts and specialists from organized
professional medical societies, academe and the pharmaceutical
industry and which is updated every year.
Pie chart
pictorial diagram which illustrates proportion of specific items to

the entire unit.
Plan-Do-Check-Act cycle
a systematic method for identifying areas for improvement, pilot

testing solutions, evaluating results, and institutionalizing longterm solutions
Practice guidelines
the usual standard operating procedure followed by a certain

group.
Prescription drug
a drug approved by the Bureau of Food and Drug and which can
only be dispensed through a prescription order from a duly
licensed physician.
Primary care
the basic or general medical care sought by the patient for

treatment of the simpler and more common illnesses.
Problem-oriented progress notes
records regarding the developments in a patients condition based

on the most recent assessment of difficulties encountered.
BENCHBOOK
176
Process
denotes what is actually done to and for the patient in giving and
receiving care. It includes the patients activities in seeking care and
carrying it out, as well as the physicians activities in making a
diagnosis and recommending or implementing treatment.
Process Decision Program Chart
used for contingency planning after the identification of a possible

solution to a certain problem, wherein possible problems are
identified for each step of the proposed solution and reasonable
steps are listed as countermeasures.
Provider organization
see Health care provider
Quality assurance
a formal set of activities to review and ensure the quality of services

provided. It includes quality assessment and corrective actions to
remedy any deficiency identified in the quality of direct patient,
administrative and support services.
Quality circle
a group of 5 to 10 workers from one work area of an organization

who meet regularly to identify and solve problems in their work
area using their own resources.
Quality control
inspection of finished products to detect deviations from

predetermined design.
Quality health care
optimum attainable outcome as a result of health care provision.
Quality improvement
upgrading from previously accepted minimal performance

standards.
Quality management
the organization-wide pursuit of quality.
Quality team
see Quality circle.
Radar chart
data analysis tool which illustrates in one graph the size of the gaps
between a number of current organizational performance levels and
ideal performance levels.
Randomized control trial (RCT)
an experimental study in which participants have equal

opportunity to be assigned to a treatment or control group.
Reinstatement
see Accreditation.
Glossary
177
Renewal accreditation
see Accreditation.
Risk management
an organized effort to identify, assess, and reduce, where

appropriate, risks to patients, visitors, staff and organizational
assets.
Scatterplot diagram
data analysis tool which shows whether or not two sets of

observations or data are related in a linear fashion.
Sentinel event
an unexpected occurrence involving death or serious physical or

psychological injury, and includes any process variation for which
recurrence would carry a significant chance of a serious adverse
outcome.
Skill mix
the type and number of skills/expertise available in the

organization.
SOAP
subjective-objective-assessment-plan sequence of evaluating the

care needed for any particular patient.
Stakeholder
person or group of persons with an interest in or concern with

something.
Standards
statements of expectations for the inputs, processes, behaviors

and outcomes of health systems.
Structure
concrete, countable, measurable and often visible attributes of

the setting in which the provision of health care occurs. Major
categories include: physical inputs, staffing, money and
organizational management.
Swiss cheese model
a theory proposed by human factors engineering pioneer James

Reason, which states that errors happen in any organization
because there are holes in the system and when they align
happening at a certain sequence or combinationthey form a
trajectory which opens up opportunities for errors to happen.
System problem
a difficulty attributed to the organization or its processes, in

contrast to individual attribution of cause.
BENCHBOOK
178
Terms of reference
an enumeration of expected input and output, methodology and

whatever limitations that would bind involved parties.
Timeline
timeframe showing chronological sequence
Triage
the act of assigning degrees of urgency to wounds or illnesses to

decide the order of treatment of a large number of patients.
Total quality management

(TQM)
see Quality Management.
Treatment procedure
any method used to remove the symptoms and cause of a disease.
Tree diagram
graphic tool used to organize tasks into increasing levels of detailed

actions that must or could be done to achieve stated goals.
Utilization review
a formal evaluation of the necessity, appropriateness and efficiency

of the use of medical services, procedures and/or facilities on a
prospective, concurrent or retrospective basis, including but not
limited to examination of the clinical application of medical
knowledge as revealed by medical records.
Variance analysis
data interpretation tool used to document and identify the most

common causes of deviation from routine care.
Warranties
the guarantee that a health care provider applying for accreditation

agrees to abide by the provisions of the National Health Insurance
Law (RA 7875), its Implementing Rules and Regulations and all
PhilHealth Administrative Orders during its participation in the
National Health Insurance Program.
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68. World Medical Association, e. World Medical
Association Declaration on the Rights of the Patient.
In http://www.wma.net/e/policy/14.htm. Accessed 01 April
2004.
BENCHBOOK
186
Appendix
187
Appendix
Participants in the 2001 Workshops to Develop
the PhilHealth Quality Standards for Health Provider Organizations
Participants in the 2004 Focused Group Discussions to Copytest
the PhilHealth Benchbook
World Medical Association Declaration on the Rights of the Patient
BENCHBOOK
188
PARTICIPANTS IN THE 2001 WORKSHOPS

TO DEVELOP THE PHILHEALTH QUALITY STANDARDS
FOR HEALTH PROVIDER ORGANIZATIONS
Ms. Dolores Abadiano ..........................................Philippine Hospital Association
Dr. Santiago Abaricia ............................................PhilHealth Regional Office IV A
Mr. Dennis Adre ..................................................PhilHealth Regional Office XI
Mr. Romeo Alberto ..............................................PhilHealth Regional Office IX
Datu Masiding Alonto, Jr. ....................................PhilHealth Regional Office X
Dr. Diomel Anuta ................................................PhilHealth Regional Office X
Dr. Manuel Angeles ..............................................Philippine Hospital Association
Mr. Ramon Aristoza, Jr. .......................................PhilHealth Regional Office XII
Dr. Noel Arteche ..................................................PhilHealth Regional Office VIII
Dr. Fidencio Aurelio .............................................Philippine Hospital Association
Dr. Charito Awiten ..............................................Department of Health Region XIII
Dr. Milagros Bacus ...............................................Department of Health Region VIII
Dr. Gerardo Bayugo .............................................Department of Health Region V
Mr. Ernesto Beltran ..............................................PhilHealth Regional Office I
Ms. Marieta Bernaje .............................................Department of Health Region VI
Dr. Myrna Cabodue .............................................Department of Health Region CAR
Dr. Rodolfo Cabrera .............................................Philippine Hospital Association
Ms. Melinda Camba ............................................PhilHealth Main Office
Atty. Reynaldo Capangpangan .............................PhilHealth Regional Office VIII
Dr. Dolores Castillo .............................................Department of Health Region XI
Dr. Merceditas Cavaneyro .....................................Department of Health Region II
Ms. Donna Celedonio...........................................PhilHealth Main Office
Mr. William Chavez ..............................................PhilHealth Regional Office VII
Dr. Rogelio Chua ..................................................Department of Health Region XII
Dr. Errol Ciano .....................................................PhilHealth Regional Office CAR
Dr. Dionisio Claridad ...........................................Philippine Hospital Association
Dr. Wilfredo Dacanay ...........................................PhilHealth Regional Office III
Dr. Elvira Dayrit ...................................................Department of Health NCR
Dr. Marietta Fuentes .............................................Department of Health Region X
Dr. Cirilio Galindez ..............................................Philippine Hospital Association
Dr. Conrado Galsim..............................................Department of Health Region IV
Ms. Marlyn Geduspan...........................................PhilHealth Regional Office VI
Dr. Eduardo Jamellarin .........................................Philippine Hospital Association
Dr. Lourdes Labiano .............................................Department of Health Region IX
Dr. Arthur Lanuza.................................................PhilHealth Regional Office IV B
Dr. Carmelita Laureano.........................................PhilHealth Regional Office IV A
Appendix
189
Dr. Evelia Ligan ....................................................Philippine Hospital Association

Ms. Evelyn Logoc..................................................PhilHealth Regional Office V
Dr. David Lozada ..................................................Department of Health Region VII
Dr. Romeo Maao ................................................Philippine Hospital Association
Ms. Eloisa Mangicap .............................................PhilHealth Regional Office III
Dr. Tomas Maramba .............................................Philippine Society for Quality
Ms. Rosanna Martinez ..........................................PhilHealth Main Office
Mr. Tito Mendiola ................................................PhilHealth Regional Office III
Dr. Maricar Millavas .............................................PhilHealth Regional Office I
Ms. Salie Flores Onggada ......................................PhilHealth Regional Office VI
Dr. Juvencio Ordona .............................................Department of Health Region I
Dr. Rose Paraguya .................................................PhilHealth Regional Office IX
Mr. Domingo Pauig ..............................................PhilHealth Regional Office II
Dr. Remedios Paulino ...........................................Department of Health Region III
Dr. Nelda Pe..........................................................PhilHealth Regional Office VII
Ms. Leticia Portugal ..............................................PhilHealth Main Office
Dr. Ruben Rubillo.................................................Philippine Hospital Association
Dr. Ruben Salvador ...............................................Philippine Hospital Association
Dr. Ariadne Silongan.............................................Philippine Hospital Association
Mr. Johnny Sychua................................................PhilHealth Regional Office XIII
Dr. Nelia Divina Tanio..........................................PhilHealth Main Office
Ms. Aster Veloso....................................................PhilHealth Regional Office IV A
Ms. Elvira Ver .......................................................PhilHealth Regional Office CAR
Dr. Emmanuel Vera...............................................Philippine Hospital Association
Mr. Venancio Vinegas............................................PhilHealth Regional Office VIII
Ms. Sheila Ann Palma Zarandin ............................PhilHealth Regional Office VI
Facilitators
Dr. Jose Acuin .......................................................Australian Health Insurance Commission
Dr. Denis Smith ....................................................Australian Health Insurance Commission
Dr. Clementine Almario........................................PhilHealth Main Office
Dr. Ma. eresa Bonoan .......................................PhilHealth Main Office
Dr. Mary Ann Evangelista .....................................PhilHealth Main Office
Dr. Francisco Soria ................................................PhilHealth Main Office
Dr. Madeleine Valera.............................................PhilHealth Main Office
Secretariat
Ms. Mercy Mangaoil .............................................PhilHealth Main Office
BENCHBOOK
190
PARTICIPANTS IN THE 2004 FOCUSED GROUP DISCUSSIONS

TO COPYTEST THE PHILHEALTH BENCHBOOK
Ms. Aileen Acosta .................................................Mary Mediatrix Medical Center

Ms. Elizabeth Anzures ...........................................Davao Doctors Hospital
Alden Bagarra, M..D.............................................Davao Regional Hospital
Mr. Nelson Ballecer...............................................Perpetual Help Medical Center
Jay Baucha, RN.....................................................De la Salle University Medical Center
Linda Buhat, RN ..................................................Philippine Heart Center
Delta Canela, MD.................................................Mt. Carmel Diocesan General Hospital
Errol Ciano, M.D. ................................................PhilHealth-Cordillera Autonomous Region
Ms. Josefina Cordis ...............................................Capitol Medical Center
Marissa Cueto-Velasco, M.D.................................Manila Adventist Medical Center
Prof. Wystan de la Pea .........................................University of the Philippines Diliman
Ms. Liway dela Torre .............................................Chong Hua Hospital
Antonina De Mesa, RN ........................................PhilHealth-Region IVB
Ma. Independencia Flores,M.D.............................PhilHealth-Accreditation
Ms. Sharon Fianza.................................................Pines City Doctors Hospital
Rowena Frogoso, M.D. .........................................PhilHealth-Accreditation
Eduardo Gonzalez, M.D. ......................................PhilHealth-Caraga
Alfredo Igama, M.D..............................................Baguio General Hospital and Medical Center
Elena Judiao-As, RN .............................................Cebu Peuriculture Center and Maternity Hospital
Antoniette M. Ladio, M.D....................................PhilHealth-Region XII
Arthur Lanuza, M.D. ............................................PhilHealth-Region IVB
Engr. Jesusa Llorono..............................................National Kidney and Transplant Institute
Mrs. Evelyn Logoc ................................................PhilHealth-Region V
Salvacion Madarang, M.D.....................................PhilHealth-Region II
Lourdes Maglasang, M.D. .....................................PhilHealth-Region VIII
Ms. Maria Teresa Magno .......................................San Pedro Hospital
Marivic Pula-Malate, M.D. ...................................PhilHealth-Region XI
Rosanna Martinez, RN..........................................PhilHealth-Accreditation
Ms. Ana Joy Mendez .............................................Davao Medical Center
Maricar Millavas, M.D..........................................PhilHealth-Region I
Mr. Francisco Montillano......................................Alabang Medical Clinic
Appendix
191
Ms. Marjorie Morales............................................Baguio Medical Center

Sainuddin Moti, M.D. ..........................................PhilHealth-Region X
Norma Pacalso, M.D.............................................Benguet General Hospital
Engr. Noli Pagdanganan........................................Philippine Heart Center
eresa Elizabeth Palma-Asa, M.D........................Manila Doctors Hospital
Ma. Socorro Pangantihon, M.D. ...........................PhilHealth-Region VI
Nelda Pe, M.D. .....................................................PhilHealth-Region VII
Mr. Arnel Pios.......................................................PhilHealth-Region IX
Josefina Poblete, M.D............................................Cebu Velez General Hospital
Ruel Revilla, M.D. ................................................Saint Louis University Hospital of the Sacred Heart
Ms. Helen Retuya .................................................Mandaue City Hospital
Danilo Reynes, M.D. ............................................PhilHealth-Region III
Ms. Vivian Suarez..................................................Batangas Health Care Hospital-Jesus of Nazareth
Mary Milagros Uy, M.D. ......................................Makati Medical Center
Ms. Elvira Ver .......................................................PhilHealth-AVP for Cordillera Autonomous Region
Mr. Oliver Victoriano............................................Brokenshire Hospital
Ms. Chanda Villajor..............................................Perpetual Succor Hospital
Ms. Sophia Wagas .................................................Medical Mission Group Hospital-Tagum
Winton Yap, M.D. ................................................Atok District Hospital
Resource Persons
Clementine Almario-Bautista, M.D. .....................PhilHealth-QARPDG
Ma. eresa Bonoan, D.M.D................................PhilHealth-QARPDG
Mary Ann Evangelista, M.D..................................PhilHealth-QARPDG
Francisco Soria, M.D. ...........................................PhilHealth-QARPDG
Madeleine Valera, M.D. ........................................PhilHealth-Vice President, QARPDG
Secretariat
Ms. Alma Benitez..................................................PhilHealth-QARPDG
Ms. Donna Celedonio...........................................PhilHealth-QARPDG
Ms. Merla David ...................................................PhilHealth-QARPDG
BENCHBOOK
192
World Medical Association Declaration on the Rights of the Patient

Adopted by the 34th World Medical Assembly Lisbon, Portugal, September/October 1981and amended by
the 47th General Assembly Bali, Indonesia, September 1995
PREAMBLE
e relationship between physicians, their patients and broader

society has undergone significant changes in recent times. While a
physician should always act according to his/her conscience, and
always in the best interests of the patient, equal effort must be
made to guarantee patient autonomy and justice. e following
Declaration represents some of the principal rights of the
patient which the medical profession endorses and promotes.
Physicians and other persons or bodies involved in the provision
of health care have a joint responsibility to recognize and uphold
these rights. Whenever legislation, government action or any
other administration or institution denies patients these rights,
physicians should pursue appropriate means to assure or to restore
them.
Principles
In the context of biomedical research involving human subjects

- including non therapeutic biomedical research - the subject is
entitled to the same rights and consideration as any patient in a
normal therapeutic situation.
1. Right to medical care of good quality
a. Every person is entitled without discrimination to
appropriate medical care.
b. Every patient has the right to be cared for by a physician
whom he/she knows to be free to make clinical and ethical
judgements without any outside interference.
c. e patient shall always be treated in accordance with
his/her best interests. e treatment applied shall be in
accordance with generally approved medical principles.
d. Quality assurance always should be a part of health care.
Physicians, in particular, should accept responsibility for
being guardians of the quality of medical services.
Appendix
193
e. In circumstances where a choice must be made between

potential patients for a particular treatment which is
in limited supply, all such patients are entitled to a fair
selection procedure for that treatment. at choice
must be based on medical criteria and made without
discrimination.
f. e patient has the right of continuity of health care.
e physician has an obligation to cooperate in the
coordination of medically indicated care with other health
care providers treating the patient. e physician may
not discontinue treatment of a patient as long as further
treatment is medically indicated, without giving the patient
reasonable assistance and sufficient opportunity to make
alternative arrangements for care.
2. Right to freedom of choice
a. e patient has the right to choose freely and change his/
her physician and hospital or health service institution,
regardless of whether they are based in the private or public
sector.
b. e patient has the right to ask for the opinion of another
physician at any stage.
3. Right to self-determination
a. e patient has the right to self-determination, to make
free decisions regarding himself/herself. e physician
will inform the patient of the consequences of his/her
decisions.
b. A mentally competent adult patient has the right to give or
withhold consent to any diagnostic procedure or therapy.
e patient has the right to the information necessary to
make his/her decisions. e patient should understand
clearly what is the purpose of any test or treatment,
what the results would imply, and what would be the
implications of withholding consent.
c. e patient has the right to refuse to participate in research
or the teaching of medicine.
BENCHBOOK
194
4. e unconscious patient
a. If the patient is unconscious or otherwise unable to express
his/her will, informed consent must be obtained whenever
possible, from a legally entitled representative where legally
relevant.
b. If a legally entitled representative is not available, but a
medical intervention is urgently needed, consent of the
patient may be presumed, unless it is obvious and beyond
any doubt on the basis of the patients previous firm
expression or conviction that he/she would refuse consent to
the intervention in that situation.
c. However, physicians should always try to save the life of a
patient unconscious due to a suicide attempt.
5. e legally incompetent patient
a. If a patient is a minor or otherwise legally incompetent the
consent of a legally entitled representative, where legally
relevant, is required. Nevertheless the patient must be
involved in the decision making to the fullest extent allowed
by his/her capacity.
b. If the legally incompetent patient can make rational
decisions, his/her decisions must be respected, and he/she
has the right to forbid the disclosure of information to his/
her legally entitled representative.
c. If the patients legally entitled representative, or a person
authorized by the patient, forbids treatment which is, in the
opinion of the physician, in the patients best interest, the
physician should challenge this decision in the relevant legal
or other institution. In case of emergency, the physician will
act in the patients best interest.
6. Procedures against the patients will
Diagnostic procedures or treatment against the patients will
can be carried out only in exceptional cases, if specifically
permitted by law and conforming to the principles of medical
ethics.
Appendix
195
7. Right to information
a. e patient has the right to receive information about
himself/herself recorded in any of his/her medical records,
and to be fully informed about his/her health status
including the medical facts about his/her condition.
However, confidential information in the patients records
about a third party should not be given to the patient
without the consent of that third party.
b. Exceptionally, information may be withheld from the
patient when there is good reason to believe that this
information would create a serious hazard to his/her life or
health.
c. Information must be given in a way appropriate to the
local culture and in such a way that the patient can
understand.
d. e patient has the right not to be informed on his/her
explicit request, unless required for the protection of
another persons life.
e. e patient has the right to choose who, if anyone, should
be informed on his/her behalf.
8. Right to confidentiality
a. All identifiable information about a patients health status,
medical condition, diagnosis, prognosis and treatment
and all other information of a personal kind, must be kept
confidential, even after death. Exceptionally, descendants
may have a right of access to information that would
inform them of their health risks.
b. Confidential information can only be disclosed if the
patient gives explicit consent or if expressly provided for in
the law. Information can be disclosed to other health care
providers only on a strictly need to know basis unless the
patient has given explicit consent.
c. All identifiable patient data must be protected. e
protection of the data must be appropriate to the manner
of its storage. Human substances from which identifiable
data can be derived must be likewise protected.
BENCHBOOK
196
9. Right to Health Education

Every person has the right to health education that will assist
him/her in making informed choices about personal health
and about the available health services. e education should
include information about healthy lifestyles and about methods
of prevention and early detection of illnesses. e personal
responsibility of everybody for his/her own health should be
stressed. Physicians have an obligation to participate actively in
educational efforts.
10. Right to dignity
a. e patients dignity and right to privacy shall be respected
at all times in medical care and teaching, as shall his/her
culture and values.
b. e patient is entitled to relief of his/her suffering according
to the current state of knowledge.
c. e patient is entitled to humane terminal care and to be
provided with all available assistance in making dying as
dignified and comfortable as possible.
11. Right to religious assistance
e patient has the right to receive or to decline spiritual and
moral comfort including the help of a minister of his/her
chosen religion.

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(C G H)

On Performance Improvement of Health Services

Philippine Health Insurance Corporation

on performance improvement of health services

5. Information Management ..................................................................... 65

Quality Monitoring Tools

Relationship between PhilHealth,

Sample control chart showing an out of control process

Tools for the different stages of PDCA .............................................. 88

Philippine Health Insurance Corporation

From the President and CEO

Francisco T. Duque, M.D., MSc

Philippine Health Insurance Corporation

From the Quality Assurance Research

Philippine Health Insurance Corporation

Philippine Health Insurance Corporation

As editor, Prof. Wystan de la Pea of the University of the Philippines

Madeleine R. Valera, M.D., MScCHHM

Philippine Health Insurance Corporation

Philippine Health Insurance Corporation

Philippine Health Insurance Corporation

Philippine Health Insurance Corporation

Part II contains the benchmark of performance improvement.

Patient Rights and Organizational Ethics

Goals are set to serve as targets for improvement. ese goals

Philippine Health Insurance Corporation

PhilHealth and the Health Sector Reform Agenda

Origins of Social Health Insurance

Social health insurance started in 1969 in the Philippines

Philippine Health Insurance Corporation

concept of Quality Assurance (QA). According to this concept,

e current PhilHealth quality assurance framework is primarily

Philippine Health Insurance Corporation

e new quality assurance framework aims to foster an environment of

Philippine Health Insurance Corporation

The Focus of the Quality Assurance Framework

Philippine Health Insurance Corporation

Figure 2. Assessment focus points of PhilHealths new Quality Assurance framework

Dimensions of Quality Health Care1

New PhilHealth accreditation standards and performance

Philippine Health Insurance Corporation

PhilHealth members should expect that the treatment they receive

PhilHealth shall develop measures to ensure appropriateness of

As patients have a fundamental right to be involved in health care

PhilHealth supports equitable access to health services on the

PhilHealth shall ensure cost-efficiency through the implementation

Philippine Health Insurance Corporation

As a major priority for review and action by PhilHealth, there are

PhilHealth is committed to improving the accuracy,

Philippine Health Insurance Corporation

increasingly important as PhilHealth makes allocation decisions

is refers to the extent to which an individual episode of

Philippine Health Insurance Corporation

Program (Seed Pharmacy Program). Properly coordinated care

In implementing this new framework, PhilHealth emphasizes

Philippine Health Insurance Corporation

Improving the collection of cost-data thereby improving

To successfully implement this framework, PhilHealth shall carry

rough accreditation, PhilHealth assesses an organizations

Philippine Health Insurance Corporation

Implementing the New Quality Assurance Framework

Figure 3. Implementation activities for PhilHealths Quality Assurance framework

Implementation of the QA framework involves the following interrelated activities:

In PhilHealth, the Accreditation Department takes charge of