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I. PURPOSE
The main objective of the Quality Improvement and Patient Safety (QPS) Plan is to provide a
comprehensive strategy for providing continuous development of healthcare with utmost consideration to
patients wellbeing, protection, security, and overall safety. The Quality Improvement and Patient Safety
Plan is the means by which Medical Center shall fulfill its commitment to the vision of becoming the
patients first choice in healthcare.
Define the authority and responsibility for the execution of the QPS Plan. Involve all CSMC staff to play
an active role in the implementation of QPS Plan.
II. MISSION, VISION, CORE VALUES AND PRINCIPLES
Our Mission
We are a Medical Center committed to provide only the Highest Quality of Healthcare for the welfare of
our patients through competence and professionalism as well as to maintain the financial stability of the
institution.
Our Vision
We envision Medical Center to be the Patients First Choice in Healthcare.
Our Core Values
Care and Compassion
Excellence and Thoroughness
Teamwork
Purity
Our Principles
MC shall deliver the highest quality of healthcare to its patients, within the available resources of the
hospital.
MC shall provide the safest environment facility to its patients through the appropriate management
of its workforce, machines and equipment, processes, medicines, supplies and infrastructure. It shall
continuously strive to foster an environment of cleanliness, compassion, excellence, thoroughness
and teamwork that with such, the hospital would be able to provide a healthcare facility that is
conducive for healing.
Our Cardinal Way of Life
Customer Relations
Service Quality
Productivity
Patient Safety
III. DEFINITION OF QUALITY
For MC, Quality Healthcare means providing our patients with the right amount of care in a technically
competent manner, with good communication, shared decision making, and cultural sensitivity. This
definition is embodied in our way of life, and exhibited through following five major attributes which are
influenced not only by the service needed by the patient but also by the way we treat our patient when
the service is provided.
Reliability our ability to perform the promised service to our patient dependently and accurately
Responsiveness our willingness to help our patient and provide prompt service

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Tangibles our physical facilities, equipment, and the appearance of employees who service our
patients
Assurance our knowledge or how well do we know our processes and procedures, courtesy to our
patients, and our ability to convey trust and confidence
Empathy the caring and individual attention provided by employees to our patients

IV. ALIGNMENT WITH STRATEGIC INITIATIVES

CSMCs QPS Plan evolves from the following organizational trust and strategic initiatives:
1. Establishment of MC as an organization with Caring Personnel.
This shall be the focus of the Patient and employee survey or feedback
2. Establishment of MC as an Excellent Tertiary General Hospital.
This shall be the focus of the JCI accreditation process and Quality Improvement and Patient
Safety Program or initiatives.
3. Establishment of MC as a De Facto Cancer Center of the Philippines.
This shall be the focus on medication management or high risk medication initiatives.
XIII.

MANAGEMENT PRIORITIZATION
Criteria for Prioritization
MC Executive Committee, through its representative, shall be providing appropriate resources to
address the quality improvement and patient safety needs of the hospital. Below is a prioritization
guideline which leadership will use to select quality monitors and improvement activities
Dimension
to Address

Severity
Occurrence
Detection

Description of the
existing hospital
practice proposed to be
improved
Estimate of how serious
the effect is, should it
occur.
Likelihood or frequency
that the inconvenience
will occur.
Ability of the staff to
detect that an
inconvenience occurred.

Degree of Priority
1
Very
small to
None
Very
Seldom
to Never
Can
Detect

Partial
Disability

Permanent
Disability

Fatal

Seldom

Sometimes

Always

May
Detect

May Not
Detect

Cannot
Detect

As a general rule, existing hospital practices, which garner a score of 4 in any of the three
dimensions, shall automatically merit approval. Prioritization, however, shall depend on the Risk
Priority Number, which is the product of Severity, Occurrence and Detection score. The larger the
Risk Priority Number, the higher is the priority. This planning and decision making tool shall be used
by the Managing Director and shall be linked to the strategic initiatives of the hospital.

V. GOALS AND OBJECTIVES

The QPS Plan shall focus on achieving the following:

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1. Quality Healthcare
Compliance to Patient Safety (JCI) standards.
Customer satisfaction.
Benchmark system and standard for the healthcare industry.
2. Safety
Reduced incident occurrence.
Minimized side effects and complications of treatment made to patients.
Prevent and control of infection.
Prevent and control of process hazards like Laboratory and Radiology Safety programs
Maximize Protection and security.
Achieve International Patient Safety Goal
3. Process Efficiency and Effectiveness
Implement Policies and Procedures.
Practice effective Resource Management (material, equipment, people, infrastructure, and
environment).
Maintain Continuous Performance Monitoring and Improvement
Maintain Cost efficiency
Redesign processes to improve performance (corrective and preventive measures, mistake
proofing, etc.).
Quality improvement principles and tools are applied to the design of new or modified
processes.
Elements of Good Process Design (in Intent Statement) are considered when relevant to the
process being designed or modified.
Indicators are selected to measure how well the newly designed or redesigned process
operates.
Indicator data are used to evaluate the ongoing operation of the process.
Good process design is
is consistent with the organizations mission and plans
meets the needs of patients, families, staff, and others
uses current practice guidelines, clinical standards, scientific literature, and other
relevant evidence-based information on clinical practice design
is consistent with sound business practices
considers relevant risk management information
builds on available knowledge and skills in the organization
builds on the best/better/good practices of other organizations
uses information from related improvement activities
integrates and connects processes and systems.
4. Quality Culture
Shape the Quality Culture of the organization.
Celebrate completed and effective Quality Improvement and Patient Safety projects
VI. AUTHORITY AND RESPONSIBILITY (See Appendix __, CSMC QPS Organizational Chart)

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VII. SCOPE OF THE QPS PLAN

VIII.

The MC QPS Plan encompasses the quality of healthcare and services provided to our patients, in both
the inpatient and outpatient setting. The QPS Plan is designed to comprehensively address both the
quality of clinical care and the quality of managerial services provided in the hospital directly or by
means of contracted services. The following are the primary components of the QPS Plan:

Oversight of JCI quality monitors

Oversight of adverse event reports

Coordination and support of quality teams or circles

Oversight of special quality improvement activities

Staff training and statistical support

Continuous improvement

Patient and employee satisfaction

Special quality improvement activities like in medication management and use.

Professional / provider credentialing

MC QUALITY IMPROVEMENT CYCLE

MC shall utilize the QPS Cycle as the framework for continuous improvement. See Figure 1.

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Figure 1: Quality Improvement and Patient Safety Cycle

IX. PROGRAM STRUCTURE
1. Conceptual model: (organization chart in appendix)

QPS
COMMITTEE
QPS
DEPARTMENT
DEPARTMENT
SPECIFIC
COORDINATORS
QUALITY IMPROVEMENT
(QIT)
Figure 2: Authority and ResponsibilityTEAMS
for Quality
Improvement and Patient Safety

1. QPS Committee
The QPS Committee is chaired by the Managing Director or his Management Representative,
and is composed of the following: Internal QPS Expert, Head of Nursing Division, Head of
Ancillary Division, Head of Pharmacy, Head of Infection Control, Head of Facility Management
and Safety, Department Chairmen for Surgery, Pediatrics, Internal Medicine, Obstetrics-

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Gynecology, Anesthesiology, Radiology, and Laboratory. The Managing Director also serves as
a member of the CSMC Board of Directors.
The QPS Committee has ultimate authority and responsibility for the quality of care and service
delivered by CSMC. The QPS Committee is responsible for the direction and oversight of the
QPS Plan and delegates authority to the QPS Department.
The QPS Committee is responsible for the generation, implementation and ongoing monitoring
of the QPS Plan. Through the QPS Department, the QPS Committee recommends policy
decisions, analyzes and evaluates the progress, results and outcomes of all quality
improvement activities, institutes needed actions and ensures follow-up.
QPS committee is the strategic and operational think tank for the QPS Department. The QPS
Committee select, prioritize, and recommend hospital-wide monitors, review data on adverse
events and make recommendations for improvement, review update tables and graphs on all
monitors and discuss performance status, recommends the formation of quality circles for
improving performance on a given monitor, recommend the processes for a Failure Mode and
Effect Analysis (FMEA), develop strategies to ensure monitoring is being done at the department
level, etc.
The QPS Committee sets the strategic direction for all quality activities at MC. The QPS
Committee receives reports from the QPS Department, advises and directs the QPS
Department on the focus and implementation of the QPS Plan. The QPS Committee reviews
data from QPS activities to ensure that performance meets standards and makes
recommendations for improvements to be carried out by the QPS Department and designated
groups.
The Managing Director or his Management Representative is responsible to plan, design,
implement and coordinate QPS activities. His responsibilities include but are not limited to:
Demonstration and promotion of the QPS Plan through communication, practice, and
resource allocation.
Achievement of organizational goals.
Direct involvement in QPS activities to include:
Analysis of QPS data.
Serve as chair for QPS Committee.
Ensure effectiveness of QPS activities and allocate resources.
Ensure participation of all CSMC staff.

2. QPS Department (Program Core Team)

The QPS Department is headed by the QPS Expert and is comprised of appropriately
credentialed registered head nurses, health professionals, operational managers and
supervisors who are responsible for coordination and implementation of the QPS Plan. These
include, but are not limited to:

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Coordination of clinical and service quality measurement and periodic reporting to the QPS
Committee.
Management of QPS projects, studies and interventions, preparation and submission of
QPS documents and reports, and recommendations to the QPS Committee.
Formation and management of special Quality Improvement Teams (QIT).
Identification of opportunities for improvement by providing assistance in monitoring and
data analysis of clinical and satisfaction data. Assist in designing data collection forms.
Ensuring compliance with MC and regulatory standards.
Monitoring QPS preparations for future accreditation.
Development, adoption, and implementation of relevant health education programs.
Development, maintenance and implementation of QPS procedures.
Maintenance of necessary QPS resources.
Serve as consultant to other departments.
Responds to the medical staff when requesting technical assistance in collecting physician
specific data for annual performance evaluations.

Department Specific QPS Coordinator

Department Specific QPS Coordinator is an identified person to be responsible in coordinating

the QPS activities and teams of the department. The Department Specific QPS coordinator is
chosen based on the following:
Has willingness and determination to become the QPS coordinator of the department.
He/she has inherent leadership in the department.
Has attention to details and data collection, tabulation and presentation
Computer literate
Able to communicate and coordinate to his/her department the QPS program of the entire
hospital.
The Department specific coordinator shall report to the QPS Core program team officer
regarding implementation of QPS activities in his/her department.
The Quality Improvement Team/s of the department report to the QPS coordinator of the
department.
The QPS coordinator per department shall oversee and monitor the progress of the Quality
Improvement activities and teams and shall report the progress to the QPS Core team.
Coordinate and communicate to the QPS Core team the needed trainings of the department
regarding QPS
May train his/her departments Quality Improvement Team members if needed.
Directs and performs the data collection in his/her department.

5. Quality Improvement Teams (QIT)

Quality Improvement Teams (QIT) are special working teams identified by the QPS Committee,
to address specific areas, in conjunction with the QPS Plan and performance to the identified
QPS indicators. Based on the topic or the issue, certain specialties shall be appointed, and the

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QPS Committee as needed shall designate the members of the Quality Improvement Team.
These QIT shall only exist for their specified assignment, after which it shall go out of existence.
To be managed by the QPS Department, the QIT shall assume the following responsibilities:
Collect data that will be used to report the level, trend and comparative performance of the
concerned departments Productivity Targets.
Report such level, trend and comparative performance to the QPS Department on a periodic
basis.
Investigate the issue and make necessary recommendations to improve the department
performance based on the level, trend and comparative performance of--1. Joint
Commission International (JCI) Indicators as stated in Section III-Quality Parameters and
Reporting System of this Plan and; 2. Productivity Targets of the work unit.
Utilize systematic problem solving and decision-making tools to investigate the issue, and
define and implement appropriate corrective and preventive measures.

6. CSMC QPS Workforce

All MC personnel have a key role in quality improvement and the execution of the QPS Plan,
thus they are considered the MC QPS Workforce.
The MC QPS Workforce shall participate in interdepartmental activities but also focus on
intradepartmental opportunities to improve effectiveness or efficiency.
The SMC QPS Workforce shall take part in identified QPS projects.
It is the responsibility of the MC QPS Workforce to get familiarized with the latest hospital
standards being implemented in MC. This can be made possible by attending required
orientation/training sessions, reading and internalizing the most updated department quality
manual, participating in QIT activities, reading bulletin boards and One-Point Lesson posters,
and providing improvement suggestion through the Idea Suggestion Program.
The MC QPS Workforce is composed of the following:
Medical Staff - composed of residents, interns, fellows and consultants.
Nursing Staff - composed of all registered nurses.
Allied Professional Staff - composed of all allied professionals including nursing aides.
Employees of Outsourced Service Providers - composed of all employees of outsourced
service providers, including On-the-Job-Trainees, Nursing Students, Kitchen Staff,
Construction Workers, Biomedical Equipment Engineers, security guards and janitors.
X. PROGRAM DESCRIPTION
Quality Improvement and Patient Safety Activities
To meet the purpose, goals, and scope of the QPS Plan, the activities shall be focused in the following
areas.

1.

Development of clinical practice guidelines and clinical pathways to guide and

standardize patient care processes.

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Hospital and clinical leaders use clinical guidelines and pathways to guide patient care
processes and to standardize care processes, reduce risk within care processes, especially
those associated with critical decision steps, and to provide clinical care in a timely, effective
manner using available resources efficiently. Following is the definition of clinical guideline and
pathway
Clinical Practice Guidelines are a systematically developed statement designed to assist
practitioner and patient to make decisions about appropriate healthcare for specific clinical
circumstances.
Clinical Pathways are best practice tools used to organize and integrate all levels of
healthcare delivered by providers from a number of disciplines. They identify desired client
outcomes and provide the sequence of events necessary to achieve these outcomes with
optimal efficiency.
The goals of the hospital in developing Clinical Practice Guidelines and Clinical Pathways
are
To standardize clinical care processes
Reducing risk within care processes, especially those associated with critical decision
steps
Providing clinical care in a timely, effective manner using available resources efficiently.
Clinical Practice Guidelines (CPG) and Clinical Pathways (CP) are
Selected from among those applicable to the services and patients of the hospital
Mandatory national guidelines, if any, are implemented
Evaluated for their applicability and science
Adapted when needed to the technology, drugs and other resources of the organization or to
accepted national professional norms
Formally approved or adopted by the hospital
Implemented and monitored for consistent use and effectiveness
Supported by staff trained to apply the guidelines or pathways
Periodically updated
The requirement is to adapt, adopt, or update at least one guideline and one pathway per 12month period.

Monitoring the outcomes of care against national and international practice standards.
The quality indicators are the measures used to determine over time MCs performance of
functions, processes and outcomes.
The QPS Committee identifies key measures or indicators to monitor MCs clinical and
managerial structures, processes, and outcomes and the International Patient Safety Goals.
Due to inherent limitation in resources, the QPS Committee shall choose which clinical and
managerial areas and outcomes are most important to monitor based on MCs goals and
objectives.

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For each of these areas, the QPS Committee shall decide

the process, procedure, or outcome to be measured;
the availability of science or evidence supporting the measure;
how measurement shall be accomplished;
how the measures fit into MCs QPS Plan; and
the frequency of measurement.
The QPS Committee / Department shall aggregate and analyze data in the organization using
identified benchmarking methodologies, statistical tools and techniques, at a defined frequency.
List of Quality Indicators (Key Measures), see Appendix __.
Utilization of multi-disciplinary and multi-dimensional teams (Quality Improvement

Teams) to address process improvements that can enhance care and service.

4.

Identification of appropriate safety and error avoidance initiatives:

Evaluation of pharmacy data for provider alerts about drug interactions, recall, and pharmacy
over and under-utilization.
Adverse event reporting and analysis including sentinel events and near misses

Adverse Event - An unanticipated, undesirable, or potentially dangerous occurrence in the

health care environment. Analysis is conducted on the following:
All confirmed transfusion reactions
All serious adverse drug events, as defined by the hospital
All significant medication errors, as defined by the hospital
All major discrepancies between preoperative and post operative diagnoses
Adverse events or patterns of adverse events during moderate or deep sedation and
anesthesia use
Other events defined by the hospital

Near-miss - Any process variation that did not affect an outcome but for which a recurrence
carries a significant chance of a serious adverse outcome. This is any situation (where
medical error including medications but not exclusive to medications) that an error is about
to be committed but does not actually occur, because the mistake was understood or
detected before it happened.
Medication near miss
Non medication near miss

Sentinel Event defined as

Unanticipated death unrelated to the natural course of the patient illness or underlying
condition

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6.
7.
8.

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Major or permanent loss of function unrelated to the natural course of the patients
illness or underlying condition
Wrong site, wrong procedure and wrong patient surgery.

There is a defined process to document, analyze and report the adverse event, near miss
and sentinel events.

Patient education regarding their role in receiving safe and error-free healthcare services.
Education of providers regarding improved safety processes in their practice.
Dissemination of information regarding important safety activities.
Evaluation for safe clinic environments.
Patient education regarding safe practices at home.
Intervention for identified safety issues.
Collection of data regarding hospital activities relating to patient safety.
Evaluation of the continuity and coordination of care through analysis of data.
Improvement of transition of care processes.
Medical record evaluation or audits.
Tracking quality of care issues, including adverse outcomes and sentinel events.
Focused health management programs.
Patient and practitioner complaint and appeal review.
Evaluation of all satisfaction measures for availability and access to care.
Review of practitioner surveys and proposed activities for improvement.

Review of credentialing / re-credentialing policies and procedures.

Ensure that medical records comply with standards of structural integrity and contain

evidence of appropriate medical practices for quality care by:

Review of medical record audit results and corrective actions.
Practitioner education and corrective actions where indicated.

9.

Oversight of patient satisfaction measurement and improvement activities:

Review of all sources of patient satisfaction information.
Design and evaluation of initiatives to improve satisfaction.

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Evaluation of the effectiveness of QPS activities in generating measurable

improvements in the care and service provided to patients through:

Organizations of multi-disciplinary teams to analyze service and process improvement
opportunities, determine actions for improvement, and evaluate results.
Track the progress of QPS activities through appropriate QPS Committee minutes, and periodic
review / update of the QPS Plan.
Revise interventions as required based on analysis.
Continuous Performance Improvement Strategy
Continuous Performance Improvement shall be achieved through the following steps as described in Figure

Four Steps to
Continuous Performance Improvement

Performance
Analysis

Performance
Improvement
Options

Performance
Review
Measures

Action Plan
Development

Figure __. Four Steps to Continuous Performance Improvement

Step 1 Performance Review Measures

Key Measure or Indicator shall be selected and assessed through the following:
Describe the Indicator
Describe the importance of the Indicator
Determine if you have good data to effectively define the Indicator
Describe the numerator for the Indicator
Describe the denominator for the Indicator

Data for the Key Measure shall be collected through the following:
Describe the source of data
Describe the collection method
Describe the frequency of data collection
Tabulate the data

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Establish the targets

Clinical and Managerial Key Measures Monitoring, as part of the QPS program
shall include the areas identified in the JCI standards.
shall be used to study areas targeted for improvement.
data shall be used to monitor and evaluate the effectiveness of improvements.
Clinical Key Measures Monitoring shall include the following:
Aspects of patient assessment
Aspects of laboratory services
Aspects of radiology services
Aspects of surgical procedures
Aspects of antibiotic and other medication use
Monitoring of medication errors and near misses
Aspects of anesthesia and sedation use
Aspects of the use of blood and blood products
Aspects of availability, content, and use of patient records
Aspects of infection control, surveillance, and reporting
Aspects of clinical research
Managerial Key Measures Monitoring shall include the following:
Procurement of routinely required supplies and medications essential to meet patient
needs
Reporting of activities as required by law and regulation
Risk management
Utilization management
Patient and family expectations and satisfaction
Staff expectations and satisfaction
Patient demographics and clinical diagnoses
Financial management
Prevention and control of events that jeopardize the safety of patients, families, and
staff, including the International Patient Safety Goals (IPSG).
The results of the Quality Indicator or Key Measures Monitoring shall be communicated by the
QPS Department or QPS Core Program team to the QPS Committee and periodically to the
leaders and Governance of the hospital. This shall be accomplished through the Quality
Indicator Form (see Form 1 in Appendix __).

Step 2 Performance Analysis

Data shall be aggregated, analyzed, and transformed into useful information.
Individuals with appropriate clinical or managerial experience, knowledge, and skills shall
participate in the analysis process.
Statistical tools and techniques shall be used in the analysis process when appropriate.
Graph the data using trend lines
Determine the variance of the data
Determine the reason for the variance

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Describe the analysis of graph

The frequency of data analysis shall be defined as appropriate to the process under study, shall
meet the requirements of the organization. This shall be accomplished according to the
timetable defined by the QPS Committee.
Benchmarking activities of known Best Practices shall be done over time within the organization,
and with other similar organizations when possible.

Step 3 Performance Improvement Options

The organization shall plan and implement improvements using a consistent process selected
by the leaders
The organization shall document the improvements achieved and sustained.
The priority areas identified by the leaders shall be included in the improvement activities.
Human and other resources shall be assigned or allocated.
Changes shall be planned and tested.
Changes shall be implemented.
Data shall be available to demonstrate that improvements are effective and sustained.
Policy changes necessary shall be made.
Successful improvements shall be documented.
Root Cause Analysis Tools shall be used to identify cause of the problem or sentinel event .
Root cause analysis focuses on processes that have failed and addresses the question: What
went wrong?
Root Cause Analysis (RCA) is a process for identifying the basic or causal factor(s) that underlie
variation in performance including the occurrence or possible occurrence of sentinel event.
Root causes are classified as
Common cause is the way the process is designed. Common cause is a cause that is the
baseline, inherent in the system or process, explains what is going on and no need for
intense analysis.
Special cause is unusual circumstances that occur in the process. It is attributed as a
human error/ mechanical malfunction and needs an intensive analysis.
Criteria for acceptable Root Cause Analysis are
Focus on systems and processes
Identify both special and common causes in processes
Repeatedly dig deeper by asking why
Identify changes that can be made in systems and processes to reduce risk of reoccurrence
Categories of Root Causes
Leadership
Environment
People/Staff
Processes
Equipment and supplies
Information management and communication

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Sentinel event requires intensive analysis and requires formation of Quality Improvement Team
(QIT). Intense Analysis requires Root Cause Analysis (RCA).

Step 4 Action Plan Development

The leaders shall
adopt a process by which high-risk areas in terms of patient and staff safety are identified
prioritize patient and staff safety risks at least once annually
take action to redesign high-risk processes based on the analysis.
There shall be a process using a proactive risk reduction tool at least annually on one of the
priority risk processes and it is documented.
Proactive Risk Reduction is a method for evaluating a high risk process to identify where and how it
might fail and to assess the relative impact of different failures, in order to identify the parts of the
process that are most in need of change (from the Institute of Health care improvement)
Proactive risk-reduction focuses on process that are at risk of failing, resulting serious
consequences, and addresses the question: What could go wrong?
The steps in conducting a Proactive Risk Reduction Project are:
Select and describe a high-risk process
Identify potential breaking/failure points
Identify possible effects failure could have
Prioritize potential breakdowns based on severity
Identify why breakdowns could occur
Redesign process or system to minimize risk
Test, implement and monitor redesigned process/system

MC shall use the Failure Mode and Effect Tool (FMEA) as its Proactive process tool.

Failure Mode and Effect Analysis (FMEA) is a method to evaluate processes for possible failures
and to prevent them by correcting the processes proactively rather than reacting to adverse
events after failures have occurred. This emphasis on prevention may reduce risk of harm to
both patients and staff (from the Institute of Healthcare Improvement).
The FMEA shall be used by the Medical Director, Managing Director and the QPS Committee
members.
QPS Committee shall identify on a yearly basis only 1 high risk process for an FMEA.
Process Mapping is used to define the specific activities or points per process step.
FMEA shall identify which point/s in the process might fail.
The steps in conducting Failure Mode and Effect Analysis (FMEA) are,
Step 1 - Select a Process for improvement
Always select a small focused process without a lot of sub-processes
Select a process that has high potential for failure and high likelihood of drastic
consequences on patient or staff safety

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Step 2 - Select a Team

Assign a risk priority number (1-10) for each failure mode

RPN is based on an analysis of the following 3 factors
Likelihood of occurrence: How likely is it that this failure mode will occur?
Likelihood of detection: If this failure mode occurs, how likely is it that the failure will
be detected?
Severity: If this failure mode occurs, how likely is it that harm will occur?
The score assigned to each of the 3 factors is 1-10 wherein 1 is the lowest and 10 is
highest.

Step 6 Evaluate the Results

Identify all possible failure modes for each step in the process
Identify for each failure mode the likely causes for that failure
Team brainstorm on failure modes and Risk Priority Number (RPN) scoring

Step 5 Assign Risk Priority Numbers

Have team members identify all steps in the process by doing a tracer from beginning to
the end.
Use value stream and process mapping to demonstrate the process
Develop team consensus of the process steps and sequence

Step 4 Identify Failure Modes and Causes

Identify a team leader and facilitator

Engage staff who are directly or indirectly involved in the process
Use the same recommended approach for root cause analysis

Step 3 - Identify all steps in the process

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Calculate the RPN for each failure mode:

Multiply the scores for each of the three factors:
e.g 3X5X5 = 75 RPN
Highest possible score is 1000
Add RPN for each failure mode to derive the total score for the process

Step 7 Redesign the Process

Focus redesign efforts on the failure modes with the highest priority
Use a root cause analysis process to identify the reasons for the high priority risk points.

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Step 8 Pilot Testing the improvement

CSMC QPS Workforce Education

CMSC;
determines the necessary competence for workforce performing QPS activities.
provides training or take other actions to satisfy these needs.
evaluates the effectiveness of the actions taken.
ensures that its workforce are aware of the relevance and importance of their activities and how
they contribute to the achievement of the quality objectives.
maintains appropriate records of education, training, skills, and experience.
Design of Clinical Practice Guidelines and Clinical Pathways
MC ensures that workforce with responsibility to design clinical practice guidelines and clinical
pathways are competent to achieve design requirements and are skilled in applicable tools and
techniques.
Training
SMC establishes and maintains documented procedures for identifying training needs and
achieving competence for all workforce performing QPS activities. Workforce performing specific
tasks are qualified and certified, as required.
Employee Motivation and Empowerment
MC has a process to motivate employees to achieve quality objectives, and create an
environment to continuous improvement. The process includes the promotion of Quality
Improvement and Patient Safety awareness throughout the whole organization.
The MC QPS Workforce shall be required to undergo the following certification modules, as a
minimum:
Policy on Quality Improvement and Patient Safety
The Quality Improvement Plan
Policy and Procedure on Sentinel Events
The Quality Improvement and Patient Safety Activity Cycle
The CSMC Problem Solving Tools
CSMC QPS Workforce Training Plan (see Appendix __).
You need to specify the specific training you will give to you leaders, the staff in the department,
the committee, and your department-specific coordinators including department directors. The
level and intensity of training will be different for each level and group
Quality Improvement and Patient Safety Tools
The list of preferred problem solving tools and techniques are enumerated in the Policy. Among the
many, the following are the tools that CSMC has to start with:
Data Gathering & Presentation Tools
Checksheets
Run charts/Trend charts
Sampling techniques
Pareto Analysis

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Histogram
Scatter Diagram
Stratification
Data Analysis Tools
Risk Stratification
Control chart analysis
Variance analysis
Improvement Tools / Corrective / Preventive Actions Tools
Global Eight Discipline (G8D)
Root Cause Analysis
Failure Mode and Effect Analysis (FMEA)
Risk Assessment
Statistical Process Control including Pre-Control Charts
Tracer Methodology
Comparisons
Benchmarking
Peer Review
Monitoring and Measurement Tools / Evaluation Tools
Customer Satisfaction
As one of the measurement of the performance of the Quality Improvement
and Patient Safety, CSMC monitors information relating to patient perception
and experience as to whether the hospital meets patient safety standards. The
methods for obtaining and using this information is determined through the
following:
Mystery Patient Program
Customer Feedback Survey
Tracer Methodology
CSMC evaluates its compliance to patient safety standards through the use of
Tracer Methodology.
Tracer methodology is a process used to analyze the organizations systems
by following individual patients through the organizations health care process
in the sequence experienced by the patients.
Tracer methodology identifies that problems regarding hospitals processes
and procedures.
Medical Records Review
Is a data collection method to identify clinical documentation problems that do
not meet the patient safety standards, policies and procedures.
Results of tracer methodologies and surveys shall be communicated to all hospital staff or
clinical departments and these shall be the basis in selecting indicators they want to
propose to the QPS program.

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Dissemination of survey/tracer methodology findings shall be documented through the

following reporting formats,
Work plans
Minutes of the meeting

XI. COMMUNICATION STRATEGIES

Reporting Mechanism for Events or Incidences
MC takes action to eliminate the cause of non compliance to its patient safety standards or non
conformities in order to prevent recurrence.
Corrective actions are appropriate to the outcome or effects of the non compliance encountered.
SMC documents, records or reports any incidences or events like adverse events, near misses
and sentinel events through the Incident Report form. See Appendix ____ for the Incident
Report Form.
The Incident Report Form contains the criteria for Sentinel Events, Adverse events and Near
Misses, problem description or complaint and the containment action done if necessary. MC
has a separate form for its patients and employees.
The witness of the incident or event shall document immediately what had happened using the
Incident Report Form.
MC has a system to track the incident, event or patient problem analysis completion time.
Problem verification is done within 48 hours
Containment action or temporary fix is done within 24 hours
Root cause identification for sentinel events or adverse events and improvement action plan
is done within 10 calendar days.
The witness of the incident or event shall submit the Incident Report to his/her superior.
The superior shall give a copy of the Incident Report to his/her Department head
The Department head shall affix his/her signature at the Incident Report form to ensure
appropriate communication was done.
The superior shall submit to the QPS Core Program team officer or representative the Incident
Report.
The QPS Core Program Team officer or representative shall meet with the department
concerned.
The QPS Core Program team officer shall screen the problem description written in the Incident
Report as well as the containment actions written.
The QPS Core Program Team shall prepare all the needed information for data analysis of the
QPS committee
The QPS Core Program Team shall inform the QPS committee of the event or incident.
The QPS committee shall identify if intensive analysis is necessary or a quick fix is appropriate.
If the event/incident is a Sentinel event then intensive analysis is required and the QPS
committee shall decide to form a Quality Improvement Team (QIT). The Quality Improvement
Team shall perform Root Cause Analysis (RCA).

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It is mandatory that the Medical Director and Managing Director shall be informed immediately
of any sentinel event that occurred in the hospital. The supervisor shall inform immediately
his/her department head. The Department head shall inform immediately the Medical and
Managing Directors of the hospital.
If the event/incident is an adverse event then the QPS committee shall decide based on facts or
data if Quality Improvement Team is necessary or not.

The result of the Performance Key Measures or Quality indicators are reported quarterly to the
Board or President by the Managing Director or QPS Committee.
The report shall be signed by the Board to signify receipt of the report
Minutes of the meeting shall be published.

Recommendations and project cost shall be approved by the board.

MC shall ensure that appropriate communication processes and tools are established within the
organization, and that communication takes place regarding the implementation, monitoring and
effectiveness of the QPS Plan. The following are the major communication strategies:

Communication Channels for Leadership

Policies and procedures.
Process Change Notification (refer to (spec number), (spec title). This procedure is
applicable in managing all changes or revisions in the hospital policies, procedures,
processes, forms, checklist and work instructions.

Communication Channels for Staff

Work Instructions (Process Flow Charts)
Information Dissemination Procedure (refer to (spec number), (spec title). This procedure is
applicable to all information that will be communicated or disseminated to all hospital staff.
One Point Lesson (OPL) (refer to (spec number), (spec title). A One Point Lesson (OPL) is
a 5 to 10 minutes written communication tool that describes in picture or illustration the
process or procedure or work flow or work instructions. The key points are emphasized in
the One Point Lesson. Owners of the processes shall be the one to generate the One Point
Lesson. All attendees are required to sign their names in the attendance record sheet when
attending a One Point Lesson.
Endorsement Meeting (Eyeball-to-Eyeball). This is a meeting done first hour per shift to
communicate updates or special instructions that will be done in the next shift or for the day.
Assembly meetings, weekly meetings & departmental meetings. This is an activity that
requires all hospital staff to attend for information dissemination. Attendance record is use
to monitor the presence of all hospital staff.
Bulletin board postings. All important announcements, memos, process changes or
revisions, policies & procedures are posted at the bulletin boards per department.

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QPS Meeting Minutes. All minutes are recorded in the Minutes of the Meeting templates and
shall be distributed to all concerned hospital staff.
MC Quarterly Newsletter. This is our quarterly communication tool that records all significant
or relevant information, features, activities and events of the hospital. All hospital staff are
encourage to demonstrate their creativity in writing based on the themes of the newsletter.
MC electronic mail facility. All hospital leaders and doctors are given an electronic email by
the hospital for faster and more efficient communication channel.
Clinical Practice Guidelines (CPG) and Clinical Pathways (CP). These are tools to
communicate all our standard care processes.

Managers with responsibility and authority for corrective actions are promptly informed of
processes or procedures that do not conform to patient safety standards.
All processes and procedures across all shifts are staffed with personnel in charge of, or
delegated responsibility for ensuring uniform and safe care processes.
Leadership has ensured that appropriate communication processes are established within the
whole hospital and that communication takes place regarding the effectiveness of the Quality
Improvement and Patient Safety cycle.

XII. QUALITY IMPROVEMENT EXPOSITION (Recognition/Celebration)

The best Quality Improvement and Patient Safety Activity of the year shall be the highlight of the annual
Quality Month Celebration held during the month of October. The objectives of this initiative are to:
Recognize and appreciate those who participated in the Quality Improvement and Patient Safety
activities by providing them with the opportunity to make presentations;
Prove and convince the general public that Cardinal Santos Medical Center is serious in
providing quality health care;
Convince the employees that Quality Improvement and Patient Safety Activities can assist the
hospital in solving work related problems.
Obtain feedback on the problems faced in the implementation of Quality Improvement and
Patient Safety Activities in the hospital with the view to improve the effectiveness of the program.
Encourage all Quality Improvement Teams to document their improvement actions and present
to the management using Storyboard.
Internally during the Quality Month Celebration, three (3) categories will be awarded to receive
the following awards:
Directors Award on Quality (Individual Category) which is to be given to a member of the
Quality Improvement and Patient Safety Committee member who is able to provide good:
Documentation and Coordination
Generate the largest number of Quality Improvement and Patient Safety Activities
within the year. (25%)
Analysis, Implementation and Results

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Generate the largest number of successful Quality Improvement and Patient Safety
Activities within the year. (75%).
Prize:
Certificate
PhP 5,000 worth of Gift Check
Participation to the Study Tour
201 File
Director's Award on Quality (Group Category) which is to be given to a Quality
Improvement and Patient Safety Circle who is able to:
Give the greatest impact on Quality, Cost and Delivery (75%)
Review and Sustenance (25%)
Prize:
Certificate for each member
PhP 10,000 worth of Gift Check
Participation to the Regional Exposition of QCC
Participation to the Study Tour
201 File
Best Quality Jingle of the Year which is to be given to the best team who are able to
conceptualize and deliver an originally composed jingle focused on the quality of health care
that should be delivered in CSMC.
Prize:
Certificate for each member
PhP 5,000 worth of Gift Check
Participation to the Regional Exposition of QCC(Jingle Category)
Daily airing of the Jingle
201 File

XIII. CONFIDENTIALITY
Refer to MCI policy & procedure (spec # ___________) spec title _______________)
10.1 MC ensures the confidentiality of data and records related to patients, projects under development
and related service or health care information.
10.2. No patient identifier, specific data or information shall be given out.
10.3. QPS have access on confidential information used for data collection and analysis. However, a
Confidentiality Letter Statement shall be signed by the team.
XVI. RESOURCE ALLOCATION
As a start when the base data are not yet adequate to assess the appropriate resource needed for
quality improvement, management shall implement zero-based budgeting where resource shall be
provided on a per request, per activity basis. Below is the list of requirements that must be complied to
secure a budget:
Three (3) copies of the Managing Director approved request.

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Three (3) copies of Request for Payment noted by the OIC for Quality Improvement and Patient
Safety.
On the succeeding year, however, when enough bases are available already:
Request for Budget
On an annual basis, based on the results of its quality improvement and patient safety
monitoring, each department shall be given a hand in determining its required resources for
quality improvement and patient safety. The Quality Improvement and Patient Safety Officer, in
partnership with the Department head, shall create an Annual Calendar of Quality Improvement
and Patient Safety Activities with proposed budget for each activity. The said calendar shall be
forwarded to The Quality Improvement and Patient Safety Committee in coordination with the
Quality Improvement and Patient Safety Department. They shall create an Annual Calendar of
Activities where all quality improvements and patient safety activities per year will be listed and
budgeted accordingly, subject to the approval of the Executive Committee through its
Representative. Below is the list of requirements that must be complied to secure a budget per
activity:
Three (3) copies of the EXCOM approved Annual Calendar of Quality Improvement and
Patient Safety Activities;
Three (3) copies of the Request for Payment noted by the Management Representative
The Management Representative, however, shall be required to submit a formal letter of
request to the Representative of the Executive Committee in case there will be changes to
the Annual Calendar of Activities which require additional financial resources. In such case,
the following requirements must be complied to secure additional budget:
Three (3) copies of the EXCOM approved request for additional financial resources;
Three (3) copies of the EXCOM approved Annual Calendar of Activities;
Three (3) copies of the Request for Payment noted by the Management Representative
Use and access of Excel Software for data collection, tabulation and graphs for data analysis.

XIV. MANAGEMENT APPROVAL

The QPS Plan shall be approved by the Leadership and Board at least once a year.

Document Review and Revision History

Date

Originator/Reviewer

Summary of change(s)
From:
To:

PCN #

Approved by