GENERIC MANUAL ON
ISO 9001:2015-ALIGNED
QUALITY MANAGEMENT SYSTEM FOR
GOVERNMENT
HOSPITALS
AND MEDICAL
CENTERS
Generic Manual on ISO 9001:2015-Aligned Quality Management System
for Government Hospitals and Medical Centers
Copyright @ 2020 by Development Academy of the Philippines
All rights reserved
Cover and Manual Design: Mariel R. Mañibo
The information provided in this document are from the writers.
It does not necessarily state or reflect the views of the Academy and its collaborators.
This publication, once printed, is considered uncontrolled and may be used only for reference.
Latest version of this document is available online.
No part of this publication may be reproduced, sold, stored, or transmitted in any form.
Published by
Development Academy of the Philippines
through the Productivity and Development Center
Government Quality Management Program
Development Academy of the Philippines
DAP Building, San Miguel Avenue, Ortigas Center, Pasig City
Tel. (02) 8631 09 21 | (02) 8631 21 37
Website: www.dap.edu.ph
E-mail: gqmpo@dap.edu.ph
PRODUCTIVITY
AND
DEVELOPMENT CENTER
Cotabato Regional and Medical Center | Amang Rodriguez Memorial Medical Center | Mindanao
Central Sanitarium | Eastern Visayas Regional Medical Center | Margosatubig Regional Hospital |
Dr. Jose Rizal Memorial Hospital | Ilocos Training and Regional Medical Center | Cagayan Valley
Medical Center
Technical Writers
Racquel M. Barbecho
Ephraema S. Gutierrez
Consultants
Ronald Armin F. Ocampo
Arnel C. Nuñez
Aileen A. Ricohermoso
Angela C. Vargas
Project Team
Evangeline M. Macariola
Leanne Kym Jane J. Lozañes
Arianne P. Flores
Adrian A. Ramirez
Ritchell T. Furigay-Cunanan
Philip Jourdan E. Olimpiada
Mariel R. Mañibo
Copyeditor
Joanne Liezl Q. Nuque
PREFACE
Why install QMS in Government Hospitals?
Health care service providers are expected to provide the highest quality health care to all its stakeholders.
Quality health care corresponds to patient-focused care, which means: giving top priority to patient safety
while addressing vulnerability; providing compassionate patient care; providing timely and effective
treatment; complying with applicable treatment protocols; ensuring effective, efficient and secured
patient and hospital/medical center records management; providing effective and readily accessible
communication channels; and, ensuring reliable hospital/medical center support services. With these
in mind, hospital/medical centers need an extremely low tolerance for poor quality services primarily
because human lives are at stake. In the Philippines, health care is a top priority of the government in
terms of funding support for hospital facilities and equipment, subsidized health care services, and other
health care programs to ensure equitability and accessibility of the public, especially the underprivileged
Filipinos, to needed health care services.
With the adoption of the Universal Health Care Act, hospital/medical centers in the Philippines are
mandated to provide integrated and comprehensive health care to all Filipinos by ensuring equitable
access to quality and affordable health care goods and services as well as protection against financial
risks.
Government hospitals/medical centers, which include retained hospitals/medical centers of the
Department of Health (DOH) and operated hospital/medical centers of local government units, e.g.,
district and city hospitals/medical centers, play major roles in the successful implementation of Universal
Health Care in the country. The DOH-retained hospitals/medical centers deliver tertiary, rehabilitative,
and specialized health care services while the LGU-operated hospitals/medical centers deliver primary,
secondary, and long-term care. There are about 721 public hospitals/medical centers in the country, 70
of which are DOH-retained.
As early as 2010, the DOH has mandated all its retained hospitals/medical centers to establish a quality
management system (QMS) and obtain an ISO 9001 certification. These hospitals have proven that
establishing ISO 9001 Quality Management System greatly benefited them in terms of:
•
•
•
•
•
•
•
increased compliance with local and international care standards, policies, and regulations;
reduced medical procedure errors;
clearly defined administrative procedures;
improved attitude of medical personnel toward patients and their relatives;
improved hospital/medical center facilities and environment;
better and more secured records management; and,
increased satisfaction of patients and their relatives.
Purpose of this QMS Manual
This QMS Manual is designed and developed for the purpose of interpreting the ISO 9001:2015
Standards in the context of government hospitals/medical centers (GHMC), which refers to all public
hospitals/medical centers in the Philippines, i.e., DOH-retained, specialty hospitals/medical centers,
and LGU-operated hospitals/medical centers. This shall serve as a reference document in establishing,
documenting, implementing, and sustaining an ISO 9001:2015 QMS.
How to use this QMS Manual
This QMS manual is designed to provide generic and customizable content for easy and prompt adoption
by GHMCs at all levels and sizes. Below are reminders and instructions in using this manual:
A. The layout of the manual can easily be adopted by simply replicating the file.
B. In customizing the header:
GHMC Logo
Name of GHMC
Revision No.
0
Quality Management System Manual
Effective Date
DD/MM/YY
Section 1. Introduction
•
•
•
•
•
Page No.
1 of 2
Place the approved logo of the GHMC in the “GHMC Logo” part and ensure consistency
of the logo used in all sections of the QMS manual.
Change “Name of GHMC” to the actual name of the hospital/medical center.
The “Revision No.” refers to the number of times that the document is updated.
“Effective Date” refers to the reckoning date of QMS implementation.
The Manual is divided into several sections to make revisions easier. By doing so, revisions
can be done in specific section/s only without revising the entire manual. This also means
that each section starts with page 1
C. At the bottom part of the last page of each section, indicate the signatories. At a minimum, there
should be “prepared by” and “approved by” signatories. (align second and succeeding lines
with the first letter of the first line)
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
Usually, the QMS Leader prepares the QMS Manual. The QMS Leader is the designated
member of management who oversees the establishment, implementation, and evaluation of
QMS within the GHMC. The approving authority is the Chief of the GHMC.
D. The contents of each section can be copied, taking note of the following customizations:
•
•
•
•
•
Change “Government Hospital/Medical Center” and “GHMC” into the name of the
hospital/medical center or its acronym;
Change Section 2 Hospital/Medical Center Profile;
Change or remove practices, documents, records, controls and other content/s that are not
applicable to the hospital/medical center;
Change the names of offices, departments or units in blue italics font; and/or
Remove other section/s or content/s that are not applicable to the hospital/medical center.
E. Sample forms and templates as well as sample contents of documented information are provided
in the body of each section or in annexes to aid in the preparation of the required documented
information of the hospital/medical center.
F. NOTES” contained in boxes may be found in the succeeding sections, which provide guidance
or special instructions that may be considered in customizing this QMS Manual. Remember to
delete or exclude these notes when copying the contents.
A. Scope of the GHMC’s QMS
The GHMC’s QMS covers the Provision of Patient Care Services. The scope covers the
management, operations, and support processes of the GHMC as indicated in the Process
Map.
There is no ISO 9001:2015 requirement that is not applicable in the GHMC’s QMS.
NOTE 3.1
GHMC may exclude ISO 9001:2015 Clause 8.3 Design and Development with
the justification that patient care services are based on local and international
standards, thus there is no actual design and development activities in the
course of the delivery of patient care services. However, some GHMC consider
the development of clinical pathways, which are required by Philippine Health
Insurance Corporation (PHIC) among government hospitals, as design and
development activity, thus no exclusion.
G. As the QMS Manual for the GHMC is being developed and customized, it would help the
writers if a copy of the ISO 9001:2015 and ISO 9001:2015 Standards, including relevant
reference documents, e.g., issuances from oversight agencies, internal policies/guidelines,
standard operating procedures (SOPs), work instructions, among others, are readily available
as references.
H. Upon the completion of the final draft of this QMS Manual, present and discuss the contents
with the key officers and staff to gather additional inputs and suggestions, if any. Incorporate
revisions, finalize, and seek approval of the relevant authorities within the GHMC.
Overview of the Manual Selections
Each section of the QMS Manual has its specific purpose. The Manual intends to ensure that the GHMC’s
QMS is completely described for its intended users, which include the management and employees, the
external auditors, and other relevant interested parties.
Section 1.0 Introduction - This section provides the purpose and applicability of the QMS Manual.
This also defines the controls needed to ensure appropriate identification and traceability of document;
formatting and media; and, review and approval for suitability and adequacy.
Section 2.0 GHMC Profile – This section is an overview of the GHMC to provide the users with the right
perspective of its mandate, overarching goals and policies, and the organizational structure it operates
on. It may also refer to the organizational context of the GHMC. However, if the GHMC already has an
established and updated Operations Manual or other documents with similar purpose and contents,
the GHMC may opt to delete this section and instead provide cross-reference/s when describing or
presenting the profile of the GHMC.
Section 3.0 Definition of Terms – This section defines the different terminologies, technical or common,
that are used in the entire QMS Manual. This provides an assurance that terms are appropriately used
and interpreted in the context of the GHMC. The definition of terms indicated in this section may be
customized depending on how the GHMC defines them.
Section 4.0 GHMC and Its Context – This section refers to the specific translation of the requirements
of ISO 9001:2015 Clause 4.0 into the context of the GHMC. It intends to clearly describe how the
GHMC identifies its internal and external issues as well as the needs and expectations of its relevant
interested parties. It also includes the description of the scope of the GHMC’s QMS and presents the
high-level process map that provides an illustration of the QMS processes and their interface to deliver
expected outputs and desired outcomes of the GHMC. Non-applicable ISO 9001:2015 requirement/s
and justification for its non-applicability is also defined in this section.
Section 5.0 Leadership and Governance – This section translates the ISO 9001:2015 Clause 5 into the
context of the GHMC. It describes how the GHMC Management demonstrates its commitment to the
establishment, implementation, and sustainability of the QMS as well as the GHMC Quality Policy.
Section 6.0 Management and System Planning – This section describes how the GHMC performs its
planning based on the requirements of ISO 9001:2015 Clause 6.0. The planning activity includes: (a)
identifying risks and opportunities from the identified internal, external, and customer-related issues;
(b) planning to address the identified risks and opportunities; (c) implementing and evaluating the
effectiveness of actions taken; (d) setting quality objectives and planning to achieve desired outputs and
results, ad (e) planning of changes that could affect the QMS.
Section 7.0 Management System Support - This section describes all the processes that provide support
services for the provision of patient care services. Practices on how support services are provided
effectively and efficiently to all individuals/units/offices of the GHMC are generally identified and
described in this section.
Section 8.0 Provision of Patient Care Services – This section gives an overview of the processes
performed by the GHMC in the provision of patient care services. It is designed to include how the
GHMC addresses the specific requirements of ISO 9001:2015 Clause 8. All the controls needed to
effectively and efficiently perform the patient care processes are described in this section to serve as a
guide to the users.
Section 9.0 QMS Performance Evaluation – This section discusses the different evaluation mechanisms
of the GHMC to ensure that process performance is properly checked and assessed at appropriate
stages. It has considered the specific requirements of ISO 9001:2015 Clause 9 to ensure that the required
monitoring, measurement, analysis, and evaluation of processes are adopted and implemented by the
GHMC.
Section 10.0 Continual Improvement – This section describes the specific requirements of ISO
9001:2015 Clause 10.0, which highlights the importance of continually improving and sustaining the
QMS. This also defines the need to ensure that nonconformities are identified and corrective actions
are taken to eliminate the causes of nonconformity and prevent its occurrence or recurrence within the
GHMC.
Section 1.0 - Introduction
01
Section 2.0 - GHMC Profile
02
2.1
2.2
2.3
2.4
2.5
-
GHMC History
Mandate
Vision, Mission, and Core Values
Organizational Structure
Functional Description
Section 3.0 - Terms and Definitions
08
Section 4.0 - GHMC and its Context
13
4.1
4.2
4.3
4.4
-
Understanding the GHMC and its Context
Understanding the Needs and Expectations of Relevant Interested Parties
Scope of the GHMC’s QMS
GHMC’s QMS and its Processes
5.1
5.2
5.3
5.4
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17
Demonstration of Leadership and Governance
Focus on Patients and Relevant Interested Parties
Quality Policy
Organizational Roles, Responsibilities, and Authorities
Section 6.0 - Management System Planning
20
6.1 - Addressing Risks and Opportunities
6.2 - Management System Objectives
6.3 - Planning of Changes
Section 7.0 - Management System Support
26
7.1 - Management System Resources
7.2 - Control of Monitoring and Measuring Resources
7.3 - Management of Organizational Knowledge
Section 8.0 - Provision of Patient Care Services
8.1
8.2
8.3
8.4
8.5
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Operational Planning and Control
Requirements for Products and Services
Design and Development of Clinical Pathways
Control of External Processes, Products, and Services
Patient Care Services and Treatments
35
TABLE OF CONTENTS
Section 5.0 - Leadership and Governance
Section 9.0 - QMS Performance Evaluation
9.1
9.2
9.3
9.4
-
46
Monitoring, Measurement, Analysis, and Evaluation
Stakeholders’ Feedback Management
Internal Quality Audit
Management Review
Section 10.0 - Continual Improvement
51
10.1 - Improvement of the GHMC
10.2 - Corrective Action
Annexes
53
A. List of Needs and Expectations of Relevant Interested Parties
B. Risk and Opportunity Register
C. Corrective Action Request Form
TABLE OF CONTENTS
Name of GHMC
GHMC Logo
Quality Management System Manual
Section 1. Introduction
Revision No.
0
Effective Date
Page No.
1 of 1
The Quality Management System (QMS) Manual of the Government Hospital/Medical Center (GHMC)
documents the structure and design of the GHMC’s QMS, the interconnectedness of the processes that
constitute the QMS, and the operational arrangements, which support the quality assurance activities
and hospital/medical center standards. Thus, it defines the critical elements of the key processes of the
GHMC’s QMS with reference to relevant policy issuances and provides a holistic and integrative view
of the GHMC’s QMS.
This QMS Manual, which also articulates the GHMC’s commitment to quality and continuous
improvement, is intended to be used by all the offices, departments, or units of the GHMC. It defines
and clarifies policies, systems, and procedures adopted to implement and continually improve the
GHMC’s QMS. Likewise, it serves as a reference and a guide for GHMC personnel in decisions and
actions related to: (a) the performance of their day-to-day tasks; (b) ensure awareness and consistency
in the implementation of processes as well as conformance to planned arrangements; (c) compliance
with legal requirements; and (d) providing relevant stakeholder requirements.
This QMS Manual is a controlled documented information. Thus, its review, revision, and re-issuance
are subject to existing policies and procedures. Revision and re-issuance are reflected when there are
changes in the QMS such as change in management and/or organizational structure, operational
process/es improvements, shifts in strategic direction, among others.
Controlled copies of this QMS Manual are issued to authorized copyholders identified by the Records
Office/Unit for safekeeping and prompt updating of necessary revisions.
NOTE 1.1
The GHMC may indicate the sites or offices covered by its QMS to define the
scope and applicability of the policies and guidelines set forth.
Additional information such as the management’s reason for establishing the QMS
and the expected outcomes of the established QMS may also be added here.
NOTE 1.2
The GHMC may refer to any document (e.g., policy issuance, memorandum,
procedure, etc.) that defines the specific controls for this Manual to ensure proper
identification, traceability, relevance, suitability, and adequacy.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
1
Name of GHMC
GHMC Logo
Quality Management System Manual
Section 2. GHMC Profile
Revision No.
0
Effective Date
Page No.
1 of 6
2.1 GHMC HISTORY
NOTE 2.1
A brief background or history of the GHMC may be included in the QMS Manual
to establish the context of the GHMC. It will help the users learn more about the
historical milestones and how the GHMC came to be, where, and what it is now.
2.2 MANDATE
NOTE 2.2
The GHMC’s mandate will help set the tone of its QMS. It will ensure that the
scope of the QMS is within the mandate of the GHMC. Moreover, the main
reason for the GHMC’s existence, i.e., providing quality health care to all should
be emphasized in the QMS scope statement.
2.3 VISION, MISSION AND CORE VALUES
NOTE 2.3
The statements of the GHMC’s vision and mission may also be part of the QMS
Manual to ensure the users’ awareness of the long term goals of the organization.
This is also indicated as part of the QMS Manual to ensure the alignment of the
QMS policies and objectives to these long term goals. The core values, on the other
hand, enables the users to better imbibe the values upheld by the organization in
their day-to-day tasks.
2.4 ORGANIZATIONAL STRUCTURE
NOTE 2.4
The organizational structure of the GHMC shows how roles, responsibilities, and
authorities in the GHMC are defined, as part of the requirements of ISO 9001:2015
Clause 5.3 Organizational Roles, Responsibilities, and Authorities. Moreover,
the documented information on organizational structure serves as a supporting
document to define the scope of the QMS because it shows the different offices/
units that are covered in the GHMC’s QMS.
The organizational structure should show the offices, departments, or units of the
GHMC, and NOT the names and pictures of the offices and staff. This will avoid
unnecessary revisions when there are changes in the assignments of personnel.
Moreover, office/department/unit functions remain the same even after the
changes in personnel assignments are implemented.
2
Emergency Roomand Non-Surgical
• Emergecny Service Complex
• Internal Medicine
• Neurology
• Payward
• Pediatrics
Surgical:
• Anesthesia
• Obstetrics-Gynecology
• Ophthalmology
• Operating Room Complex
• Orthopedics
• Surgery
• Urology
Health Programs:
• TB Dots
• Smoking Cessation
• Non-Communicable Disease
• Immunication Program
• Pre-Natal and Family
Planning
• Violence and Injury
Prevention
Clinical Areas:
• Emergency Room
• Out-Patient Department
• Operating Room
• Delivery Room
• Ward
• Intensive Care Unit
• Central Supply Room
Nursing Division
Quality Management System Manual
Section 2. GHMC Profile
Patient Support Services
• Admitting and Information
Unit
• Medical Records
• Nutrition and Dietetics
• Pharmacy
• Medical Social Service Unit
• Patient Assistance and
Complaints Desk (PACD)
Financial Management:
• Accounting Unit
• Budget Unnit
• Billing and Claims Unit
• Cash Management Unit
General Services
• Engineering Unit
• Linen and Laundry Unit
• Housekeeping Unit
• Security Unit
Internal Administrative
Management:
• Human Resource
Management Unit
• Procurement Unit
• Property and Supply
Management
• Central Information
Management Unit
Hospital Operations & Patient Support
GHMC Logo
Out-Patient and Ancillary:
• Pathology and Laboratories
• Radiology
• Radiotheraphy
• Physical Medicine and
Rehabilitation
Medical Division
Office of the GHMC Chief
Name of GHMC
Revision No.
Page No.
0
Effective Date
2 of 6
Sample Organizational Structure
3
Name of GHMC
GHMC Logo
Quality Management System Manual
Section 2. GHMC Profile
Revision No.
0
Effective Date
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2.5 FUNCTIONAL DESCRIPTION
NOTE 2.5
A complete list of the functional description of the offices, departments, and units
listed in the organizational structure should be enumerated in this QMS Manual.
It will be a good reference for the users to know the responsibilities of offices,
departments, or units with respect to the processes covered by the QMS.
Should the GHMC have no clear description of duties and responsibilities, this will
be a good opportunity to discuss and clarify the roles of each office, department,
or unit.
Sample of Functional Description of a GHMC
CHIEF OF GHMC
The chief of hospital/medical center assumes the overall management and administration of the
hospital/medical center, including the formulation of policies, programs, strategies, and plans to
achieve the desired results of the Quality Management System. The chief shall oversee the day-today activities of the hospital/medical center.
MEDICAL SERVICE DIVISION
It is the responsibility of the Medical Service Division to: deliver quality out-patient and in-patient
care; ensure the continuing medical education and training for the medical and paramedical
personnel; and, assist the Chief of Hospital/medical center in the formulation and implementation
of policies and programs. Departments under Medical Division include Internal Medicine,
Pediatrics, OB-Gyne, Surgery, Orthopedics, Anesthesia, Ancillary, among others.
NURSING SERVICE DIVISION
The Nursing Service Division provides full support in the provision of patient care services.
Responsibilities include: recording of medical history and symptoms; collaboration with medical
team to plan for patient care; advocacy for health and well-being of the patient; monitoring of
patient health and recording signs; administration of medications and treatments; handling and
operation of medical equipment; monitoring of implementation of diagnostic tests; and, educating
patients about management of illnesses.
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Name of GHMC
GHMC Logo
Quality Management System Manual
Section 2. GHMC Profile
Revision No.
0
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Units under Nursing Service Division include Emergency Room, Out-Patient Department,
Operating Room, Delivery Room, Ward (Service) and Central Supply Room. The major health
programs of the Nursing Service include the: Tuberculosis Directly Observed Treatment (TBDOTS); Smoking Cessation Program; program for non-communicable diseases, which include
advocacies on healthy lifestyle, immunization program, pre-natal and family planning programs,
and, violence and injury prevention program.
HOSPITAL OPER ATIONS AND PATIENT SUPPORT SERVICES (HOPSS) DIVISION
The HOPSS Division directs and manages the activities and functions of units under its supervision
and implements policies and guidelines for the delivery of effective and efficient support services.
Units under the HOPPS are Internal Administrative Management, Financial Management,
General Services and Patient Support Services.
Human Resource Management Unit – This unit develops and administers comprehensive
the Human Resource Management Plan, which includes recruitment, selection, promotion,
separation, welfare and benefits, training, and other personnel actions and transactions.
Procurement Unit - This unit develops and administers a comprehensive plan of systematic
management of procurement and acquisition of supplies and materials, health care equipment,
vehicles, services, infrastructures, work and other required logistics for the effective and efficient
delivery of quality service.
Property and Supply Management Unit – This unit receives, stores, issues, and conducts
an inventory of supplies, materials and equipment, and disposes of unserviceable/condemned
hospital/medical center properties.
Central Information Management Unit – This unit develops and administers a comprehensive
plan of systematic management of data and research for the improvement of acquisition, utilization
of finances, assets, and development of human resources, operating systems and procedures.
Accounting Unit - This unit directs and coordinates the systematic recording of all financial
transactions, preparation of financial statements and relevant reports, and maintenance and
safekeeping of books of accounts.
Budget Unit – This unit directs and coordinates with the persons concerned in the consolidation
and preparation of the budget proposal, work and financial/operational plans, including its
implementation and monitoring.
5
Name of GHMC
GHMC Logo
Quality Management System Manual
Section 2. GHMC Profile
Revision No.
0
Effective Date
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Billing and Claims Unit - This unit implements proper charging system, by recording all hospital/
medical center procedures, services, medical supplies, drugs and medicines incurred by patients
regardless of patients’ classification, including claims, fees and use of facilities and other nonpatient services.
Cash Management Unit - This unit directs, controls, and ensures the proper disbursement and
collection transactions of the hospital/medical center.
Engineering Unit – This unit prepares and implements comprehensive preventive/corrective/
rehabilitative maintenance program of biomedical, electronic and communication equipment,
electrical, mechanical, structural, civil works, physical plant, motor vehicles, and other health
care equipment/devices.
Linen and Laundry Unit – This unit provides laundry services, and ensures an adequate supply
of clean linens for patients and other hospital/medical center units.
Housekeeping Unit – This unit provides and maintains clean, safe, and sanitary facilities and
environment for hospital/medical center personnel, patients, and clients.
Admitting and Information Unit – This unit directs and controls the centralized registration and
documentation of admission and discharge of patients, including providing information.
Medical Records Unit – This unit directs and ensures an organized system of processing,
analyzing, maintaining and safekeeping of all patients’ records, measuring the quality of patient
care through the written data in the sequence of events covering the diagnosis, treatment, and
discharge of patients.
Nutrition and Dietetics – This unit directs, maintains, and ensures the provision of safe, high
quality, and nutritious food to patients and personnel.
Pharmacy – This unit directs and implements programs, projects, and activities for the provision
of safe, affordable, and efficacious drugs and medicines consistent with the Generics Act of 1988,
Philippine National Drug Formulary, and DOH policies, rules and regulations.
Medical Social Service Unit – This unit directs and implements the programs, projects, and
activities on social services which include social casework, multi-sectoral networking and linkages
in understanding the socio-behavioral and economic plight of patients and their families for the
holistic approach in their management and treatment.
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Name of GHMC
GHMC Logo
Quality Management System Manual
Section 2. GHMC Profile
Revision No.
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Patient Assistance and Complaint Desk (PACD) –This unit assists patients with their complaints,
evaluates their concerns, and facilitates immediate action for their needs. A PACD Officer on duty
helps clients when filling-out a complaint form and forwards it to the department and/or unit
concerned.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
7
Name of GHMC
GHMC Logo
Quality Management System Manual
Section 3. Definition of Terms
Revision No.
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The GHMC adopts the following terms and definitions within its QMS Manual. Where no definition is
provided, the GHMC adopts the definitions provided in ISO 9001:2015 Quality Management SystemFundamentals and Vocabulary.
Annual Procurement Plan (APP)– a requisite document that the hospital must prepare to reflect the
necessary information on the procurement of goods, services, and infrastructure within the calendar
year.
Bids and Awards Committee (BAC) – designated organic office within the hospital/medical center to
monitor procurement activities and discharge functions mandated through the Republic Act No. 9184.
Calibration – an activity conducted to verify or control quality through comparison of measurement
values delivered by a device/equipment/tool/test with those of a calibration standard of known
accuracy measuring equipment or in the case of other resources/tool, applicable standards or acceptable
methodology.
Civil Service Commission (CSC) – an oversight agency that administers and enforces rules and
regulations for the hiring, promotion, and other related matters relating to government employees.
Clinical Pathways – standardized, evidence-based, multidisciplinary management plans, that identify
appropriate sequence of clinical interventions, timeframes, milestones, and expected outcomes for a
homogenous patient group.
Commission on Audit (COA) – an oversight agency that has the power, authority, and duty to examine,
audit, and settle all accounts pertaining to the revenue and receipts of expenditures or uses of funds and
properties of government offices.
Consequence (as risk and opportunity criterion) – degree of impact of the risk or opportunity identified
to the attainment of the hospital’s objectives and enhancement of patient satisfaction, if not treated
Continual Improvement – a recurring activity or effort to improve products, services, and processes
to help increase the organization’s ability to fulfill requirements and enhance the satisfaction of relevant
interested parties.
Control – any measure or action that directs or influences the process toward effectiveness and
efficiency; includes any policy, procedure, practice, process, technology, device or method that modifies
or manages processes.
Controlled documents – documents that are official and updated, the distribution and maintenance of
such are managed by the responsible unit for safekeeping and promptly updating necessary revisions.
Corrective Action – an action taken to a nonconformity detected to address the system failures and
prevent its recurrence; usually recorded in a Request for Action form.
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Name of GHMC
GHMC Logo
Quality Management System Manual
Section 3. Definition of Terms
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Effective Date
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Data Privacy Act or DPA/Republic Act No. 10173 – an act protecting individual personal information
in ICT (information and communication technology) systems in the government and the private sector.
Department of Budget and Management (DBM) – the oversight agency that monitors the sound,
efficient, and effective management and utilization of government resources.
Department of Health (DOH) – the principal health agency that holds the overall technical authority
on health as it is both a national health policy-maker and regulatory institution.
Document – documented information maintained by the hospital; contains policies, procedures,
instructions, and reference information.
Document Custodian – designated personnel or unit of the hospital tasked to manage the generated
documents and records.
Documented information – information required to be controlled and maintained or retained by the
hospital and the medium on which it is contained, e.g., manuals, procedures, hospital policies.
Executive Order No. 02 s.2016 Freedom of Information Bill – requires all executive departments,
agencies, bureaus, and offices to disclose public records, contracts, transactions, and any information
requested by a member of the public, except for matters affecting national security and other information
that falls under the inventory of exceptions.
External documents – issuances, specifications, requirements and other documented information from
other government agencies, suppliers and system standards; documented information that are NOT
created within the hospital.
Hospital – a place devoted to the timely maintenance and operation of facilities for the diagnosis,
treatment, and care of individuals suffering from illness or deformity or in need of other medical or
nursing care (Republic Act No. 4226).
Infection control - discipline concerned with preventing nosocomial or hospital care-associated
infection; a practical (rather than academic) sub-discipline of epidemiology.
Internal documents – policies, guidelines, memo, and other documented information internally
generated/originated within the hospital.
Internal Quality Audit (IQA) – systematic, independent, and documented process for obtaining audit
evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled.
IQA Team – a mobilized team within the hospital responsible for conducting the audit or performing
the audit program.
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Likelihood (as risk and opportunity criterion) – the probability of occurrence of the risk or opportunity,
when not addressed.
Management Review – An evaluation of QMS performance by the GHMC’s Chief/Head and its
Management that includes formal meeting/s, review, and status reporting of required agenda for the
purpose of gathering information as inputs to decision-making toward continual improvement.
Masterlist of Documents – register of internal and external documents maintained by the Document
Custodian; contains information like title, document code, effective date, and the like.
Monitoring and measuring resources – devices/equipment/tools/tests needed by
the hospital to provide evidence of conformity of product or services to determined
requirements, e.g., cardiac monitor, blood pressure apparatus, psychiatric tests, among others.
National Archives of the Philippines (NAP) – a government agency that guarantees the preservation and
accessibility of public documents and records through its formulation and implementation of a records
management and archival administration program for the efficient creation, utilization, maintenance,
retention, preservation, conservation, and disposal of public records including the adoption of security
measures and vital records protection program for the government.
Needs and expectations – feelings, needs, and ideas that patients and other relevant interested parties,
either explicitly or implicitly stated, have toward certain products or services provided by the hospital.
Nonconformity (NC) – non-fulfillment of a requirement, i.e., hospital policy, documented procedure,
statutory and regulatory requirements as well as client requirements.
Obsolete copy –outdated documented information for archiving.
Office Performance Commitment Review (OPCR) – a performance evaluation tool that all heads
of offices accomplish; must officially identify and declare the targets for the rating period and be in
accordance with the overall strategy map and commitments of the GHMC.
Opportunities – set of circumstances that can lead to the adoption of new practices, launching of new
products and services, addressing new clients and other desirable and viable possibilities to address the
GHMC’s needs.
Organizational knowledge – specific knowledge to the organization, generally gained by experience,
which is used and shared to achieve the objectives of the hospital; can come internally, such as intellectual
property, lessons learned from failure and successes, or the results of improvements; or it can come
externally from conferences, customer knowledge, or supplier knowledge.
Patient – the main client of the hospital who receives medical care and attention.
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Stakeholders’ satisfaction survey – a methodology to measure how patients and their significant others
feel about the hospital or their experience with the hospital.
Performance targets – the desired level of performance as measured by indicators that represent success
at achieving hospital outcomes.
Personal protective equipment (PPE) – garments worn to minimize exposure to hazards that cause
serious workplace injuries and infection, which may include safety glasses, shoes, masks, respirators,
coveralls, vests, and full body suits .
Philippine National Drug Formulary – an integral component of the Philippine Medicines Policy,
which contains essential medicines list and ensures rational prescribing, dispensing, and administration
of medicines.
Process – set of interrelated or interacting activities that use inputs to deliver an intended result, e.g.,
provision of patient care services is a process with a set of interacting activities performed by authorized
offices, departments or units, and personnel to ensure patient safety and treatment.
Process Map – planning and management tool that visually describes the interaction of interdependent
processes.
Quality Management System (QMS) – management system to direct and control an organization with
regard to quality.
Quality Objectives – result to be achieved by the hospital; can be strategic, tactical or operational.
Quality Policy – intentions and direction of the hospital as regard to the quality of its management
system.
Records – documented information retained by the hospital; provides evidence of implementation of
the QMS.
Records Disposition Schedule (RDS) - documents the major records (including electronic records)
related to the activities of each office; identifies temporary and permanent records; provides mandatory
instructions for the retention and disposition (retirement or destruction) of each record based on their
temporary or permanent status.
Relevant Interested Parties – persons or organizations that can affect, be affected by, or perceive itself
to be affected by the hospital decision or activity; also refer to stakeholders in this Manual.
Republic Act No. 9184 Government Procurement Reform Act – prescribes the necessary rules and
regulations for the modernization, standardization, and regulation of the procurement activities of
government offices.
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Request for Action (RFA) form – the tool used to document the nonconformities, including those
from audit findings, and the corresponding root causes, corrective action plans and results of the
implementation of the corrective action plan.
Risk – effect of uncertainty on objectives; often described by an event, a change in circumstance or a
consequence; characterized and measured in terms of its consequence and likelihood.
Risk analysis - a process that is used to understand the nature, sources, and causes of the risks identified,
to estimate the level of risk; used to study consequences and likelihood, and to examine the controls that
currently exist.
Risk and opportunity register – the documented information used to review and monitor the context
of the hospital and its corresponding risks, opportunities and treatment or action plan.
Significant others – the family, companion or guardian of the patient during the time of care and
treatment by the hospital.
SWOT analysis - (strengths, weaknesses, opportunities and threats analysis) a framework for identifying
and analyzing the internal and external factors that can have an impact on the viability of a hospital’s
performance and stakeholders’ satisfaction.
Statutory and regulatory requirements – obligatory requirements specified by the country’s authorities
and mandated by legislative bodies.
Top management – person or group of people who direct and control the hospital; usually refers to the
Executive Committee or Management Committee.
Treatment plan – the plan of action to mitigate risks and take advantage of opportunities.
Validation of processes – collection and evaluation of data prior to delivery of products and services to
establish evidence that the process as well as the product or service is capable of delivering its intended
results.
World Health Organization (WHO) – a specialized agency of the United Nations that is concerned
with international public health; with a function of proposing conventions, agreements and regulations,
and making recommendations with respect to international health matters.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Section 4. GHMC and its Context
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4.1 UNDERSTANDING THE GHMC AND ITS CONTEXT
During the strategic planning and target setting of the GHMC, the management identifies internal and
external issues through SWOT (strengths, weaknesses, opportunities, and threats) analysis. The GHMC
determines internal issues (i.e., values, culture, and knowledge) and external issues (i.e., legal, market,
cultural, technological, social, economic, international, national, regional and local) that are relevant
to its purpose and strategic direction; and, that can affect its ability to achieve holistic, safe, responsive,
complete, and compassionate patient care services.
4.2 UNDERSTANDING THE NEEDS AND EXPECTATIONS OF RELEVANT INTERESTED
PARTIES
The GHMC clearly understands its relevant interested parties, which include patients, patients’
significant others, hospital management and staff, suppliers, and other key external stakeholders.
Through analysis, the needs and expectations of these relevant interested parties, which are listed in
Annex A, are identified and considered during plannig activities.
4.3 SCOPE OF THE GHMC’S QMS
The GHMC’s QMS covers the Provision of Patient Care Services. The scope covers the management,
operations, and support processes of the GHMC, as indicated in the process map below.
NOTE 4.1
GHMC may exclude ISO 9001:2015 Clause 8.3 Design and Development with
the justification that patient care services are based on local and international
standards. Thus, there is no actual design and development activitites in the
course of the delivery of patient care services. However, some GHMC consider
the development of clinical pathways, which are required by the Philippine Health
Insurance Corporation (Philhealth) among government hospitals, as design and
development activity; thus, Clause 8.3 is not an exclusion.
NOTE 4.2
Medical Centers have Research and Training as one of its core functions, other than
the provision of patient care services. This Manual does not cover this function.
However, should the GHMC decide to include Research and Training in the QMS
Scope, it has to be integrated into the process map with specific details added as a
separate section after Section 8.0.
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4.4 GHMC’S QMS AND ITS PROCESSES
The GHMC’s high-level process map, Figure 1, illustrates that processes of the GHMC’s QMS and their
interaction in providing patient care services. The process map is divided into three groups of processes,
namely:
•
•
•
Management Processes - processes needed for oversight and governance of GHMC’s quality
management system;
Opetations Processes - processes needed to realize the planned activities in performing
processes and allow GHMC to deliver the intent of the output of the operations, i.e., provision
of patient care management services, that define the core of GHMC’s service; and,
Support Processes - processes needed to manage the resources necessary to ensure the
satisfactory performance of the provision of patient care management services.
These three groups of processes (with appropriate controls over the external providers of products,
services, and processes) are working together to provide an integrated and comprehensive health care
as the end goal of the GHMC’s QMS.
A. Management Process
The GHMC, through its planning activities, sets directions, policies, and work and financial plans
for the operations to perfrom and deliver the desired outputs and organizational outcomes. it also
implements regular monitoring and evaluation of the effectiveness of the GHMC’s QMS through
accomplishment reporting, exercutive committee meetings, management reviews, internal audit,
and analysis of stakeholders’ feedback, among others.
B. Operational Processes
The GHMC’s operational processes refer to the provision of patient care services that include, but
not limited to, the following: (a) receiving and registration of patients; (b) initial assessment and
treatment in the out-patient department and emergency room; (c) laboratory diagnostics; (d) inpatient care and treatment; (e) disposition and discharge of patients; and, (f) care for discharged
patients.
Controls for the patient and relevant interested parties’ requirements and operational inputs, GHMC
processes, and patient care services and products are applied by the concerned units or departments
to ensure an integrated and comprehensive health care.
C. Hospital/Medical Center Support Processes
The hospital/medical center’s support processes provide the necessary administrative and logical
support to the operations for the effective delivery of patient care services. Support processes include
the administrative services, ancillary services, financial management, and hospital/medical center
information management.
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Patient & Relevant Interested Parties
Performance
Evaluation
Diagnostics
• Laboratory
Exams
• Diagnostic
Imaging
• Other
Diagnostic
Services
In-Patient Care
& Treatment
• Admission
• Medical
Treatment
• Nursing Care
• Dietary Services
• Pharmacy
• Medical Social
Service
Financial
Management
Procurement of
Goods and Services
Ancillary
Services
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Section 4. GHMC and its Context
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Patient & Relevant Interested
Parties’ Satisfaction
Performance
Targets
Externally-Provided Products, Services, and Processes
Management of
Hospital/ Medical
Center Information
Hospital/ Medical
Center Infrastructure
Disposition
& Discharge
of Patients
• Discharged
• Referral
• Expired
Continual
Improvement
Hospital/Medical Center Operations and Patient
Initial
Assessment &
Treatment
• Consultation
• Out-Patient
• Care and
Treatment
Core Processes
Provision of Patient Care Services
Management System
Planning
Human Recource
Management
Receiving &
Registration
of Patients:
• Issuance/
Retrieval
of Patient
Record
• Triaging
Leadership &
Governance
Management Processes
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Needs and
Expectations
Internal and External Issues
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Figure 1. Sample GHMC Process Map
Patient Care
Services
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NOTE 4.3
The process map may be changed based on how the GHMC prefers to illustrate
the interaction of processes covered in the QMS. Use the terms more commonly
and appropriately used in the GHMC. Ensure that all key processes performed by
all offices, departments, and units are included in the process map. Key processes
refer to the major processes. There is no need to include sub-processes. Instead,
sub-processes may be defined in the respective sections of this QMS Manual and/
or in the Procedures Manuals and other documented procedures.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Section 5. Leadership and Governance
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5.1 DEMONSTR ATION OF LEADERSHIP AND GOVERNANCE
The GHMC Executive Committee (ExeCom) includes the chief of hopsital/medical center, the departments/
section Heads, and the service/division Heads. The management views its QMS as a strategic asset that
will help in achieveing their organizational goals and in the continual improvement of GHMC as an
organization. It provides evidence of leadership and commitment through the following:
•
•
•
•
•
•
•
Active involvement in the establishment, implementation, monitoring, and evaluation of the
QMS;
Establishment of the quality policy and quality objectives, i.e., Office Performance Commitment
Review (OPCR), Division Performance Commitment Review (DPCR), and Balanced Scorecard;
Integration of the GHMC’s QMS with its operations, promotion of the process approach and
risk-based thinking;
Provision of appropriate and adequare resources, dissemination of the importance of
conformance to requirements;
Ensuring achievement of the intended results of its QMS;
Creating a work environment that encourages the GHMC’s management and staff to contribute
to the effectiveness of QMS; and
Encouraging continual improvement and providing support to all the management and staff of
the GHMC.
NOTE 5.1
The top management may be referred as Execom or Mancom. This may be
customized based on the applicable terminology.
NOTE 5.2
The quality objectives of the hospital/medical center may also refer to a balanced
scorecard, or other planning, documents specifying the performance targets for
a year.
5.2 FOCUS ON PATIENTS AND RELEVANT INTERESTED PARTIES
The GHMC management ensures that the needs and expectations of the patients and other relevant
interested parties as well as the statutory, regulatory, and other relevant requirements are determined
to ensure the delivery of integrated and comprehensive health care services towards stakeholders’
satisfaction. This is accomplished through the conduct of regular and effective communication with the
patients and other relevnt interested parties through various feedback management mechanisms, such
as the conduct of Stakeholders’ Satisfaction Survey to gather relevant feedback on the delivery of the
GHMC’s services, and the presence of a Patient Assistance and Complaint Desk (PACD) to ensure that
complaints and issues of relevant interested parties are addressed in a timely manner.
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5.3 QUALITY POLICY
The GHMC maintains its Quality Policy, which is documented in Figure 2 of this QMS Manual. The
Quality Policy specifies the GHMC’s commitment to deliver the highest standard of quality health
care services that is compliant with statutory, regulatory, and other relevant requirements to ensure
an integrated and comprehensive health care and attain stakeholders’ satisfaction. This policy is
communicated to ensure that it is understood at all levels of the hospital/medical center. Employees’
comprehension and understanding of the quality policy may be verified through, but not limited to,
QMS audits, management reviews, and staff meetings.
The GHMC management is responsible for ensuring that the quality policy is appropriate to the hospital/
medical center’s mandata and provides a framework for establishing and reviewing quality objectives
and goals. This is reviewed at least once a year to ensure continuing improvement and suitability to the
GHMC’s mandate and thrusts, including the relevant stakeholders’ requirements.
Figure 2. Sample Quality Policy
The GHMC Quality Policy
We, the GHMC management and employees, are dedicated to fulfilling the highest quality patient
care services to delivery an integrated and comprehensive health care to the Filipinos.
We shall provide quality, compassionate, effective, efficient, equitable, and holistic health care
services; comply with all pertinent laws, locl, and international health care standards; and
continually enhance our skills, upgrade hospital/medical center facilities and equipment, sustain
the availability of safe and quality medical supplies.
NAME
Hospital/Medical Center Chief
NOTE 5.3
The Quality Policy in this QMS Manual may be signed by the hospital/medical
center chief. It should be issued as an approved documented information using the
GHMC’s existing system for internal issuances, e.g., memo. It may be approved
and issued earlier than the approcal and issuance of this QMS Manual, for early
dissemination and implementation.
Some best practices to ensure awareness of employees of the Quality Policy include
recitation during flag ceremonies and posting of Quality Policy on strategic places
(e.g., desktop/laptop wallpapers, hallways, among others).
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5.4 ORGANIZATIONAL ROLES, RESPONSIBILITIES, AND AUTHORITIES
The responsibilities and authorities of all personnel and functions within the GHMC are defined in the
approved organizational structure, issued special orders/personnel orders, functional/organizational
charts, job/position descriptions, and manuals or work procedures. Although some authority may be
delegated, the overall responsibility and accountability of the GHMC’s QMS, including the management
of changes, as may be needed, remains with the GHMC’s top management.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Section 6. Management Systems Planning
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6.1 ADDRESSING RISKS AND OPPORTUNITIES
During the strategic planning of the GHMC, an analysis of the needs and expectations of the relevant
interested parties and the internal and external issues is done. Through this, the GHMC identifies risks
that it needs to address to prevent negative effects on its performance as well as the opportuniteis that it
wants to pursue to improve its performance.
The organizational level issues are identified through the SWOT analysis, where strategies are determined
and planned to ensure that the internal strengths are utilized to address weaknesses, minimize threats,
and take advantage of opportunities. These are usually documented in the GHMC Strategic Plan.
Each office, department or unit also identifies process-related risks and opportunities with corresponding
treatment/action plans. These risks and opportunities are registered in Annex B, where risk and
opportunity level is analyzed through the impact of consequence and the likelihood to happen, and
treatment plans are identified, implemented, monitored, and evaluated regularly. The results of the
evaluation of the effectiveness of the actions taken to address risks and opportunities are discussed
during management review.
Below are the instructions in filling out the Risk and Opportunity Registers:
•
•
•
•
•
•
•
•
Risk/Opportunity Description - Define risk/opportunity area, short description of risk/
opportunity event, and its consequences. What can go wrong (risk) or what can happen
(opportunity)? What are the impacts/consequences if it foes go wrong (risk) or it actually
happens (opportunity)?
Risk/Opportunity Causes - Describe the risk/opportunity event cause/s. What would cause it
to go wrong? Or for it to happen?
Current Controls/Situation - Describe any existing policy, procedure, practice or mechanism
that acts to minimize the risk or maximize the oppotunity. What is in place now that reduces the
likelihood of this risk occuring or its impact if it does occur? What is being done to maximize
the benefits of the opportunity if it does occur?
Likelihood - Rate the level of the likelihood of occurence of the current risk/opportunity from
1 to 5 based on the appropriate criteria below. How likely is this risk/opportunity to occur?
Severity - Rate the level of impact from 1 to 5 based on the appropriate cirteria below. To what
extent would the impact/consequence of this risk/opportunity be if it occurs?
Risk/Opportunity Magnitude - Multiply the rating for Likelihood and Consequence. The
product, based on the criteria below, is used to determine whether the risk or opportunity level
is high, medium or low, and the corresponding level of action that needs to be taken.
Treatment Plan - Describe the actions to be undertaken for the risks/opportunities requiring
further treatment, as indicated in the criteria set forth.
Responsible - Identify the office, department, or unit responsible ot implement the treatment
plan.
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Target Date - Define the target date of implementation of the treatment plan.
Risk/Opportunity Rating After Treatment - Evaluate the risk/opportunity after completion of
the treatment plan by reassessing using the criteria for likelihood of occurrence and consequence.
The GHMC uses the following criteria as reference in analyzing the likelihood of risks and opportunities:
Rate
Risk/Opportunity Likelihood
Rare
1
Not known to happen
Low
2
Low occurrence of one (1) in a year
Medium
3
Known to happen, occurrence of one (1) in a quarter
High
4
Very likely to happen, occurrence of more than one (1) in a quarter
Very High
5
Highly likely to happen, occurrence of one (1) in a month
In analyzing the severity of risks, the following rating scale is used:
Rate
Risk Severity
Insignificant
1
Not known to happen
Minor
2
Low occurrence of one (1) in a year
Significant
3
Known to happen, occurrence of one (1) in a quarter
Major
4
Very likely to happen, occurrence of more than one (1) in a quarter
Catastrophic
5
Highly likely to happen, occurrence of one (1) in a month
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LIKELIHOOD
The following table shows the risk ratings where the likelihood and severity criteria are mapped out.
The higher the number means the higher the prioritization/degree of treatment plan to be done in order
to minimize the negative consequences of risks:
Rare
1
2
3
4
5
Low
2
4
6
8
10
Medium
3
6
9
12
15
High
4
8
12
16
20
Very High
5
10
15
20
25
Insignificant
Minor
Significant
Major
Catastrophic
SEVERITY
In analyzing the benefits of opportunities:
Rate
Opportunity Consequence
Not Very
Beneficial
1
No perceived calue for improvement and sustainability
Not Beneficial
2
Pursuing the opportunity will slightly improve QMS and its sustanability
Moderately
Beneficial
3
Pursuing the opportunity will considerately improve QMS and its
sustainability
Beneficial
4
Pursuing the opportunity will highly improve QMS and its sustainability
Very Beneficial
5
Pursuing the opportunity will greatly improve QMS and its sustainability
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LIKELIHOOD
Meanwhile, the following table is used for the identification of the opportunity ratings, in which the
higher the value, the better is the effect to the QMS:
Rare
1
2
3
4
5
Low
2
4
6
8
10
Medium
3
6
9
12
15
High
4
8
12
16
20
Very High
5
10
15
20
25
Not Very
Beneficial
Not
Beneficial
Moderately
Beneficial
Beneficial
Very
Beneficial
SEVERITY
The following table shows the criteria in addressing risks and opportunities ratings, individually. It
has three (3) levels of priority, which serves as a guide for management’s treatment plan on risks and
opportunities:
Risk/
Opportunity
Rating
Opportunity
10 - 25
Treatment Plan
Risk
Opportunity
High
Take immediate appropriate
action to eliminate the risk
Pursue the opportunity
5-9
Medium
More frequent monitoring of
performance/complaints
May consider pursuing the
opportunity
1-4
Low
No action required
No action required
Moreover, the following table shows a matrix used as basis whenever specific programs, activities,
and projects are proposed toward the improvement of the QMS such as the proposal of new policies,
procedures, reorganization, opening of new programs etc.
Risk
High
HR/HO
HR/MO
HR-LO
Medium
MR/HO
MR/MO
MR-LO
Low
LR/HO
LR/MO
LR-LO
High
Medium
Low
Opportunity
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The GHMC updates the Risk and Opportunity Register where the last column indicates the reassessment
of the risk and opportunity after completing the implementation of the treatment plan. If the risk rating
lowers and the opportunity rating remains high or even gets higher, it means that the treatment plan
is effective, otherwise, the GHMC Chief reviews the Registers to evaluate the effectiveness of actions
taken, and take subsequent action thereafter.
NOTE 6.1
The GHMC may have other risk assessment guidelines being used. This is also
acceptable and may be used provided that the minimum requirements of the ISO
9001:2015 standard Clause 6.1, Actions to Address Risks and Opportunities, are
fully met.
NOTE 6.2
For further reference on the Risk Management System, please refer to ISO
31000:2018 Risk Management Guidelines.
6.2 MANAGEMENT SYSTEM OBJECTIVES
The GHMC management ensures that quality objectives, including those needed to meet the requirements
for the delivery of patient care services, are established at relevant functions and levels within the
organization through the Office Performance Commitment Review (OPCR) documents. Each office,
department, or unit also prepares operational plans, work and financial plans, annual procurement plans,
documented procedures, among others, to define clearly the activities to be performed, responsibilities
of offices and individuals, and the resources needed generally to attain the set quality objectives.
The GHMC management ensures that the planning for the QMS is carried out in order to meet the
general requirements of QMS as well as the GHMC’s quality objectives by preparing and continually
reviewing and measuring patient care processes and services, organizational structures and operations
plans, and documenting management and work processes. These processes of monitoring, documenting,
reviewing, and measuring ensure that the integrity of the QMS is maintained when changes to the QMS
are planned and implemented.
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NOTE 6.3
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The GHMC may also use any other form of document, e.g., balanced scorecard, to
document the quality objectives. The quality objectives should be:
• specific, measurable, attainable, realistic, and time-bound;
• established at all levels, functions, and processes within the GHMC, which
means that all offices/units and processes have quality objectives and these
are aligned with the overall objectives of the GHMC;
• consistent with the overall direction and commitments of the GHMC
established in the Quality Policy;
• supported by the necessary resource in order to achieve them;
• monitored, reviewed, and evaluated regularly; and,
• communicated and cascaded to all employees.
6.3 PLANNING OF CHANGES
The GHMC prepares transition plans, project work plans, and other similar documented information
whenever needed to ensure that operations of the hospital/medical center are not affected in times of
management and operational changes.
NOTE 6.4
If the GHMC has existing guidelines on managing changes in the organization,
e.g., Change Management Plan or Change Management Procedure, this should be
mentioned in this section. Ensure that existing practices to manage organizational
changes are also mentioned here.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Section 7. Management System Support
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7.1 MANAGEMENT SYSTEM RESOURCES
The GHMC determines and provides the necessary resources to ensure that the QMS is maintained,
sustained, and continually improved. These resources include human resource, infrastructure and
work environment, budget and finance, procured goods and outsourced services, and documented
information.
NOTE 7.1
Note that additional support services may be provided, as appropriate to the
GHMC. The titles of each sub-section should reflect the actual name of the
process/es used by the GHMC
NOTE 7.2
In some GHMC, the unit in-charge of support processes may not be responsible for
the GHMC infrastructure management and financial management. The GHMC
may revise and customize this section as applicable.
A. Human Resource Management
GHMC believes that human resource is its greatest asset. Thus, it ensures to provide: an effective
recruitment, selection, and placement; relevant learning and development interventions; effective
performance management; and, employee welfare and development in accordance with the CSC’s
PRIME HRM.
NOTE 7.3
The GHMC may also cite the Philhealth’s Benchbook in maintaining the
requirements for accreditation, particularly on GHMC personnel, if PRIME HRM
is not yet implemented.
1. Recruitment, selection, and placement
The recruitment, selection and placement of personnel are based on the existing CSC rules and
regulations. While the CSC Qualification Standards set the minimum qualification for hiring, the
GHMC may set its specific standards both for medical and non-medical personnel as basis for
hiring to ensure that they could perform their functions competently and at par with applicable
local and international standards.
The GHMC and Credentials Committee ensures that the recruitment, selection, and placement
procedures are implemented in accordance with the minimum standards of the CSC and the
DOH, i.e., equal opportunity policy. All appointments are made based on merit to attract
sufficient applications from potential candidates for appointment with the skills, qualities,
abilities, experience, and competencies deemed as necesssary to the job. The Human Resource
Management Unit (HRMU) observes the regulatory requirements that apply to the recruitment
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To ensure effective delivery of patient care services, the GHMC augments its manpower
requirement through the employment of personnel under Job Order or Contractual status.
2. Learning and development
The GHMC is committed to continually and strategically address the competency needs of its
employees and ensure continual improvement to adapt to the ever-changing health environment
and keep abreast of technological and technical advancements in their respective medical fields.
The HRMU assesses the competencies of all the GHMC employees periodically through the
Competency-Based Training Needs Analysis where employees’ current levels of competency,
behavior, skill or knowledge, in one or more areas, are identified and compared with the
required competency standards established for their positions or other positions within the
GHMC. Another form of competency assessment is through the performance evaluation of the
employees, i.e., Individual Performance Commitment Review (IPCR), where the immediate
supervisor assesses the competency gaps of an employee based on his/her performance and
recommends appropriate action plans to address those gaps.
The results of assessments are used in the preparation of the office, department or unit annual
learning and development (L&D) plan which contains the human resource development
interventions such as in-house and externally provided technical and behavioral training courses,
education program, coaching and mentoring, on-the-job training, and other formal and informal
interventions, for each employee.
These are consolidated and reviewed by the HRMU, together with the Professional Education,
Training, and Research Office (PETRO), ensures the proper consolidation and coordination of
all personnel professional education, training, and research activities and develops the GHMC
L&D Plan for the year. The plan also includes the conduct of the regular programs initiated by the
HRMU such as orientation for new employees, values orientation, stress and time management
courses, and team building workshops.
The effective implementation of the L&D Plan is supervised and monitored by the HRMU
through facilitation, documentation, and evaluation of the in-house training and other internally
initiated L&D interventions, for traceability and continual improvement of the L&D activities.
The evaluation of the effectiveness of the L&D interventions is done through the Course
Evaluation Form that is being accomplished by the employees. The Course Evaluation measures
the attainment of the course objectives, appropriateness and relevance of the course to the job of
the participants, effectiveness of the methodology and resource persons, and the appropriateness
of the training venue and other training logistics. Also, after three to six months of attending
the course, the immediate supervisor is required to evaluate the effectiveness of the course
in improving employee performance in relation to the course attended. The results of these
evaluation mechanisms are used continually improve the type of L&D intervention.
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3. Performance management
The GHMC believes that career advancement is one of the most important elements for employee
satisfaction and retention in the GHMC. Thus, through the semestral rating of the IPCRs of the
employees, the immediate supervisor provides clear career paths to motivate them and make
them more focused at work. Employees are provided with opportunities to expand their skill sets,
handle additional responsibilities that can lead to promotion, acknowledge accomplishments,
and offer a tailored career advancement plan that aligns with their personal and professional
goals.
The promotion of employees are done through recommendations that are being reviewed by the
Personnel Selection and Recruitment Board (PSRB) and the Medical Credential Committee in
accordance with the CSC rules and regulations.
4. Employee welfare and benefit
Other than the statutory benefits for the employees, the GHMC provides welfare and benefits
as well as rewards and recognition schemes to keep the employee motivation high, improve
camaraderie, ensure their health and safety, and promote employee satisfaction. These include
mandatory government benefits and other approved benefits issued by the GHMC, regular teambuilding activities, birthday celebrations, etc.
B. GHMC Infrastructure Management
The GHMC ensures the provision of adequate, conducive, safe, and sanitary infrastructure to
efficiently deliver the needed health care services. Among the infrastructure provided and maintained
are GHMC building, facilities, utilities, and equipment which include, but not limited to, electrical
power distribution, elevators, PWD access, air-conditioning units, water supply and drainage system,
emergency power generator, ICT equipment, and biomedical equipment.
A standard procedure is maintained by the GHMC for the identification of needs and requirements
for new, and/or modification or repair of its existing infrastructure and facilities
1. Facilities and equipment
Health Engineering and Maintenance Unit (HEMU) ensures that infrastructure, equipment,
and facilities such as building, workspaces, and associated utilities are appropriate and are
properly maintained to achieve conformity and provide a safe environment in compliance with
local, national and/or international codes, standards, and regulations on the construction and
operation of the GHMC facilities and utilities.
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HEMU also implements the preventive maintenance of all infrastructure, facilities, and equipment
of the GHMC and responds to repair requests to ensure its availability and serviceability at all
times in support of GHMC operations.
2. GHMC vehicles
HEMU is also responsible for ensuring the adequacy, availability, and serviceability of the service
vehicles and ambulance through the conduct of daily monitoring of fuel, oil, gauges, and other
accessories and regular preventive maintenance such as the change oil, parts inspection, etc. It is
also responsible for ensuring that ambulance drivers are licensed and trained in accordance with
the ambulance services guidelines.
3. Housekeeping
The primary function of the Housekeeping Section (HS) of the GHMC is the maintenance of a
clean, sanitary, and safe environment for patients and GHMC employees. The HS also ensures
the cleaning, sanitation, and disinfection of comfort rooms, lavatories, and all assigned areas,
and implements proper tools/supplies and equipment management. To ensure that infection
prevention controls are in place, the GHMC Infection/Prevention Control Committee promulgates
policies and guidelines to ensure the safety of GHMC employees, patients, and other relevant
interested parties.
Wastes are disposed of in accordance with the GHMC waste management standards set by the
regulating bodies. The collection of segregated wastes is regularly done in various areas of the
GHMC and dumped at the GHMC collection bin prior to the collection of the LGU General
Services.
4. Information technology
The IT Unit maintains the IT infrastructure, which includes the computers, network, and
database systems, of the GHMC. It processes requests for troubleshooting through an effective
system of monitoring of job requests and feedback mechanisms. The IT Unit also implements
preventive maintenance activities for IT infrastructure like scheduled data back-up, hardware
cleaning, software virus scanning, and the like.
The GHMC ensures the safety and security of data and complies with the Data Privacy Act.
5. Security and disaster risk management
The Security Personnel, externally provided but supervised by the General Services Division,
maintains peace and order and enforces rules and regulations within the GHMC. Inspection
upon entry to the GHMC, regular roving within the GHMC facilities, and reporting of incidents
are some of the security activities being performed by the externally-provided Security Personnel.
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Appropriate precautionary measures are also installed to prevent/mitigate the impact of natural
and man-made disasters such as floods, earthquakes, climate change, and noise, among others.
Disaster risk management plans are also prepared, implemented, and monitored by the Disaster
Risk and Recovery Management Committee.
NOTE 7.4
In some GHMCs, security and disaster risk management are two separate
functions. The GHMC may customize this section accordingly.
C. Financial Management
The Finance Service is composed of Accounting, Budget, Cash Operations, and Billing and Claims
Units, which facilitates accountability, continuously improves and refines financial plans, ensures
the use of appropriate accounting standards for timely, complete, and accurate financial reporting,
ensures prudent and effective use of financial resources and application of internal controls at all
levels, and recommends measures to improve management of financial resources.
The Finance Service also safeguards the assets of the organization through strict compliance with the
National Government Accounting System and the Government Accounting and Auditing Manual.
D. Logistics and Supplies Management
The GHMC ensures that goods and services needed in hospital/medical center operations are
managed effectively and efficiently. This includes the procurement of goods and services, supplies,
and inventory management.
1. Procurement of goods and services
The procurement of goods and services for the GHMC is in accordance with Republic Act No.
9184, and other regulatory and statutory requirements. All procurement activities shall be within
the approved budget of the GHMC and shall be meticulously and judiciously planned. No
procurement shall be undertaken unless it is in accordance with an approved Annual Procurement
Plan (APP). The GHMC adopts competitive bidding as the general mode of procurement.
Alternative methods such as negotiated procurement, shopping, and emergency procurement
shall be resorted to only in highly exceptional cases and duly approved by the chief of GHMC.
The Bids and Awards Committee (BAC) oversees and manages the procurement activities of
the GHMC. The BAC and the Technical Working Group (TWG) evaluate and select suppliers
or providers of the goods and services in accordance with the GHMC’s requirements. Criteria
for selection, evaluation, and periodical re-evaluation of suppliers are established. The results of
evaluations and necessary follow-up actions are recorded and maintained. The BAC Secretariat
provides administrative support to the BAC and the TWG and keeps the records of the GHMC’s
procurement activities.
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2. Inventory and supplies management
The GHMC ensures that all supplies, materials, equipment, and other resources in its care
are accounted for and safeguarded against loss and wastage. The Supply Section is responsible
for receiving, managing, monitoring, and issuing supplies, materials, equipment, and other
resources to the end-users.
To ensure that goods and services received are in accordance with specified requirements by
the end-users, an Inspection Committee implements inspection and other activities necessary for
verification of the purchased product/service in relation to the specified purchase requirements.
The Supply Section also conducts regular inventories and updating of the stock card to ensure
that supplies, materials, equipment, and other resources are readily available and provided to the
end-users. Issuance of supplies, materials, equipment, and other resources are based on request
from end-users.
NOTE 7.5
The GHMC may mention its good practices in inventory and supply management.
E. Management of Documented Information
The GHMC’s QMS has established and consistently monitors controls of all essential documented
information affecting the processes within the scope of its QMS to ensure their availability, suitability
for use and their protection.
1. Control of documents
The documented information that is maintained for the effective operations of the GHMC
are referred to as documents. This includes documents that provide directions, guidance, and
instruction by nature. Thus, examples of these include internal and external documents, such
as Memorandum Orders, Special Orders, Plans, QMS Manual, Service/Operations Manuals,
Standard Operating Procedures, Flowcharts, Guidelines, Registers/Matrices, issuances and
Memorandum Circulars of oversight agencies, among others.
All documents are created or updated by a process owner, reviewed and approved for adequacy
by authorized personnel prior to use. Once the document is approved, the document is forwarded
to the Document Custodian (DC), who is designated to manage the process of creation, review,
distribution, use, and revision of GHMC’s QMS documents. A Local Document Custodian
(LDC) is also designated to facilitate the same process within offices, departments or units. The
DC/LDC maintains a Masterlist of Documents that serves as a directory of officially released
documents indicating the current versions of all documents.
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Documents are reviewed by the original author or another subject matter expert or GHMC
management every three years or as necessary. The DC ensures reevaluation is conducted and
that documents are updated, if required. The DC maintains a record of document reevaluations
to identify when documents are due. If a document requires updating, the changes are made and
a new version is issued.
Controls for the effective distribution of documents apply to documents that are of internal and
external origin. The DC/LDC maintains a Distribution List containing the offices/units that
were provided hardcopy of the documents. The DC affixes a signature on hardcopy documents
to identify the officially distributed documents.
Any changes to documents that require interested parties’ review and approval are submitted
accordingly, and not implemented until such approval is obtained. If document changes require
Interested Parties’ approval prior to implementation, this is obtained in writing. When processes
are changed, the appropriate documentation is updated.
The DC or LDC maintains a compilation of hardcopy versions of documents. Any obsolete
or superseded hardcopies are filed separately as obsolete document file to prevent the use of
incorrect, invalid or obsolete information. Obsolete documents later follow the disposition
controls as specified by the General Records Disposition Schedule of the GHMC.
For external documents such as policies from oversight agencies, standards, or third party
specifications, the DC obtains the latest version of the document and maintains it on the GHMC
server (for electronic versions) or in compilation of controlled external documents (for hard
copies).
2. Control of records
The documented information needed to be retained by the GHMC is referred to as records.
This includes evidences of implementation of processes conformity to requirements and of the
effective operation of the GHMC’s QMS. Examples of these include accomplished forms, reports,
obsolete documents, logbooks, and the like. Each office/department/unit of the GHMC has the
responsibility of managing records. The Medical Records Section manages the patient records as
well as implements the policies of National Archives of the Philippines (NAP) in the hospital/
medical center.
The GHMC clearly defines its policies for the identification, storage, protection, retrieval, retention
time, and disposition of documented information that are retained by the GHMC. Records are
retained based on the GHMC’s approved Records Disposition Schedule in accordance with the
NAP guidelines.
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Storage methods are identified depending on the type of record. Softcopy records and data are
stored in the server or computers. In all cases, the GHMC should make a backup of records
stored in computers. Hardcopy records are stored in suitable cabinets to prevent damage or
deterioration. Archived records are stored in-house as well as offsite, in a controlled environment
to protects it from damage or deterioration.
Records that are discarded after the retention period shall also follow the disposition methods
prescribed by the NAP. Availability and issuance of records requested by interested parties are
guided by the GHMC’s Manual on Freedom of Information as required by Executive Order No.
2 s. 2016 Freedom of Information Bill. Records are maintained legible, readily identifiable, and
retrievable.
Records of electronic medium are subject to periodic backups. The IT Unit is responsible for the
backup stored in the server. All entries by hand, on hardcopy forms, are made using permanent
ink.
NOTE 7.6
If there is an existing policy issuance on control of documented information, the
GHMC may cite the policy in this section and provide a brief description or a
summary of the policy. Ensure that the contents of this section are in accordance
with the said policy issuance.
The GHMC may also consider developing a separate procedure for controlling
documented information.
7.2 CONTROL OF MONITORING AND MEASURING RESOURCES
The GHMC determines the monitoring and measuring resources such as the cardiac monitor, BP
apparatus, among others, needed to provide evidence of conformity of service provided. To ensure
valid, accurate, and reliable results, these monitoring and measuring resources are:
•
•
•
•
•
•
periodically calibrated or verified against standards traceable to national or international
standards and calibration records are periodically reviewed/maintained;
adjusted or re-adjusted, as necessary;
checked if batteries are replaced, as necessary;
labeled and identified for the calibration status as standard quality control, such as equipment
type or process to be validated, location, frequency, methods of verification, acceptance criteria,
and corrective actions taken;
safeguarded from unintentional adjustments; and,
protected from damage and deterioration due to environmental conditions during handling,
maintenance, and storage.
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Also, when the results of calibration are found to be unsatisfactory or the instrument malfunctions, such
equipment is tagged as “non-functional.” These are referred to the Engineering Unit through job request
for appropriate action or to the supplier in case of tie-up agreements.
Computer software used for monitoring and measurement are also assessed and periodically calibrated.
Initial testing is also conducted prior to application.
7.3 MANAGEMENT OF ORGANIZATIONAL KNOWLEDGE
The GHMC recognizes the importance of organizational knowledge as a resource for the GHMC to
support its QMS processes to ensure conformity in the delivery of integrated and comprehensive quality
health care services. This knowledge, which includes those that are gained through training, conferences,
experiences (lessons learned), and the like, are documented and shared through minutes of meetings,
re-echo sessions, and compilation of materials gained from activities attended, fora on sharing of best
practices, and documented work procedures, standards, and manuals.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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The GHMC needs to look into the contents of this section carefully and make
necessary revisions to remove those that are not practiced by the hospital/medical
center and/or add practices. This section is also better supported by GHMC
policies, manuals, procedure, work instructions, and other reference documents
used as a guide in the performance of the users’ day-to-day tasks.
8.1 OPER ATIONAL PLANNING AND CONTROL
The GHMC ensures that it formulates and establishes necessary processes and sub-processes to fulfill
product and service requirements. Each office, department or unit prepares various documents, such
as the OPCR/DPCR/IPCR, Work and Financial Plan, operations plans, service manuals, guidelines
and procedures, schedule of duties and facilities, calendar of activities, training plans, and other
related documents, including those externally-generated documents from oversight agencies, to ensure
effective planning that is consistent with the goals and objectives of the GHMC and requirements of
other processes in the provision of patient care services.
8.2 REQUIREMENT FOR PRODUCTS AND SERVICES
A. Communication with Relevant Interested Parties
The GHMC implements effective strategies in communicating with patients and relevant interested
parties relating to the following:
•
•
•
service information through the Citizen’s Charter, Public Assistance and Complaints Desk,
advocacies, posters, billboards, bulletin boards, signages, brochures, web presence, radio,
etc.;
queries through the hospital’s telephone, text and email hotlines; and,
feedback and perception on hospital products and services through the Patient/Client
Satisfaction Survey.
B. Determination of Requirements
The Medical, Nursing, and Hospital Operations and Patient Support Services Divisions determine the
requirements for the patient care services, which include the following:
•
•
•
patient’s health information, such as health records and other information on their needs and
expectations, as specified or implied;
available services/activities or strategies before, during, and after treatment;
requirements necessary for services such as the availability of medicines, medical supplies,
instruments, facilities and equipment, and medical expertise on the specific service;
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statutory and regulatory requirements and standards applicable to the services such as DOH
policies, medical/clinical practice standards, and PhilHealth guidelines;
medical information and internal GHMC requirements for a specific service such as doctor’s
order, patient’s consent, and requests form; and
additional requirements, as decided by the management.
C. Review of Requirements
The concerned medical personnel reviews the requirements related to the patient care services,
together with additional requirements as determined, such as patient’s information, physician’s
diagnosis, and prescriptions, requests for diagnostic tests, etc. This review is conducted prior to the
provision of service to the patient, and follow up is recorded through the Patient Chart.
D. Changes of Requirements
The GHMC ensures that whenever service requirements are changed as a result of the review of
such, the relevant documents, particularly those that are related to the provision of patient care
services, are amended. The concerned persons are made aware of the changed requirements and the
basis for such. This is recorded in the Patient Chart, and patient, including his/her significant others,
is informed about it.
The GHMC also ensures that all agreements such as patients’ consent are conveyed clearly to all
concerned and are subject for review. This includes the release of health record information, patient’s
payment agreements, and third-party arrangements.
8.3 DESIGN AND DEVELOPMENT OF CLINICAL PATHWAYS
Clinical Pathways (CPW) are some of the main tools used to standardize and manage the health care
processes in the GHMC. These are developed and implemented in the GHMC to reduce the variability
in clinical practice and improve outcomes for a homogenous patient group. The GHMC develops CPWs
that are aligned to its local socio-cultural and economic health care situation.
A. Planning the Development of Clinical Pathways
Series of orientation sessions and meetings on the establishment of the CPWs are conducted. These
are also cascaded to the Medical, Nursing, and Support Services staff. The planning for the design
and development of the CPWs include the determination of the following:
•
•
•
the design and development stages;
the review, verification, and validation that are appropriate to each design and development
stage; and,
the responsibilities and authorities for design and development.
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The process of development of a CPW considers why tasks and interventions are performed and by
whom as it promotes greater awareness of the role of each professional involved in the patient care
cycle.
B. Inputs to the Clinical Pathways
CPWs are developed based on the clinical practice guidelines of the specialty societies, WHO
guidelines, DOH guidelines, consensus statements, and treatment protocols. Current practices in
the GHMC are also reviewed and the most recent evidence is incorporated into the pathway. The
design of the CPW also considers the local socio-cultural and economic health care situation in the
community that GHMC serves. Existing similar clinical pathways used internationally or locally are
also reviewed for additional inputs to the design and development of the GHMC’s CPW.
C. Contents of the Clinical Pathways
The Departments’ Clinical Pathway Committee prepares and develops reviews their respective
CPWs. Elements of the GHMC clinical pathways include the following:
•
•
•
•
•
•
•
•
•
•
processes and procedures
timeframe
checklist of history and physical examination
checklist of specific signs and symptoms
checklist of diagnostic tests
checklist of medications
checklist of non-drug treatment
remarks/advice
disposition
references
D. Control on the Design and Development of Clinical Pathways
Reviews, verification, and validation activities are implemented to ensure that clinical pathways are
evaluated based on the ability to achieve coordinated care and desired outcomes within an anticipated
timeframe, and to identify problems in its design or potential problems during its implementation
and propose necessary actions.
The CPW is presented to the management and staff and to the Chief Medical Professional Specialist
of the Department for review and verification. The review and verification undertaken should ensure
that each clinical pathway:
•
meets the applicable Clinical Pathway Guidelines (CPG), and all locally and internationally
accepted guidelines;
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provides information on the drugs, supplies, equipment and other resources needed for its
implementation;
contains standards and expected outcomes; and
Provides mechanisms for recording variations/deviations from planned care/activities and
continuous feedback via variance tracing and analysis.
Approved CPWs are communicated to concerned professionals for implementation. Treatment for
the specific diseases covered by clinical pathways is then based on these guidelines. An induction
period of a minimum of one quarter or one trial implementation is allowed to validate the CPWs.
Variations/deviations from planned care/activities and continuous feedback via variance tracing
and analysis are monitored and recorded. CPWs are reviewed/evaluated as the need arises. All the
changes made as results of the actions taken are recorded for traceability and future reference.
NOTE 8.2
There may be a need to allow a certain level of flexibility in the design and
development of CPWs. CPWs are standardized but there may be a need to allow
variations due to differences in patients’ response to the treatment. This should
also be considered in customizing this section.
8.4 CONTROL OF EXTERNAL PROVIDERS
The GHMC manages its relationship with its external providers, such as interns, medical consultants,
medicine suppliers, waste disposal services, among others, to ensure that they conform to specified
requirements. The requirements of the GHMC to these external providers are specified in the
memorandum of understanding/agreement, contracts, terms of reference, among others.
8.5 PATIENT CARE SERVICES AND TREATMENT
A. Control of Processes for Patient Care
The GHMC plans and delivers the provision of patient care under controlled conditions, including
the following, when necessary or applicable:
•
•
•
availability of medical information such as diagnostic/treatment plan, patient’s medical
history, electronic medical records (e-MR), and other necessary information such as medical
procedures, other treatment options, related risks, etc.;
availability of service manuals, procedures and guidelines, medical standards and studies,
and the like;
availability and use of suitable medicines, medical supplies, equipment, and facilities;
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availability and use of the monitoring and measuring devices;
implementation of patient care service monitoring and measurement activities such as patient
assessment and evaluation, vital signs monitoring and medication recording in-patient chart,
and other treatment verification and validation activities; and,
implementation of patient discharge/transfer plan and follow-up check-up.
NOTE 8.3
The GHMC should comply with the Data Privacy Act (DPA). Thus, there is a
need to highlight and mention in this section, as part of the controls, the different
practices of the GHMC in implementing the DPA.
The GHMC operational processes performed/implemented by the Medical and Nursing personnel
of the concerned department or unit of the Medical and Nursing Divisions as well as concerned
support units are guided by departmental manuals, clinical practice guidelines, CPWs, and other
reference documents.
B. Validation of Process for Patient Care
The Medical Division, Nursing Division and concerned support units validate the critical steps
of the process in the provision of patient care services. However, the effectiveness of treatments
implemented or the expected results of the services provided may not be completely verified upon
discharge of the patient from the hospital/medical center due to differences in patients’ response to
the treatment.
Process validation activities may include the following:
•
•
•
•
•
•
•
review and approval of the medical procedures by the chief of GHMC or chief medical
specialist by affixing his/her signature on the Patient’s Chart;
ensure the availability of the necessary supplies, instruments, equipment, and facilities for the
procedure;
designate specific competent personnel who have the necessary minimum training,
qualification, and/or experience to perform the procedures as established by the WHO, DOH
and GHMC procedures and guidelines;
use of locally and internationally accepted clinical practice guidelines, WHO guidelines, DOH
guidelines, treatment protocols, consensus statement, clinical pathways, and other medical
procedures and methods;
record the pertinent information in the patient’s chart to allow feedback based on the actual
process results;
correlate the results clinically by reassessing the condition of the patient prior to discharge,
which is recorded in the patient’s chart; and,
conduct of health education and counselling of the patient, family, relatives, significant others,
or caregivers on medications’ effect during and after treatment and home care, as applicable.
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C. Identification and Traceability
The GHMC identifies the service provided by suitable means throughout the process of provision of
patient care services. It identifies the status of the service with respect to monitoring and measurement
requirements.
The GHMC controls and records the unique identification of patients, and associated products and
services through the following:
1. Patient identification
•
•
•
•
•
•
•
Attachment of patient wrist tag with information such as patient name and age.
Attachment of bed tags with information such as patient name, age, date of admission, chief
complaint, and name of attending physician.
Patients directory to identify the service provided.
Patient chart to provide traceability of service provided.
Use of hospital/medical center number, complete name, age, and sex in the patient chart.
Color-coded baby tags (blue for male and pink for female) are attached to the left leg of
newborn patients with information such as baby’s name, the complete name of mother, and
date and time of delivery.
Cadavers are tagged properly with information such as patient name, age, and date and time
of death.
2. Laboratory specimen and results
•
•
•
Specimens are provided with specimen tags with information such as patient name and type
of specimen.
X-ray films have identification markers which contain information such as patient name, age,
date and time of the procedure, and film number.
X-ray result contains information such as patient name, age, gender, date, ward, requesting
physician, examination requested, and result.
3. Medicines and hospital/medical center food for in-patients
•
•
•
•
Preparation of medicines is based on the patient’s prescription.
Medicines are labeled before dispensing to the clients with information such as the patient’s
name and ward.
Patients’ medications dispensed from the pharmacy are double-checked by the nurses and
logged into specific logbooks.
Modified diets are provided with meal tags with information such as patient name, ward, and
specified diet.
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Quality Management System Manual
Section 8. Provision of Patient Care Services
NOTE 8.4
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The GHMC may cite other practices that could reflect the different identification
and traceability of patients, laboratory specimen and results, medicines, and
hospital/medical center food, among others.
D. Care of Property Belonging to Patients and External Providers
The GHMC exercises the utmost care and confidentiality of the patient’s personal belongings and
data as necessary for the treatment. Inadvertent use or mishandling of data and loss of personal
properties, entrusted to the hospital/medical center by both the patients and external providers, are
dealt with accordingly.
1. Patient personal effects
•
•
•
•
All jewelry is removed and properly handed to the patient or immediate family, companion,
guardian, or significant others.
In case of trauma/emergency case where the patient is unconscious without a responsible
companion, all personal belongings are removed by the ER personnel and properly logged
and endorsed to the authorized custodians on duty.
Dentures are removed if the patient will undergo surgery or possible intubation and handed
to a responsible companion or guardian.
Patients and their significant others are consistently reminded to be responsible for the
protection of their personal belongings as the GHMC may not be liable for any damage and
loss of their belongings.
2. Patient’s body, body parts, and foreign object lodged
•
•
•
•
•
When patients are treated, the significant others can observe and listen as applicable, except
in critical conditions, such as surgery, intensive care, among others, and during the use of
radiation for their safety.
Foreign objects lodged in patients’ bodies such as bullets, knife, scissors, among others, when
removed, are properly labeled and secured at the OR/ER stockroom for possible medico-legal
use.
Body parts, such as amputated part and removed cyst, are properly packed and the option is
given to the patient or significant others to take them for proper disposal or the GHMC will
take the responsibility of disposal.
During the expiration of a patient, the cadaver is shown to the significant other and they are
informed of the procedure for post-mortem care and discharge.
Include infection control.
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3. Patient data
•
•
•
•
•
Personal data and medical information contained in the patient chart are considered
confidential.
Access to the all GHMC information is restricted only to GHMC center personnel only.
Medical Records Section is not allowed to use the health record, in any way, which will
jeopardize the interest of the patient or of the GHMC.
A court order is required for access to records for medico-legal purposes. The records may
also be used to defend the GHMC against any legal proceedings.
Volatile and flammable liquids are never placed inside the records room.
4. Medicines and medical supplies for in-patient
•
•
Medicines and supplies given by the patient’s significant others at the nurse station are
recorded in the logbook and signed by the receiving nurse.
Only the GHMC is allowed to purchase dangerous drugs according to the existing Guidelines
on Dangerous Drugs. Prescriptions provided to the patient are duly approved by the doctor
in-charge. The Pharmacy can only dispense the medicine to patients with their approved
prescription.
5. Properties of external providers
•
Effective handling and maintenance, which are usually explicitly mentioned in contracts
or memorandum of agreement/understanding with the external providers, is strictly
implemented.
NOTE 8.5
The GHMC may customize the different practices in caring for the properties of
the patients, other relevant interested parties, and external providers.
E. Proper Handling and Protection of Patients and Related Products
The GHMC preserves the conformity of the service with the patient’s requirements through the
use of the Automated Inventory System and/or the GHMC Information Systems. This covers the
determination of required patient support services, planning, processing, delivery of service, and
monitoring.
1. Handling of patients
The medical doctors and nursing personnel ensure that the services provided match the
treatment plan prepared for the patient within the given timeframe, as discussed during the initial
consultation. All medical personnel should have undergone the General Clinical Practice (GCP)
training. All medical procedures follow the guidelines set by medical societies.
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The patients reserve the right to refuse a medical procedure. In cases where patients prefer a
certain procedure to be undertaken, this shall be accommodated in developing the treatment
plan. On completion of the treatment, the patient is given a summary of the service rendered.
Safe and appropriate care in handling and transporting patients from one area to another is
performed by trained personnel only. Appropriate wheelchairs and stretchers are provided.
The medical Doctor and nursing personnel regularly monitor and check the patients’ response to
the treatment and record the necessary information in the patients’ medical records. Appropriate
home care instruction and medication to the patient and his/her significant others or caregivers
before discharge. The GHMC may be sued by the patient if there any deviation in the medical
procedure conducted.
Post-mortem care of the cadaver is done appropriately and then brought to the morgue. It will
stay there for a minimum of two hours before release, with proper documentation, depending on
the circumstances surrounding the post-mortem.
2. Storage and preservation of medicines and supplies
The Central Supplies Room and the Pharmacy practices close monitoring of expiration dates of
medicines and supplies. “First expiration, first out,” “first in, first out,” and adherence to cold chain
management is observed. Near expiry medicines are separated in a specified area labeled as “near
expiry” and are disposed of in accordance with FDA and DENR policies. The pharmacist then
informs the suppliers of the status and processes the return of such medicines to the suppliers in
accordance with the terms of reference, as specified in the bidding process.
The Pathology and Laboratory, and Radiology Department preserves and controls reagents through
temperature monitoring, proper storage, and conduct of monthly inventory. Unprocessed/
unexposed x-ray films are kept in a required room temperature of 27 degrees Celsius and stocked
vertically; while processed/exposed x-ray films are placed in an envelope categorized and filed by
patient number. Solutions (developer and fixer) are also kept in a controlled room temperature.
The Property and Supply Management Unit stores medical supplies in a stock room preferably
accessible to concerned parties. The room should have proper ventilation, adequate space, open
shelves, ample lighting, and necessary security. Stocks are stored and classified according to
demand (i.e., fast or slow-moving), size, weight, shape, and perishability. Regular monitoring
as to condition and quality of stocks is conducted to ensure quality and availability at all times.
Supplies are labeled with the name and corresponding expiry dates. Only authorized personnel
are allowed in the stockroom
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The Nutrition and Dietetics properly preserves the food served to patients by controlling time
throughout the process of preparation and distribution of meals. Storage of food products is
also handled through monitoring of expiry dates upon receipt and prior to use and practice of
“first in, first out” policy. During food preparation, time spent in room temperature is minimized
and the boiling period is observed and guaranteed until the desired tenderness is achieved. The
holding period of cooked food prior to distribution does not exceed two hours.
3. Infection control
The Infection Control Committee promotes policies which prevent health care associated infection
among patients, health care workers, and other persons involved in the care of the patient. It
provides policies and guidelines on surveillance, isolation precautions, hand hygiene, use of
protective equipment, microbiology services, housekeeping, patient care environment, waste
collection and handling, toxic waste disposal, care of cadavers, and rational use of antimicrobials.
Activities to enhance infection control awareness such as Anti-Microbial Stewardship Program
are also regularly done by the Committee.
NOTE 8.6
The GHMC should ensure that proper controls are established to ensure proper
handling of patients, laboratory specimen and results, medicines and supplies as
well as to prevent infections in the hospital/medical center. The GHMC may cite
guidelines/policies on proper handling of patients, their properties, medicines,
and supplies, among others. Ensure that the write-up in this section is in line with
the existing guidelines/policies.
F. Post-Patient Care Activities
The GHMC’s patient care services do not end when the patient is discharged from the hospital/
medical center. Continued care and treatment are ensured through the following:
•
•
•
•
•
issuance of home care and treatment instructions by the doctor;
nurse briefing and orientation;
follow-up check-ups and continued laboratory testing, as advised and scheduled, whenever
necessary;
referral to other hospitals/medical centers, as necessary, through the service delivery network;
and,
facilitation of home visitations for critical cases.
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For released products, the GHMC provides the following post-delivery activities:
•
•
•
return policy for medicines and other medical products that are defective/expired;
correction and reprinting of erroneous laboratory results; and,
customer feedback on items purchased and services received.
NOTE 8.7
The GHMC may customize the different practices in caring for the properties of
the patients, other relevant interested parties, and external providers.
G. Control of Nonconforming Outputs
The GHMC recognizes that nonconformity may occur within any phase of the provision of patient
care services. Such nonconformities could come from unmet targets, complaints from patients and
other interested parties, sentinel reports, audit reports, among others. The GHMC ensures that
appropriate mechanisms are established to identify, control, and prevent unintended use or delivery
of nonconforming products and services. Mechanisms are compiled in Annex C - Incident Report by
the hospital/medical center personnel in cases of nonconformity.
When nonconformities are corrected, they are reviewed in accordance with applicable documented
procedures/standards.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Name of GHMC
GHMC Logo
Quality Management System Manual
Section 9. Performance Evaluation
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9.1 MONITORING, MEASUREMENT AND ANALYSIS
The GHMC effectively measures its performance through the duly approved monitoring and evaluation
system. The data collected from the monitoring, evaluation, and analyses are used for the continual
improvement of the policies/guidelines, systems, and procedures of the GHMC.
The GHMC identifies specific and customized tools to be used in the monitoring and evaluation of
processes that will determine the achievement of planned results. If these are not achieved, correction
and corrective action are determined and implemented, as necessary.
The following tools are some tools utilized in monitoring and measuring performance:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
GHMC Scorecard
Office/Division/Department/Individual Performance Commitment Review
Operational Plan
Project Procurement Management Plan/Annual Procurement Plan
Equipment Calibration Status and Report
Work and Financial Plan
GHMC Statistical Report
Infection Control Committee Report
Division Accomplishment Report
Patient Safety Report
GHMC Epidemiologic and Surveillance Report
Financial Statement Report
Inventory of Supplies
Departmental Medical Audit
Nursing Service Audit
Monitoring of Nonconformity of Laboratory Examinations
Customer Satisfaction Survey Report
PHIC Mandatory Report
24 hours Floor Census (Daily Census-MD’s) - Daily Census is accomplished by the Nursing
Service
Reports on the performance of external providers.
The GHMC analyzes data gathered from monitoring and evaluation activities as bases for the
improvement of the QMS. The data include, but is not limited to, internal and external stakeholders’
feedback, process monitoring reports, internal quality audit reports, management reports, and product
and service nonconformity reports. As applicable, graphs, trend analysis, among others, are the tools
used for data analysis.
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9.2 STAKEHOLDERS’ FEEDBACK MANAGEMENT
Feedback from patients, together with their significant others, are crucial to the GHMC. The hospital/
medical center’s products and services are directed to them. Thus, their perception of the quality of
these products and services are highly valued by the GHMC. Stakeholders’ feedback is obtained through
available mechanisms such as the stakeholders’ satisfaction survey, public assistance and complaints
desk, suggestion box, comments through a phone call, text messages, e-mail, and letters, which are
being monitored by responsible units.
The Integrity Management Committee or the Customer Service Committee collects data, using available
feedback mechanisms, tabulates and analyzes them for reporting to the ExeCom.
The reports are submitted to the ExeCom and concerned units or departments for action. Thereafter,
the Integrity Management Committee or the Customer Service Committee reports status of actions
taken on the results of the Customer Satisfaction Survey during the Management Review.
Complaints are considered nonconformity. As complaints are received, the responsible units issue a
Corrective Action Request (CAR, see Annex C) form to the concerned office, department, or unit for
proper action. The issuing unit monitors the accomplishment of the CAR and the implementation of the
correction and corrective actions to ensure that all complaints are properly attended to and addressed.
When this happens the complaints are forwarded to the IQA for issuance of an CAR form to the
concerned office, department, or unit for proper action.
NOTE 9.1
The GHMC may add other reports used to monitor, measure, and evaluate the
performance of its QMS. Other evaluation activities, as practiced by the GHMC,
may also be enumerated or further described in this section.
NOTE 9.2
Depending on the nature of nonconformities, some complaints are not registered
in the CAR, especially those arising from emergency situations. These are
immediately acted upon by the customer/service office concerned.
NOTE 9.3
CARs are issued when there are customer complaints depending on the frequency
and nature of the complaint.
9.3 INTERNAL QUALITY AUDIT
The GHMC conducts a semi-annual Internal Quality Audit (IQA) to evaluate the processes’ conformity
with the requirements of ISO 9001 and the requirements of the GHMC, and determine the effectiveness
of its QMS.
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A. Managing the IQA
An IQA Committee is established to manage IQA activities. Likewise, a pool of competent auditors
coming from different offices, departments, and units are mobilized to compose the IQA Team. They
are identified and trained to ensure that they are capable of conducting and carrying out the audit.
In the selection and assignment of IQA Teams, objectivity and impartiality of the audit process is
considered. Thus, auditors do not audit the processes within their respective offices, department, or
unit.
B. Planning and Conducting the Audit
An Audit Program is established to arrange the audits for the entire GHMC. An Audit Plan is
communicated to the GHMC containing the audit criteria and scope for the conduct of the IQA.
An audit is initiated through the opening meeting with the Head of the office, department, or unit.
Audit methods include direct observation of the processes, interviews with relevant persons, and
examination of documented information.
C. Reporting the Audit Results
After the IQA is completed, a closing meeting conducted to report the results of the audit to the Heads
of the offices, departments, and units and clarify the audit findings. Once the findings are clarified,
the auditors issue the audit report to the auditee. Based on the results, appropriate correction and
corrective actions may be necessary. A nonconformity finding, recorded in the CAR form, requires
corrective action. Response time is established to correct nonconformities and to take corrective
actions to ensure that these are effectively implemented in a timely manner.
The identification of potential weaknesses or opportunities for improvement in the QMS adds value
to the conduct of IQA. As this is part of the report, it can provide the heads of offices, departments,
and units with the information to decide whether it is appropriate to initiate action for improvement.
The results of the IQA are used as inputs to Management Review.
D. Monitoring, Verification, and Closing of Actions Taken on Audit Findings
The IQA Committee also monitors all the CARs issued as a result of the IQA. Timely implementation
of correction and corrective actions are ensured to mitigate consequences. Verification of the
implementation may be done through a follow-up audit or during the next audit cycle. This
verification may also include evaluation of the effectiveness of the actions taken, i.e., prevention of
recurrence of nonconformity, an improvement on the performance, and the like.
Upon verification of the effectiveness of action taken, the IQA Committee shall close the
nonconformity. Otherwise, it recommends another audit verification until the evidence that such
action taken to address the nonconformity is proven effective.
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9.4 MANAGEMENT REVIEW
The ExeCom reviews the QMS at least twice a year to adopt measures for its continuing suitability,
adequacy, and effectiveness. The review includes assessing the performance of the QMS and the adequacy
of resources as well as determining opportunities to improve performance and the need for changes to
the QMS, especially in the quality policy and quality objectives.
A. Initiating the Management Review
In coordination with the chief of GHMC, the QMS Leader and Secretariat prepare the agenda and
template of presentation or report. The agenda is submitted to the Chief of GHMC for approval and
issuance of a Notice of Meeting. The Secretariat/Office of the Chief of GHMC distributes the Notice
of Meeting, the approved agenda, and other templates needed to all concerned at least five working
days before the date of the Management Review.
If possible, the Secretariat consolidates the reports prior to the conduct of the Management Review.
B. Agenda for the Management Review
The Management Review covers the following inputs:
•
•
•
•
•
•
•
•
•
•
•
•
status of actions from previous management reviews or ExeCom meetings;
changes in external and internal issues that are relevant to the QMS;
customer satisfaction and feedback from relevant interested parties;
extent to which quality objectives have been met;
process performance and conformity of products and services;
monitoring and measurement results;
nonconformities and corrective actions;
audit results;
performance of external providers;
adequacy of resources;
effectiveness of actions taken to address risks and opportunities; and
opportunities for improvement.
C. Conducting the Management Review
The chief of the GHMC presides the Management Review. It starts with the confirmation of the
quorum and agenda. The QMS Leader shall ensure that all the required agenda inputs are discussed;
actions, decisions, and recommendations are made to ensure the continual improvement of the
QMS; and resources are allocated to ensure implementation of actions.
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D. Documenting the Management Review
The Secretariat ensures that findings, outputs, and action plans are properly documented and filed.
Specifically, the Secretariat records and documents proceedings such as decisions/actions regarding
the improvement of the QMS and products/services related to customer requirements, and decisions/
actions regarding resource needs, among others.
The Secretariat prepares the minutes of the meeting and distributes the draft to all attendees for
review and inputs on the status of immediate action items. The Chief of GHMC approves the minutes
of the meeting in the next management review.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
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Quality Management System Manual
Section 10. Improvement
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10.1 IMPROVEMENT OF THE GHMC
Continual improvement of the GHMC is the main objective of the QMS. As such, various inputs are
considered for continual improvement such as the quality policy, performance targets, audit findings,
analysis of performance data, corrective actions, and management reviews.
The GHMC ensures that improvement actions are implemented through small-step improvement
activities within existing processes and services such as benchmarking activities, implementation of
new projects and programs, introduction of new processes and services, and use of new technologies
and innovations in the medical field. These improvement activities may result in changes in the policies
and procedures, work instructions, recalibration of performance targets, and reassessment of risks and
opportunities needed to implement the selected solution.
10.2 CORRECTIVE ACTION
The GHMC takes necessary actions to address nonconformities detected during operations as a result
of IQA and management reviews and as gathered from stakeholders’ feedback. All nonconformities
are recorded in the CAR form which is issued to the concerned office, department, or unit for proper
response and action, within ten working days, to ensure proper monitoring.
Upon receipt of the CAR, the division/department/section/unit heads identify concerned personnel
who need to be involved in the corrective action. Coordination with the other concerned division/
department/section/unit is done as the nonconformity may affect them.
When the need for corrective action is established, the concerned division/department/section/unit
conducts root cause analysis to identify root causes and eliminate them, thus, preventing the recurrence of
the nonconformity. Methods for identifying the root causes of the nonconformities include the five whys
method, cause and effect diagram, and the like. From the root causes identified, appropriate corrective
actions are determined and planned for proper implementation. The corrective action plan includes the
activities, resources, responsibilities, and timelines needed to implement the selected solution.
Corrective actions are collectively reviewed during the Management Review. Depending on the nature
of the solution and the associated nonconformity, monitoring, and review continue for at least six
months after implementation, after which the corrective action is deemed completed. It is then that
the division/department/section/unit reviews the effectiveness of any corrective action by confirming
through objective evidence that the actions/corrections have been implemented or taken, and as a result,
the nonconformities have not recurred or that the process performance has improved.
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After the review of corrective actions, the GHMC considers whether there are risks or opportunities that
have not been determined previously, or if the actions for risks and opportunities were not effectively
addressed. Updates are made to the Risk and Opportunity Registers.
Prepared by:
Approved by:
NAME
QMS Leader
NAME
Chief of GHMC
52
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Name of GHMC
Revision No.
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Effective Date
Annex A. List of Needs and Expectations
of Relevant Stakeholders
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1 of 2
External Stakeholders
Stakeholders
Needs and Expecation
Patients and their Significant
Others
•
•
•
•
•
•
•
•
Better health condition
Effective medical treatment services
Courteous Hospital personnel
Skilled medical staff
Responsive services
Equitable and Affordable services
Accurate diagnosis
Appropriate and functional facilities and equipment
Community and Civil Society
Organizations:
• Local Government Unit
• Civil Society Organizations
• Non-Government
Organizations
• International Organizations
•
•
•
•
•
Environment-friendly processes
Socially responsive systems
Effective and needs-based health programs
Accessible services
Conformance to local and international standards
Oversight Agencies:
• DOH
• DBM
• CSC
• COA
• PhilHealth
•
•
•
Timely submission of reports
Accurate reports
Compliance to statutory and regulatory requirements
Medical Professional Organizations
•
•
Availability of data
Cooperation on relevant activities/events
Suppliers
•
•
•
Clear specifications
Timely payment
Timely feedback
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Annex A. List of Needs and Expectations
of Relevant Stakeholders
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Internal Stakeholders
Stakeholders
Hospital Employees
Needs and Expecation
•
•
•
•
•
Hospital Management
•
•
•
Training and other professional development
interventions
Employee welfare and benefits
Protection from health hazards
Clear directions and policies
Appropriate and adequate facilities and equipment
Supportive and performing staff
Accurate and timely submission of reports
Relevant and accurate data to support management
decision
54
The lack of
budget to
renovate the
kitchen facilities
Getting a
competent
consultant who
can assist the
Hospital in
establishing QMS
and securing
ISO 9001:2015
certification
R
O
O
2 The poor
physical
condition of the
Hospital kitchen
potentially
contaminating
the food
prepared and
distributed to
the patients
3 Directive of the
DOH for all
DOH- retained
hospitals to
secure ISO 9001
certification
potentially
improving the
processes and
systems of the
Hospital
4 Availability
of cuttingedge medical
equipment
can help the
Hospital
provide better
patient care
services
Engineering
c. Facilitate the renovation of the
hospital kitchen
Medical Dept
Heads
NAME
GHMC President
NAME
Department Head
b. Submit proposals based on the
Budget &
DOST timelines
Procurement Unit
a. Assisgn a qualified team
b. Forge MOU with industries
Admin Officer
Budget &
Procurement Unit
b. Realign budget from MOOE
and procure contractor to
renovate the Hospital kitchen
a. Network with the industries
and explore partnerships
Engineering
HRDO
b. Conduct customer relations
training for medical
personnel
a. Prepare the renovation plan
OPD
a. Do process streamlining
and finalize the revision on the
procedures of the OPD
Responsible
Dec. 15,
2019
Dec. 15,
2019
Dec. 15,
2019
Dec. 31,
2019
Nov. 30,
2019
Target
Date
L
I
R/O Rating
Risk/
Opportunity
Rating after
Treatment
Page No.
Approved by:
15
High
20
High
25
High
15
High
Treatment/ Opportunity
Pursuit Action Plan
Revision No.
Prepared by:
3
4
5
3
R /O
Rating
(LxC)
Annex B. Risk and Opportunity Register
5
5
5
5
Likelihood Consequence
(C)
(L)
Quality Management System Manual
Most equipment
are old and below
the international
standard
specification
Procedures and
manuals are
established but
need updating.
The Planning Unit
is scouting some
consultant.
The budget was
proposed last year
but it has been
slashed by the DBM
Procedures are being
reviewed and target
timelines in OPD are
indicated in IPCR.
On discourteous
staff, the EXECOM
has consistently
reminded the
Department Heads
to emphasize to their
staff the need to
always be courteous
to the patients and
their significant
others.
Current
Controls/
Situation
GHMC Logo
Acquisition of
modern medical
equipment for
areas needing
these
The main
risks are that
patient waiting
time in OPD
is extremely
long and the
medical staff are
discourteous
R
Risk/
Type Opportunity
(R /O)
Causes
1 Failure to
address
significant
patient
experience/
concerns
potentially
impacting the
reputation of
the Hospital
Risk/
Opportunity
Description
Name of GHMC
0
Effective Date
1 of 1
55
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Quality Management System Manual
GHMC Logo
0
Effective Date
Annex C. Corrective Action Request
Page No.
1 of 1
Section 1 - Details of Nonconformity (To be accomplished by the Auditor/Initiator)
References:
Date Issued:
(manuals, procedures, policies, ISO clauses, etc.)
Auditor/
Initiator:
CAR Number:
Occurring in other offices?
Provide details:
Yes
No
Signature over printed name
Details: (As a result of)
Internal Quality Audit
Nonconforming Outputs
Complaints
Non-Attainment of Targets
Others (Pls. specify)
Office:
Issued to: (Office Head)
Noted by:
Signature over printed name
Signature over printed name
Description of Nonconformity: (Include criteria and evidence)
Acknowledged by:
Section 2 - Necessary Action (s) (To be accomplished by the Auditee/Process Owners)
Correction:
Target Completion Date:
Root Cause Analysis:
Analyzed by:
Describe the necessary Corrective Action(s):
Target Completion Date:
Approved by:
Section 3 - Verification of Implementation and Effectiveness (To be accomplished by the Inititator)
Results of Action(s) Taken
Remarks
Verified by:
Verification Date:
Acknowledged by:
Results of Action(s) Taken
Next Verification Date:
Verified by:
Verification Date:
Acknowledged by:
Next Verification Date:
Remarks
56
PRODUCTIVITY AND DEVELOPMENT CENTER
Government Quality Management Program Office
DAP Building, San Miguel Avenue, Ortigas Center, Pasig City
www.dap.edu.ph | gqmpo@dap.edu.ph
(02) 8631 09 21 loc. 171 or (02) 8631 21 37
DEVELOPMENT ACADEMY OF THE PHILIPPINES