Principles in Promoting Patient Experience

Know the essential requirements of health care.

Knowing the patient as an individual.

Tailoring the health services for each patient.


ROJ@18apr21

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Top Management Manifestation of Commitment and Support for Hospital Risk Management System

The commitment and support should be manifested in writing and renewed as often as needed.

Below is a sample of a manifestation of commitment and support for hospital risk management system.



Manifestation of Commitment and Support by Governing Body and Top Management on Establishment and Development of ROJHMC Risk Management System

Risk is any uncertainty that, if it occurs, could have a positive or negative effect on the achievement of one or more goals and objectives of the hospital.

All activities in a hospital involve risk.

Thus, in view of the necessity for ROJHMC

– to manage effectively the risks of uncertainties in all its activities;

– to ensure that ROJHMC is able to determine the factors that could cause its processes and its quality and safety management system to deviate from the planned results and then to put in place preventive controls to minimize negative effects and to make maximum use of opportunities; and 

– to comply with Philippine statutory and regulatory requirements as well as international standards on hospital Risk Management System,

the undersigned representing the governing body and top management of ROJHMC hereby wholeheartedly commit to lead and to provide support in establishing and developing Risk Management System or Program in ROJHMC starting January 24, 2018.

We also hereby authorize the ROJHMC Task Team on Risk Management System to administer the program.

This Manifestation of Commitment and Support by the governing and top management by ROJHMC shall be renewed every three (3) years.

Signatories:

 

 

 

   
XXXXX YYYYY ZZZZZ
Chair, ROJHMC Board of Directors President, ROJHMC Hospital Director, ROJHMC
Date: Date: Date:

 


ROJ@18mar19

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Top Management Commitment and Support in Hospital Administration

In all activities, programs and projects, it is essential that there is top management commitment and support.  Otherwise, they will not fly.

The commitment and support should be manifested in writing and renewed as often as needed.

Below are examples of manifestations of commitment and support:



Manifestation of Commitment and Support by Governing Body and Top Management on Establishment and Development of Maternal Death Control Management System

In view of the necessity for Zamboanga City Medical Center

  • to continuously control maternal death;
  • to continuously provide quality and safe maternal care service; and
  • to collaborate with the Department of Health on the control of maternal deaths to meet the Millenium Development Goal,

the undersigned representing the governing body and top management of Zamboanga City Medical Center hereby wholeheartedly commit to lead and to provide support in establishing and developing a Maternal Death Control Management System in Zamboanga City Medical Center starting May 13, 2015.

We also hereby authorize the Zamboanga City Medical Center Maternal Death Control Management System Team to administer the program.

This Manifestation of Commitment and Support by the governing and top management by the Zamboanga City Medical Center shall be renewed every three (3) years.

 

Romeo A. Ong, MD, MHA

Chief of Hospital

Zamboanga City Medical Center

May 13, 2015



Manifestation of Commitment and Support by Governing Body and Top Management on Establishment and Development of ROJHMC Risk Management System

Risk is any uncertainty that, if it occurs, could have a positive or negative effect on the achievement of one or more goals and objectives of the hospital.

All activities in a hospital involve risk.

Thus, in view of the necessity for ROJHMC

– to manage effectively the risks of uncertainties in all its activities;

– to ensure that ROJHMC is able to determine the factors that could cause its processes and its quality and safety management system to deviate from the planned results and then to put in place preventive controls to minimize negative effects and to make maximum use of opportunities; and 

– to comply with Philippine statutory and regulatory requirements as well as international standards on hospital Risk Management System,

the undersigned representing the governing body and top management of ROJHMC hereby wholeheartedly commit to lead and to provide support in establishing and developing Risk Management System or Program in ROJHMC starting January 24, 2018.

We also hereby authorize the ROJHMC Task Team on Risk Management System to administer the program.

This Manifestation of Commitment and Support by the governing and top management by ROJHMC shall be renewed every three (3) years.

 Signatories:

 

 

 

   
XXXXX YYYYY ZZZZZ
Chair, ROJHMC Board of Directors President, ROJHMC Hospital Director, ROJHMC
Date: Date: Date:


Manifestation of Commitment and Support by Governing Body and Top Management on Establishment and Development of ROJHMC Safe Hospital Management System

One of the risks faced by ROJHMC is disasters, both natural and man-made.

The disasters can lead to financial losses which may lead to financial instability and bankruptcy.
 
The disasters can cause destruction to hospital properties and injuries to patients and staff.
 
The disasters can lead to downtime of building, equipment and workforce which in turn can affect maximal utilization of hospital services.
 
The disasters can lead to lawsuits that the hospital is not safe thereby leading to financial expenses to counter the suits.
 
The disasters can lead to a tarnished reputation that the hospital is not safe which may affect maximal utilization of services by clients.
 

Thus, in view of the necessity for ROJHMC

– to manage the risks of uncertainties of disasters with their potential negative effects or consequences;

– to ensure that ROJHMC is a SAFE HOSPITAL based on the concepts of Safe Hospital (a health facility whose services remain accessible and functioning at maximum capacity and in the same facility or infrastructure, during and immediately following the impact of a disaster; it will not collapse in disasters, killing patients and staff; it will be able to continue to function and provide critical services in emergencies; and it will be organized, with contingency plans in place and health personnel trained to keep the network operational); and

– to comply with Philippine statutory and regulatory requirements as well as international standards on a Safe Hospital,

the undersigned representing the governing body and top management of ROJHMC hereby wholeheartedly commit to lead and to provide support in establishing and developing Safe Hospital Management System or Program in ROJHMC starting March 1, 2018.

We also hereby authorize the ROJHMC Task Team on Safe Hospital Management System to administer the program. 

This Manifestation of Commitment and Support by the governing and top management by ROJHMC shall be renewed every three (3) years.

Signatories:

 

 

 

   
XXXXX YYYYY ZZZZZ
Chair, ROJHMC Board of Directors President, ROJHMC Hospital Director, ROJHMC
Date: Date: Date:


ROJ@18mar19

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Task Teams in Hospital Management

What are Task Teams?

Task Teams are similar to Task Forces except that in ROJHMC, the term to be used is Task Team to emphasize teamwork in performing tasks or assignments.

One of the criteria for performance excellence of a hospital or medical center is that there are evidences of participation and collaboration in accomplishing corporate and / or business unit tasks by all staff of the medical center from governing body to the rank and file.  The best evidences to present are the formation of task teams with involvement of all staff and with distribution of work, their terms of references and their accomplishments. Every staff has to present evidence that he / she is a member of a Task Team.

Aside from the benefits of teamwork and collaboration among all the staff of ROJHMC, specialization, continuity and succession planning can be derived from the formation of Task Teams.

Note: Task Teams will be institutionalized in ROJHMC as they together with created committees will constitute the concrete evidences of teamwork and collaboration of all staff of the medical center. (Task Teams vs Committees – essentially the same. However, committee usually refers to a group of persons created on a long-term basis for making policies or for development of certain programs or projects. Task Team usually refers to a group of persons created on a short-term basis for making policies or for development of certain tasks. Task Teams may be kept or maintained for a long time as indicated such as there is recurring need for them or they may be transformed into Committees.)

There will be documented terms of references (TOR) or job descriptions for each Task Team.  (This also applies to Committees.)

Terms of References for Task Teams

  • Name of Task Team

  • Objectives

  • Key Result Areas and Key Performance Indicators

  • Members and Role and Duties of Members

  • Activities with Persons-in-Charge

  • Timelines of Activities

  • Documentation and Archiving Plan

  • Deployment Plan

  • Implementation Plan

  • Evaluation Plan

  • Budget


ROJ@18mar19

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Risk Identification with General Causes in a Medical Center – A Facilitation Template

 

Slide2This template may facilitate comprehensive risk assessment of all departments and business units of a medical center.  The risk assessment consists of risk identification, risk analysis, and risk evaluation.   There will just be adjustment based on the types of department, their functions and services (context).

Illustrations and Explanations:

All departments will include risk of downtime of the building of the medical center in their risk identification or register.  The downtime of building may be caused by earthquake, typhoons (strong winds), floods, fire and bombing.  Since all the departments are usually housed within one particular structure, then the risk analysis and risk evaluation will probably be the same. Risk treatment may also be the same, such as complying with the safe hospital initiative of the Department of Health.

Note: Downtime of building may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments with equipment will include risk of downtime of the equipment used to render medical care and provide support to business development such as IT and facility.  The downtime of equipment may be caused by natural calamities and man-made causes or factors (like fires, lack preventive maintenance, buying non-durable equipment, suppliers with no or poor after sale services, etc.)  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of equipment.

Note: Downtime of equipment may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments will include downtime of workforce as potential risk.  This is usually caused by lack of workforce and labor strike.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of workforce.

Note: Downtime of workforce may lead to non-maximal utilization of services and financial losses (a negative effect).

All departments will include risk of lawsuits in their risk identification or register.  Lawsuits may be classified into medicolegal or non-medicolegal.  Medicolegal suits are those associated with medical care of patients.  Non-medicolegal suits are those not associated with medical care of patients.  The risk analysis and risk evaluation and risk treatment are essentially the same in all clinical departments (departments involved in medical care of patients) but may vary in degree (likelihood and impact) depending on the harm incurred by the patients.  Likewise, the risk analysis and risk evaluation and risk treatment are essentially the same in all non-clinical departments (departments not involved in medical care of patients) but may vary in degree (likelihood and impact) depending on the non-medical related harm incurred by the patients,guests and staff.

Note: Lawsuits lead to financial losses due to ligation (a negative effect) unless the risk is transferred to an insurance.

All departments will include risk of theft and losses in their risk identification or register. Theft are due to criminal acts committed either by staff or outsiders.  Losses may be due to faulty safekeeping of material goods or products, wrong counting or spoilage.   The risk analysis and risk evaluation and risk treatment of theft are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of theft.  For losses, the risk analysis and risk evaluation and risk treatment  are also essentially the same in all departments but may vary in degree (likelihood and impact) depending on the type of losses.

Note: Theft and losses lead to financial losses (a negative effect).

All clinical departments (departments rendering medical care of patients) will include account receivables in their risk identification or register.  Account receivables may be due to faulty assessment of financial capability of patients and lack or no control mechanism for prevention (faulty financial management system).  The risk analysis and risk evaluation and risk treatment are essentially the same in all clinical departments but may vary in degree (likelihood and impact) depending on the cost of medical services being rendered.

Note: Account receivables lead to financial losses (a negative effect).

All departments whether revenue or cost units will include risk for faulty accounting system in their risk identification and register.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the extent of errors in accounting.

Note: Faulty accounting system leads to financial losses (a negative effect).

All departments whether revenue or cost units will include inefficient management system in their risk identification and register.  Inefficiency is due to poor alignment and integration of staff within a department and with other departments.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the extent of inefficiency.

Note: Inefficient management system leads to financial losses (a negative effect).

All departments whether revenue or cost units will include non-maximal utilization of services in their risk identification and register.   This is usually caused by weak business development strategies and bad or tarnished reputation (aside from the downtime of building, equipment and workforce).  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the types of services.

Note: Non-maximal utilization of services leads to financial losses (a negative effect).

All departments shall include continual maximal utilization of services in their risk identification and register (on the positive effect side).  They should include strength, weakness, opportunity and threat analysis in their strategic planning to come out with a robust business development strategy.  The risk analysis and risk evaluation and risk treatment are essentially the same in all departments but may vary in degree (likelihood and impact) depending on the types of services.

Note: Continual maximal utilization of services leads to positive financial growth (a positive effect).


ROJ@18jan29

Posted in Quality, Safety and Risk Management System, Risk Management | Leave a comment

Integrating Quality, Safety and Risk Management Systems

Integrating Quality Management System, Safety Management System, and Risk Management System

Quality Management System and Risk Management System shall be integrated = Quality and Risk Management System
 
Slide5
 
“Quality” will subsume “Safety” if not otherwise specified.  If specified, Quality Management System and Safety Management System shall be integrated = Quality and Safety Management System.
Slide6
“Risk” will subsume “Safety” if not otherwise specified.  If specified, Risk Management System and Safety Management System shall be integrated = Risk and Safety Management System or Safety and Risk Management System.

Slide7

Slide8

Risk Management Policy – statement of the overall intentions and direction of an organization related to risk management.

To always use risk-based thinking and processes in planing and deciding all activities in the hospital so as to minimize negative effects and to maximize positive effects on accomplishment of objectives.

This policy shall be realized through:

  • Understanding the potential risks on quality and safe health care services, products, facility,  environment and business development;
  • Complying with all statutory and regulatory requirements on risk management;
  • Designing a structured, comprehensive, integrated, effective and efficient risk management system;
  • Providing adequate resources and highly competent staff to support the implementation of the management system;
  • Regularly evaluating and reviewing the results of implementation of the management system;
  • Continually improving the management system with innovations.
Quality and Safety Policy– statement of the overall intentions and direction of an organization related to quality and safe management.

To continuously provide quality and safe health care services, products, facility and environment to all our stakeholders (communities, families, patients, workforce and partners).

This policy shall be realized through:

  • Understanding the expectations of our stakeholders on quality and safe health care services, products, facility and environment;
  • Complying with all statutory and regulatory requirements;
  • Designing effective and efficient quality and safe management systems
  • Providing adequate resources and highly competent staff to support the implementation of the management system;
  • Regularly evaluating and reviewing the results of implementation of the management system;
  • Continually improving the management system with innovations.

ROJ@18jan28

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An Introductory to ROJHMC – Hospital Design and Operations Manual

Introductory on ROJHMC
ROJHMC stands for Reynaldo O. Joson Hospital and Medical Center.
This is a fictitious 100-bed capacity private level 2 general hospital and medical center that I, Dr. Reynaldo O. Joson, will use in designing and developing a governance and operations manual that can be used as a guide or template by hospitals and medical centers in the Philippines.
At this writing (2018), there are a lot of private hospitals and medical centers being constructed in the Philippines.  Everybody knows it is not easy to design and develop a hospital or medical center.
At this writing (January 24, 2018), I will be 69 years old in one week’s time (January 31, 2018) and will be 70 years old in one year’s time (my first count-down in life), and at the start of the year (January 1, 2018), I made a resolution to start 4 new projects for the next 5 years (up to 75 years old – my second count-down in life).  These 4 projects are (as published in https://rojoson.wordpress.com/2017/12/31/2018-life-plan):

– 100-Bed Level 2, Private General Hospital Design and Operations Manual
– Medical Curriculum Enhancement
– Options for Medical Management – Diagnostic and Treatment Procedures
– Clinical Research

Thus, this ROJHMC 100-Bed Level 2 Private General Hospital Design and Operations Manual.

I intend this Manual to be another one of my legacies to the Filipino people and to hospital administrators.
Why “hospital and medical center” in the name?  Why not just “medical center”?
Strictly speaking, “hospital” and “medical center” are the same and can be used synonymously although “medical center” has the connotation of bigger and being sophisticated. The Philippine Department of Health has these definitions:

DOH Definitions of Hospitals and Medical Centers

Hospital – a place devoted primarily to the maintenance and operation of health facilities for the diagnosis, treatment and care of individuals suffering from illness, disease, injury, or deformity or in need of obstetrical or other surgical, medical and nursing care. It shall be construed as any institution, building, or place where there are installed beds, cribs, or bassinets for 24-hour use or longer for patients in the treatment of diseases.

Medical Center- a hospital staffed and equipped to care for many patients and for a large number of kinds of diseases and dysfunctions using modern technology.

I purposely included “hospital” in the name of ROJHMC because “hospital” is more commonly used in the Philippines than “medical center” and is readily understood by the laypeople. Second, when I write the manual, particularly the operations part, I foresee it will be easier and shorter to use and write the term “hospital” than “medical center” (of course, with the caveat that these two terms will be used interchangeably).  For example, hospital quality management system instead of medical center quality management system; hospital infection rate instead of medical center infection rate; hospital financial management system instead of medical center financial management system; etc.  If I use “ROJMC,” I feel obliged to use “medical center” all the time and have to refrain from using “hospital” even when it is easier to use “hospital.”
ROJHMC, therefore, is a fictitious 100-bed capacity private level 2 general hospital and medical center. Furthermore, the context is that it is located in a Philippine urban community with modern amenities (as of 2018).  At the moment, there will be no specification as to the population and distribution of socioeconomic strata of the catchment community.

ROJ@18jan25

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