1.1 Mandatory Background

        The East Avenue Medical Center by virtue of the Republic Act No. 8345 dated August 1997 entitled “An Act Increasing the Bed Capacity of the East Avenue Medical Center Located in East Avenue, Quezon City, from Three Hundred and Fifty (350) to Six Hundred (600) Beds, Upgrading the Service Facilities and Professional Health Care Therein and Appropriating Funds Therefor”.

East Avenue Medical Center has at present (2020), pending implementation of the above mentioned Republic Act, a manpower complement of 1939 employees consisting of 594 medical, 719 nursing, 239 Paramedical and 387 HOPSS/Finance.

East Avenue Medical Center is a National Government Hospital under the Department of Health being regulated by the Civil Service Commission for its Human Resource activities, and the Department of Budget and Management for the efficient management and development of its financial transactions. The Commission on Audit on the other hand is in charge of the general accountabilities of the hospital.

1.2         History

               On October 8, 1969, the GSIS General Hospital (GSISGH) opened its doors and offered services to heal and cure the sick. By virtue of a GSIS Board Resolution, the hospital was originally conceived for GSIS members, then numbering about 850,000. Later moral imperatives of attending to all patients, regardless of their station in life, demanded the hospital to extend its care to non-GSIS members.

               Eventually, the hospital expanded services to an increasing number of sick clientele over time, with the support of a talented and reputable group of medical specialists, well-trained nurses and administrative staff. Its support facilities, including a Cobalt machine. Power x-rays, a blood analyzer, and other equipment, were, at that time, the latest in technology. Soon afterwards, the hospital gained the recognition and enviable distinction for total hospital care and post-graduate medical training. Indeed, the first professional specialty board in the country-the Philippine Board of Surgery, Inc. – was structured and organized at the GSIS General Hospital in November 1969, a reflection of the hospital’s reputation.

               On June 9, 1978 under Martial law by virtue of Presidential Decree # 1411, the GSISGH, a government controlled corporate health institution, was dissolved and transferred en toto to the Ministry of Health. The move not only meant changing the name to Hospital ng Bagong Lipunan (HBL), but also the concept, philosophy and principles of the hospital so that 90% of the admission are categorized as services cases or indigent. Dominantly service oriented, professional training had taken a lower key. Moreover, hospital equipment and facilities deteriorated with wear and tear, and were neglected in disrepair. HBL’s image had to suffer, particularly in terms of material facilities. Yet, the quality of patient care endured.

Since 1978, the hospital has been supported in all its financial operations by the national government through the Department of Health. This operational budget has increased according to the growing needs of the hospital.

               The February 1986 Revolution came and the Cory administration took over. The hospital took on a dramatic new course. To begin with, the hospital was renamed East Avenue Medical Center by virtue of Executive Order #48 s. 1986, the new director, Dr. Adriano Dela Paz, officially assumed the office. Pledged with resources/administrative support and budgetary assistance by a liberal Health Department, he assumed the EAMC helm with confidence and optimism.

               After a year of his administration, there has been a general perception of improvement in most levels of hospital functions and activities.

               At the same time, the hospital has earned substantial income, mainly from pay patients, room and board, donations, pharmacy, operating and delivery rooms, radiology and laboratory services and procedures.

               The numbers of hospital employees have consistently remained constant. The hospital has systematically programmed personnel for optimum performance and maximum service with a minimum working force.

               In line with the objectives of education and training, the hospital encouraged all departments to have a training program accredited by the specialty societies and monitored their continuous accreditation. At present, a total of 15 clinical departments have an accredited training programs (both for specialty and sub-specialty training).

               Resident-trainees of all departments are screened and evaluated based on their credentials and entrance examination and pre-residency evaluation.  Each department has their own performance evaluation for the promotion and graduation of their resident-trainees.  Included in their requirements for board eligibility and graduation is a completed quality research.

The East Avenue Medical Center Department of Ophthalmology was established on August 10, 1986 when it was recognized as an independent entity from the Department of ENT. Since then, the department has grown immensely and has established a reputation as a premier national eye referral center through the facility that it operates – The DOH Eye Center. Also, at this time, a new unit – the Intensive Care Unit has been organized to take charge of serious patients who need intensive management.

Under the outreach program of the hospital, a number of medical missions served the indigents in Metro Manila and the nearby provinces of Mindoro, Quezon, Nueva Ecija and Bicol Region as far as the Visayas and Mindanao. Most of these were undertaken jointly by the Department of Surgery, Ophthalmology, Otolaryngology, Medicine and Dentistry in cooperation with the various Rotary Clubs and other civic organizations requesting assistance. The medical teams of the hospital conducted not only preventive but also curative medical missions.

               The years 2005 to 2017, under the leadership of Dr. Roland L. Cortez, have been characterized by vigorous renovation and rehabilitation of hospital wards and physical facilities and manpower development. “There is always room for improvement” is the organization guiding principle. Thus, despite some problems brought about by the pressure of development and change, the management did its best and moved on progressively with the changes needed.

               The certification and accreditation for ISO 9001:2008 (QMS) was received in March 29, 2014. The hospital transitioned to ISO 9001:2015 (QMS) in November 29, 2017 and recertification was done in September 29, 2020. The hospital explored the Performance Governance System (PGS) by joining the 6^th Bootcamp for Hospitals on November 7-9, 2018. With the strategy map crafted, the hospital took the first step in PGS Initiation Revalida   was conferred in November 16, 2020.        

               Hospital operations continued despite the COVID pandemic.

And on August 2020, the hospital inaugurated an additional 250 beds housed in a new 6-storey building named as EAMC–CERID building. This additional physical facility is dedicated as a Center for Emerging and Re-Emerging Infectious Diseases.

1.3         Vision and Mission

               Through a series of Strategic Planning Workshops, the management group was able to come up with the five-year development plan that is regularly monitored and discussed extensively. (See Appendix ___ EAMC 5-year Development Plan). Implementation and completion of programs and projects included in the plan are also being accomplished according to schedule. Indeed, the hospital had undergone transformation since its establishment in the 60’s. Presently, the EAMC has become a major government health facility that plays crucial role in the health delivery network all over the country. As the hospital continuous re-journey towards a new direction 1. in alignment to the needs of both our Quality Management, 2. system and Performance Governance System, 3. commit ourselves to deliver our vision, mission and core values.

OUR VISION

               East Avenue Medical center is a globally recognized health institution offering the highest standard of multi-specialty services.

OUR MISSION

               We provide quality tertiary healthcare services, train medical and allied health care professionals, and conduct relevant and bioethical researches.

CORE VALUES

• Excellence
• Adeptness
• Moral Integrity
• Compassion

1.4         Objectives of the Hospital

The East Avenue Medical Center, being a government hospital under the Department of Health, has for its goals the delivery of a high quality standard of medical care and treatment to an optimum number of patients irrespective of their social, educational, economic and religious creed.

As training and teaching center under DOH, training facilities are available for both the physicians and the allied professions to give them the opportunity to develop their proficiencies in their respective lines of specialization with an end goal of making them viable members of the national health care delivery team.

OUR OBJECTIVES

Figure 1. Strategy Map: The hospital position in our governance.

1.4.1     Patient Care – To care and treat all people suffering from various types of diseases regardless of age, race, creed religion, and belief and to take part in the prevention of diseases. It has been the aim of the hospital to give out a high quality standard of medical care and treatment to the optimum number of populace coming from the whole country.

1.4.2     Education and Training (Manpower Development) – To train and educate medical and non-medical staff as well as allied medical students from other institutions in the field of medicine and allied services. This is carried out by providing an integrated, comprehensive and progressive educational / development trainings programs for each discipline / category.

1.4.3     Research – To train, update and stimulate medical and non-medical staff in the field of research thus updating and contributing to the medical and non-medical information of the country.

1.5         Quality Policy

We, at the EAST AVENUE MEDICAL CENTER a tertiary DOH hospital, commit ourselves to provide the highest standard of hospital care, in compliance with the statutory and regulatory requirements by continually improving Quality Management System to the highest satisfaction of our Customers.

1.6         QMS Implementation

To ensure the effective implementation of QMS, the EAMC created a functional structure outlining the role to provide efficient flow of communication and coordination activities.

Figure 1.  Strategy Map

The EAMC is a hospital under the Department of Health thus is headed by the Secretary of Health, and assisted by the Undersecretaries and Assistant Secretaries with the Medical Center Chief as Chief Executive Officer.

               The office of the Medical Center Chief is supported by the line division headed by Division Chiefs and offices performing and pursuing the various functions and objective of the center.

               The organizational structure is seen in Figure 2 (see page 14 of 45).

The offices are:

               Professional Education Training and Research Office (PETRO) – Headed by a Chief who conducts the continuing program of the Center, both medical and non-medical as well as post graduate programs. Likewise, monitors and undertakes scientific research programs.

Division of Medical Professional Service – is responsible for providing patient care both curative and preventive.

Division of Nursing Service – Provides nursing support services as well as education and training in nursing.

Division of Support Service (HOPSS) – Renders administrative support to the overall objectives of the center.

Division of Finance Service – Renders financial support to the overall objectives of the center.

Office for Strategy and Quality Management (OSQM)– Functions are 1. Internal Quality Audit 2. Customer Experience Management 3. Records Management 4. Workplace Monitoring 5. Performance Governance System

National Reference Laboratory (NRL)– Mandated by the Department of Health to 1. Provide laboratory reference/ referral services for confirmatory testing, surveillance and research. 2. Train laboratory personnel. 3. Maintain quality assurance program for laboratory tests through proficiency testing. 4. Perform technical evaluation of reagents and in-vitro medical devices.

Institutional Ethics Review Board (IERB) – an independent body created by the East Avenue Medical Center under the Medical Center Chief II, aims to ensure the protection of the rights, safety and well-being of human subjects involved in health and health-related research and to provide public assurance of that protection. In accordance with applicable national and international regulations, the East Avenue Medical center has the authority to approve, require modifications to, or disapprove research protocols and related documents as well as ensure compliance with its relevant procedures after approval. The Standard Operating Procedures of the EAMC IERB is under the direct regulation and approval by the Philippine Health, Research Ethics Board of the Philippines.

Legal Office – Offers a wide range of legal services to EAMC employees, clients and patients. Renders legal opinion, provides legal advice, delivers legal aid and assistance on issues concerning the hospital, its employees and the services rendered to clients and patients. In pursuit of the hospital’s mandate, the Legal office ensures that its officials and employees observe high standards of personal conduct in the discharge and execution of their official duties in order to guarantee the delivery of quality health care services to the people. The Legal Office is also tasked to review and evaluate contracts entered into by the Hospital with other government agencies and private entities.                                                                                        Integrated Hospital Information and Management Program (IHOMP)– Creates IT policies, recommends IT development plan to the management, leads the implementation of the hospital information system, manages information technology resources and ensures compliance to IT related regulatory and stationary requirements.

Public Health Unit (PHU)- Ensures comprehensive quality health care services in support of the National Objectives for Health. Bridges the gap in the implementation of public health programs between hospitals and primary health facilities, not only through collaborative efforts with networks and linkages but the incomparable assistance from the Health Promotion and Communication Services and the Epidemiology Bureau of the Department of Health as well.

2.1         Scope

 This International Standard specifies requirements for a quality management system where EAMC;

• Needs to demonstrate its ability to consistently provide products and services that meets customer and applicable statutory and regulatory requirements.
• Aims to enhance customer satisfaction through the effective application of the system, including processes for continual improvement of the system and the assurance of the conformity to customer and applicable statutory regulatory requirements.

2.2         Application

 For EAMC to function effectively, it has to determine and manage numerous linked activities. An activity or set of activities using resources, and managed in order to enable transformation of input into outputs, can be considered as a process. Often the output from one process directly forms the input to the next.

The application of a system of process within EAMC, together with the identification and interactions of these processes, and their management to produce the desired outcome, can be referred to as the “process approach”.

An advantage of the process approach is the ongoing control that it provides over the linkage between the individual process within the system of process, as well as over their combination and interaction.

When used within a Quality Management System, such an approach emphasizes the importance of:

• Understanding and meeting requirements,
• Need of considering processes in terms of added value
• Obtaining results of performance and effectiveness, and
• Continual improvement of process based on objective measurement.

2.3         Terms and Definitions

 For purposes of clarifying the Quality and Procedures Manuals, the following terms and definitions, shall apply:

a. ISO – An acronym for the International Organization for Standardization, a worldwide organization that is responsible for developing documents of “requirements, specifications, guidelines or characteristics that can be used consistently to ensure that materials, products, processes, and services are fit for their purpose.

b. Top Management – Group of people who directs and controls the organization, composed of the Medical Center Chief and the Division Chiefs.

c. Quality Management System (QMS) – Management system to direct and control an organization with regards to quality.

d. Management Review Meetings – Meetings to have a proper evaluation of the management system and discuss what areas are successful, and what areas need improvement.

e. Policy – Documented information about a set of standards.

f. Process – Set of tasks that are completed to work towards an ultimate goal. Within ISO 9001, all processes are focused on satisfying the customer.

g. Continual Improvement –Recurring activity to increase the ability to fulfill the requirements.

h. Audit Criteria – Set of policies, procedures or requirements used as reference.

i. Audit Evidence – Records, statements of fact or other information which are relevant to the audit criteria and are verifiable.

j. Non-conformity (NC) – Non-fulfillment of requirement.

k. Risk – Revolves around calculating the difference in negative and positive features of a process. By assessing risk, organizations are able to determine exactly how much there is to gain from changing a particular aspect of a system or process.

l. Risk Assessment – is a process that analyzes potential risks and its effects on both customers and employees. A risk assessment can also include a series of possible solutions to overcome such risks.

m. Risk Identification – is a process that is used to find, recognize, and describe the risks that could affect the achievement of objectives.

n. Risk Analysis – is a process that is used to understand the nature, sources, and causes of the risks that you have identified and to estimate the level of risk. It is also used to study impacts and consequences and to examine the controls that currently exist.

o. Risk Evaluation – is a process that is used to compare risk analysis results with risk criteria in order to determine whether or not a specified level of risk is acceptable or tolerable.

p. Risk Source – is where a risk originates.

q. Control – is any measure or action or plan that modifies a risk. It includes any policy, procedure, practice, process, technology, device or method that modifies or manages risk.

r. Risk Treatment – A risk-modification process. It includes any policy, procedure, practice, process, technology, device or method that modifies or manages risk (either to avoid, transfer and share the risk).

s. Risk Owner – Person or entity with the accountability and authority to manage a risk.

t. Risk Register – The documented information used to review and monitor the context of the organization and its corresponding risks, opportunities and action plan.

u. Clients/Customer – Refers to both internal and external clients, where the service requirements emanate.

v. Core Services – Processes needed to achieve the overall mission and objectives of the agency, specifically the medical and nursing processes.

w. Support Services – Processes needed to ensure the satisfactory performance of the core services.

x. External Service – Acquired from external service providers relevant to the performance of the agency’s services needing specialized skills, knowledge or technology. The organization shall apply appropriate control measures set by the agency. Examples of control measures are Contracts, Term of Reference, and Memorandum of Agreement.

y. External Documents/ Legal Basis – Documented Information of external origin determined to be necessary for planning and operations. These include Republic Acts, Executive Orders, Administrative Orders, Circulars, Guidelines and Manuals; Examples include the manuals of New Government Accounting System (NGAS) Manual, Department of Health (DOH), Department of Budget and Management (DBM), Civil Service Commission (CSC).

z. Standard Forms – A structured document with specified data field, whether as a requirement of a certain regulation or necessary in achieving desired service outputs; Standard forms are considered documented information when duly filled out.

aa. QMT – Quality Management Team

bb. QMR – Quality Management Representative

cc. DCC – Document Control Custodian – is the action officer for all changes/ updates on any part of the quality manual, procedures manual, work instructions and forms.

dd. IQA – Internal Quality Audit

A Quality Management System (QMS) is defined as a formalized system that documents processes, procedures, and responsibilities for achieving quality policies and objectives. A QMS helps coordinate and direct an organization’s activities to meet customer and regulatory requirements and improve its effectiveness and efficiency on a continuous basis.

QMS helps the organization meet the customer’s requirements, which helps to instill confidence in the organization, in turn leading to more customers, more sales, and more repeat business. QMS also meet the organization’s requirements, which ensures compliance with regulations and provision of products and services in the most cost- and resource-efficient manner, creating room for expansion, growth, and profit.

 3.1 EAMC Process Map

The EAMC Process Map defines the interaction of the processes within the quality management system.

Core Process includes Medical and Nursing Services. These services are implemented with the support from the Hospital Operation Patient Support Services and Finance Services.

The Support Processes consist of Services under Hospital Operation Patient Support Services; namely, Engineering and Facilities Management (EFMS), Procurement, Materials Management Section (MMS), Human Resource Management and Finance Services which includes Accounting, Billing and Phil health, Budget and Cash Operation. Support Service Integrated Hospital Operation Management Program, Public Health Unit, Infection Control Committee, Professional Education and Training Office (PETRO) and Legal Office.

               Management chooses external service provider for the following services: Janitorial, Laundry, Pest Control, and Security services and other ancillary, diagnostic, therapeutic and manpower services deemed needed by management to achieve quality patient care. Management shall establish control over these external service provider processes to ensure that said processes commit to and conform to EAMC’s quality management system and quality improvement policies.

Management processes consist of services, under the Medical Center Chief. These include processes such as planning, direction setting, decision-making and management review.

Improvement process is integrated in all processes of the quality management system. Internal Audit processes ensure that the quality management system conforms to establish audit criteria such as ISO 9001:2015, Objectives and Targets, establish policies and procedures and, is effectively implemented and maintained. Corrective Actions and Preventive Actions or Risk Assessment are carried out to address and eliminate nonconformities and potential nonconformities in the quality management system. Customer Analysis and Feedback processes are also integrated into processes to monitor and measure levels of customer satisfaction and where continual improvement can be made.   

3.2         Process Effectiveness

In order to become more effective and efficient organization, process under the quality management system of EAMC shall be measured as to its effectiveness. Quality Objectives consist of measureable targets and once achieved, these will signify that processes are effective and/or efficient. Quality Objectives of all the units are aligned to the Office Performance and Commitment of the hospital.

Work and Financial Plan (WFP) represents planned arrangement for the processes and are itemized in the Quality Plans of each unit. Planned activities and financial resources necessary are determined in the WFP. Information necessary on how to conduct specific processes are documented in procedures wherever practical.

3.3         Process Monitoring, Measurements and Improvements

The Internal Quality Audit serves as the primary tool in monitoring and measuring processes. This tool demonstrates the ability of the process to achieve planned result. In cases where targets are met, the process owner shall consider improving target for the next period. When objectives and targets are not met, improvements shall be carried out through corrections and corrective actions by initiating Corrective Action Request (CAR).  Risks are unforeseen events that may need an action plan to minimize or mitigate its effects on the organization. The positive side of risk is opportunity. Risk are itemized in the Risk Registry of each unit with their treatment and analysis and verification of the effectiveness of its controls / actions.

3.4         QMS Documentation 

               EAMC shall document its quality management system whenever necessary to ensure effective planning, operation and control of all of its processes. Documentation should add value to process and should ensure compliance to statutory and regulatory requirements related to the processes.

3.5         Documentation Structure

The Documentation Diagram shows the hierarchy and level of documentation of EAMC QMS according to importance.

Quality Policy – expresses EAMC’s overall goal anchored on its mandate and its commitment to observe quality standard in planning, implementing and evaluating its programs and projects towards sustained and continual quality service to clients.

Quality Objective – is the declaration of EAMC’s overall goal of achieving its mission productive jobs for all. These are further translated into several programs and projects, some of which are covered in the Procedures Manual. The quality objectives are consistent with the quality policy and are measurable to ensure effectiveness of EAMC’s programs, projects or services.

Quality Manual – provides the general guide in implementing EAMC QMS program which include some general information on EAMC (the scope, the agency quality policy, the organizational structure, the QMS structure, the Process Map, and the policy statements).

Procedure Manual – provides the general guidance and quality control in the conduct of EAMC (controlled processes for ISO certification). Each of these processes provided for are:

1. Procedures
2. Work Instructions
3. External Documents (Guidelines, Administrative Order, Republic Acts)

Quality Records – serve as evidences of the performance of the services in the clinical wards and offices. These include duly filled-up standards forms, supporting documents and other record generated in the delivery service.

3.6         Document and Records Control

               EAMC shall ensure that documents necessary for the effective planning, operation and control of processes are controlled. Documents include the Quality Policy, Quality Objectives, Quality Manual and Operations Manual. Controls applied to these documents are specified in the Records Management Manual (see Appendix D).

               Quality Records that provide evidences of the implementation of the quality management system shall likewise be controlled. Process owners shall ensure that their records are readily identifiable, retrievable and legible. Controls applied to records are specified in the Records Management Manual (see Appendix D)

4.1         EAMC Top Management 

EAMC Top Management consists of the Medical Center Chief and the Division Chiefs. Inherent to the position, the Medical Center Chief serves as the highest authority in the EAMC Quality Management System.

4.2         Management Commitment

    Under the direct supervision of the Secretary of DOH and the Cluster Undersecretary, the Medical Center Chief represents the leadership in his respective area of responsibility. EAMC Top Management aims to adapt a principle-based quality management system by advocating the following management principles:

3. Customer Focus – by properly communicating throughout the organization, the importance of meeting the requirements of its clients as well as the statutory and regulatory requirements, adopting a balanced approach between satisfying client expectations and complying with the prescribed rules and guidelines; as well as measuring client satisfaction through reliable survey instruments;
4. Leadership – by providing clear direction and instilling unity of purpose within EAMC, creating and maintaining an environment for the operation of processes in which members of the organization get involved in achieving the agency’s Quality Policy and Quality Objectives and in adopting the spirit of accountability, transparency, good and democratic governance;
5. Engagement of People – by acknowledging that people at all levels of the organization make up EAMC as an agency, and that their full involvement by using their skills and competencies shall benefit the organization in achieving its goals and objectives;
6. Process Approach – by managing the programs/projects and activities efficiently and effectively and treating these as a process to best achieve the desired results;
7. Improvement – by ensuring that EAMC overall performance undergoes periodic review/assessment for continual improvement. EAMC shall also provide appropriate capacity building to its employees and shall equip them with the necessary tools and techniques to make the service delivery responsive to the needs of clients.
8. Evidence-Based Decision Making – by making an effective decision based on analysis of sufficient, accurate, timely data and information.
9. Relationship Management – by recognizing that EAMC and its external providers, although are independent, need mutually beneficial relationship to achieve respective goals and create value to organization.

4.3         Customer Focus

               EAMC aims to become customer-focused organization. The customers’ satisfaction shall be the primary concern of EAMC management in planning and implementing programs, activities and projects. Thus, the needs and expectations of the customer shall always be determined and met satisfactorily within the framework of its legal powers and resources available. Management shall ensure a balance approach in satisfying customer vis-à-vis its mandate.

4.4         Quality Policy

               Based on the organization’s mandate, vision and mission, the management shall develop the Quality Policy to focus on a customer responsive service delivery, giving emphasis on providing better, faster and more efficient processes. As such, management shall ensure that the quality policy is understood, by its officers and employees, posted in conspicuous places within the hospital. It shall be recited after the flag raising ceremony and in meetings to serve as a guide in decision making.

4.5         QMS Planning

               To achieve the goals and objectives of EAMC, an annual planning exercise at various levels in the organization shall be held to discuss the thrust and priorities for the year, set achievable, realistic, measurable and fair targets, and identify necessary resources to achieve the same.

               The approved plans and programs/projects as reflected in the Work and Financial Plan, shall be implemented within the time frame during the year.

               Continuous monthly monitoring of the programs and projects with Quality Objective Plan and Monitoring (QOPM) and breakthrough report shall be undertaken by the respective process owners. These will be validated and verified during an internal audit at a planned interval and through the semi-annual assessment of the agreed targets by the respective division Strategy and Quality Management Team. The planning process shall consistently adopt the quality management principles.

4.6         Responsibility, Authority and Communication

               The management of EAMC shall define individual roles within the organization to effect the implementation of programs, activities and projects. These shall be embodied in the organizational chart, presenting the hierarchical levels of authority. Position Description Form shall state the duties and responsibilities inherent to each and every position. Office order shall be issued for additional designation not stated in the Position Description Form.

               The management shall provide the appropriate communication facilities and mechanisms to ensure the seamless flow of information to all offices. A system of tracking incoming and outgoing communication is being implemented in the offices.

4.7         Management Review

               Management shall ensure that Management Review (MR) or Management Committee (MANCOM) Meeting is conducted.

Levels of Management Review:

EXPECTED OUTPUT

1. Agreements and Actions Plans

The following shall include as Management Review Records or Minutes of Meetings especially decisions by management on vital issues and concerns:

1. Corrective actions to non-conforming services;
2. Progress of implementation of actions relative to agreements, including corrective actions;
3. Assessment of the effectiveness and improvement of programs, activities and projects and their compliance to ISO 9001 standards;
4. Action related to policy changes;
5. Resource management; and
6. Prioritization of programs, activities and projects. 

5.1         The Core Processes of East Avenue Medical Center

The Core processes of EAMC consist of frontline services anchored on its mandate. Core processes consist of the following:

1. Department of Anesthesiology
2. Department of Dermatology
3. Department of Emergency Medicine
4. Department of Family Medicine and Community Health
5. Department of General Surgery                              
6. Department of Internal Medicine
7. Department of Neurosciences
8. Department of Obstetrics and Gynecology
9. Department of Ophthalmology
10. Department of Orthopedics
11. Department of Otorhinolaryngology- Head and Neck Surgery
12. Out Patient Department               
13. Department of Pathology and Laboratories
14. Department of Pediatrics
15. Department of Physical Medicine and Rehabilitation
16. Department of Radiological Sciences
17. Department of Urology
18. Emergency Room and Trauma Center
19. Department of Hospital Dentistry
20. Pharmacy Section
21. Medical Social Work Department
22. Nutrition and Dietetics Service
23. Health Information Management Department
24. Admitting and Information Unit
25. Special Care Areas
    1. Breast Care Tumor
    2. Breast Care Surgery
    3. Toxicology
    4. Heart Station
    5. Otorhinolaryngology Maxillofacial Aesthetics Center (OMAC)
    6. Skin Center
    7. TB-DOTS
    8. Nursing Service

5.2         Planning for Service Realization

Planning for the CORE Processes is generally carried out during the annual planning workshop. The Work and Financial Plan (WFP) shall be carried out in order to meet the Quality Objectives or targets. Financial data included in the WFP shall be used to measure effectiveness of the programs. These can be evidenced in the QOP (FM-QMS-008) and QOPM (FM-QMS-009).

               Procedures for delivery of diagnostic, therapeutic, and ancillary care shall be developed to ensure the safe, efficient, and timely delivery of health care services. These shall include among others guidelines for patient safety, infection control, infrastructure and workplace accessibility, and healthcare manpower competence. Procedures for each process shall be established and shall include preparation, validation, monitoring, measurements and corrective actions. Persons responsible shall also be indicated in the procedure established.

5.3         Customer-Related Processes

EAMC shall determine and review the requirements of each services required by its customers. In general, customer requirements are determined and embodied in the forms and medical records submitted. Statutory and regulatory requirements shall be determined and be strictly complied with in the performance of the processes. These requirements shall also be defined in the established procedures for the process.

Customer feedback, whether verbally or on paper, shall be dealt with utmost importance, being inputs in planning, program implementation and as basis for providing appropriate action by management.

Effective communication arrangements with customers shall be implemented and shall be specified in the Procedures to be established. Effective communication arrangement includes, but not limited to the following:

1. Citizens Charter (posting of services and steps in the office);
2. Website information;
3. Memos, letter and request;
4. E-mail and Short Message Service (SMS);
5. Customer Feedback Reports;
6. Orientations prior to registration;
7. Exit conference during inspections; and
8. Focus Group Discussions and Meetings with other Stakeholders.

5.4         Design and Development

Design and development and activities are integrated in the different processes of the Quality Management System. Design and development of services are generally carried out for services through documented information. The unit’s design and development program is incorporated in the Development Plan of the Hospital.

5.5         Process Control

In order to ensure that processes within the EAMC are carried out consistently and will produce quality outputs that meet customer requirements, organizational requirements and legal requirements, the following controls shall be applied to each process, as applicable.

1. Strict adherence to statutory and regulatory requirements pertaining to the process.
2. The use of documented procedures to ensure effective control of the processes and to provide clear step by step instruction on how a specific activity in the process will be carried out.
3. The implementation of monitoring and measurement activities within the process to ensure that quality requirements will be fulfilled and that acceptance criteria shall be met.
4. The use of suitable materials and equipment to ensure the quality output of the service.

5.6         Process Monitoring Improvement

               Annual measurable targets of each division shall serve as measurement tools for process effectiveness. The method to be used in measuring these targets is through the Internal Quality Audit and through self-assessment of the area using the QOPM form (FM-QMS-009). When these targets are achieved, it signifies that the process is effective. If the target is not achieved, it signifies that the process is ineffective and, hence, will be treated as nonconformity.

In order to demonstrate continual improvement of the processes, process owners shall consider setting a higher target for the next period once targets are met. If targets, however, are not met, correction and corrective action shall be taken using the CAR Form (FM-QMS-019).

5.7         Products and Services Monitoring

Monitoring shall be carried out at different stages of the process in order to ensure that customers meet specified requirements.

Monitoring tools used are the QOPM Form (FM-QMS-009), PGS Status Report Form (Catch-up Plan) (FM-QMS-034), PGS Status Report Form (Plans Moving Forward) (FM-QMS-035), and PGS Evaluation Report Form (Dashboard) (FM-QMS-036).

5.8         Validation of Processes

Overall assessment and evaluation are the processes which programs, projects and activities are validated. Impact assessment of programs, projects and activities can only be carried out after services have been delivered to the customers. Hence, criteria for impact assessment shall be established and included in the Post Activity Reports.

5.9         Identification and Traceability

For each process, reference code system shall be applied to provide identification of services provided.

5.10      Customer Confidentiality and Preservation of Products and Services

Personal data and customer information are the primary customer property under the care of the organization. EAMC shall identify, verify, protect and safeguard customers’ properties that are entrusted to it as it provides the services. These include customer information and documents submitted, among others, which should be treated with due diligence. Personal customer information shall be treated with utmost confidentiality. Appropriate controls on these properties shall be adopted such as the conduct of inventory, restrictions in the release or access to these by unauthorized party. Unauthorized release or release access to any party shall be dealt with in accordance with existing rules and regulations.

Preservation of products and services are generally carried out by maintaining appropriate documented information for each process. These shall also be carried out under the records control procedure. The rules and regulations as stated in the Data Privacy Act 10173 will be referenced.

6.1         The Support Processes of EAMC

The primary role of support processes is to provide necessary support function to the management and core processes in order for them to effectively discharge their respective function in fulfillment of its mandate. Services under support services are governed by relevant statutory and regulatory requirements.

 The Support Processes of EAMC Quality Management System covers the following services:

1. Accounting – Processing of Claims, Preparation of Accounting Reports, Remittances
2. Budgeting – Budget Allocation and Obligations, Preparation of Budget Reports
3. Cash Operation – Payment of Claims and Remittances, Preparation of Reports
4. Human Resource Management – Hiring and Selection, Training and Competency Assessment
5. Supply – Procurement through Bids and Awards Committee, Requisition and Issuance
6. Documented Information (IHOMP) – Documented Information Management including hospital information system (IT), Internal and External Communication Tracking
7. Engineering Services – Operation Maintenance of the physical plant and the numerous facilities and equipment of the hospital
8. Billing and Collection/PhilHealth – Guidelines in costing hospital services, assists PhilHealth patients, preparation of patient’s statement of accounts
9. Transport – Provides transportation services to patients, authorized hospital personnel and keep all hospital vehicles in good working condition
10. Linen/Laundry – Stock of hospital linen and laundry servicing
11. Housekeeping – establishes standards for sanitation/cleanliness thru janitorial services
12. Security Personnel – Enforcing laws, rules and institution policies.

6.2         Planning for Support Service

Planning for Support Processes is generally carried out during the annual planning workshop.

Inputs for planning process shall include:

1. Inputs from the Core Processes as to their budgetary and logistical needs;
2. Statutory and regulatory requirements; and
3. Annual Procurement Plan submitted by the Core Process Owner;

6.3         Determining Internal Customer Related Requirements

Support service requirements are generally defined by relevant statutory and regulatory requirements coming from the Commission on Audit, Department of Budget and Management, Civil Service Commission and other national government agencies.

Internal customer requirements are specified in pertinent government forms such as Purchase Requests, Request and Issue Slip, Disbursement Vouchers, Application for Leave and other government forms.                 

6.3         Process Controls

Support process shall ensure that its services meet internal requirements and government regulations. The following shall be used as applicable to support service.

1. Accounting: New Government Accounting System Manual and other COA Rules and Regulations.
2. Budget: DBM Budgeting Manual and other DBM Circulars
3. Supply: RA 9184 and its implementing Rules and Regulations
4. Human Resource Management: CSC Rules and Regulations
5. Documented Information: National Archives of the Philippines Act of 2007, Data Privacy Act of 2012

In addition, procedures shall be established whenever necessary in order to ensure that support process are carried consistently and to provide a clear guide to process owners on specific policies for each activity.

6.5         Process Monitoring and Improvement 

For support processes, the method to be used in measuring support processes is through the Internal Quality Audit. When these targets are achieved, it signifies that the support process is effective. If the target is not achieved, it signifies that the process is ineffective and, hence, will be treated as nonconformity.

In order to demonstrate continual improvement of the processes, process owner shall consider setting a target for the next period once targets are met. If targets, however, are not met, correction and corrective action shall be taken using the CAR Form (FM-QMS-019).

 6.6         Products and Services Monitoring

Claims, funds provided and supplies and materials issued serve as tangible output or products and services provided by the Support. Monitoring shall be carried out at different stages of the support process in order to ensure claims, funds and procurement meet specified statutory and regulatory requirements. Acceptance criteria refers to supporting document requirements, inspection requirements, bidding requirements and others are appropriate. In no case, shall a claim, fund or procurement be provided if a particular requirement or acceptance criteria is not met. Otherwise, it will be treated as nonconformity and shall undergo process of correction and corrective actions.

6.7         Identification and Traceability

For each process, coding system shall be applied to provide identification of services provided. A unique identification code shall be applied to each type of government forms and a system of tracking will be established for each particular service. The system of coding shall be included in the procedures established. (See appendix on Record Management)

6.8         Human Resource Management

As the most important resource of the organization, competence of EAMC personnel shall be developed to meet the high expectations for the job. Hiring and selection process shall ensure that the employees hired meet the minimum requirements of Civil Service Commission specified in the Qualification Standards and the competency requirements of the position.

Competencies shall be assessed on a per position basis in order to ensure that employees have the right education, training, skills and experience before they are assigned to particular task. Training Needs Assessment (TNA) shall be carried out to determined competency requirement of personnel. Action to be taken to achieve the necessary competence shall be verified if effective.

6.9         Supply Chain Management

As a national a government agency, procurement shall be primarily governed by RA 9184 or the Government Procurement Reform Act and its Implementing Rules and Regulations. A purchasing procedure shall be established in accordance with the said Republic Act. External Provider selection is carried out by the Bids and Awards Committee (BAC) with established criteria as stated in RA 9184. External Provider evaluation shall be carried out for regularly externally provided products and services.

Purchasing information is specified in the Purchase Request (PR). Process owners shall ensure that specifications are clearly and adequately defined for products and services to be procured.

Verification of externally provided products and services is accomplished by Property Inspectors. Inspection and Acceptance Reports (IAR) shall be prepared to provide evidence that inspection has been conducted and purchases meet the purchase requirements.      

  6.10      Infrastructure and Environment for the Operation of Processes

To ensure effective delivery of services, management shall provide adequate physical facilities conducive to sound and healthy environment for the operation of processes. The 7S (Sort, Set in order, Shine, Standardize, Sustain or Self Discipline, Safety and Spirit) principle shall be promoted and implemented in EAMC workplace to further enhance employees’ productivity and customers’ comfort and security.

EAMC facilities shall be maintained in good operational condition and these shall be covered by adequate insurance. Evaluation of physical facilities shall be included in internal quality audit and management review reports.

Preventive Maintenance and calibration activities shall be carried out for all Medical (Diagnostics and Therapeutic) Office and IT Equipment at planned interval.

7.1         Review and Improvement Processes

EAMC Review and Improvement Processes refer to processes needed for the continual improvement of the quality management system established. These processes are focused in providing confidence that quality requirements will be fulfilled and focused on increasing the ability of the organization to meet the requirements.

The following are the review and improvement processes of EAMC:

1. Customer Satisfaction Survey and Analysis
2. Internal Audit Control of Nonconforming Product and Service
3. Corrective Action
4. Continual Improvement

7.2         Customer Satisfaction, Analysis and Improvement and Customer Feedback

 Survey is the primary method to be used in measuring customer satisfaction. The use of Patient Satisfaction Index (PSI) (FM-CSC-001, FM-CSC-004, and FM-MED-OPD-016) shall be given to customer on a random basis. The survey shall cover criteria in terms of quality and timeliness of services and quality facilities.

At the end of the month, this survey shall be collected, summarized and analyzed using the CSAT Presentation to MANCOM (QR-CSC-021). The analysis shall include areas for improvement. The result of the survey shall be discussed in the management review for proper improvement action. The organization shall continually seek improvement opportunities in order to enhance customer satisfaction.

The same forms (FM-CSC-001, FM-CSC-004, and FM-MED-OPD-016) will be used in getting feedback from customers. Feedback that can be considered as complaints and represents customer satisfaction shall be considered as nonconformity and these shall undergo the Control on Nonconformity and Corrective Action process.

Strategy management is the process of integrating all the functions and activities of an organization into a coherent whole. Strategy management provides the “glue” that holds these processes together. It also encompassed the function of management as the process of planning, organizing, leading, and controlling people in the organization to effectively use resources to meet organizational goals.

trategy Management best fits with the planning function on how the organization will create a competitive advantage to ensure that the people in the organization support the strategy. However, these should also be motivated in compliance with standards and regulatory requirements.

OFFICE FOR STRATEGY AND QUALITY MANAGEMENT (OSQM)

               The Quality Management Office (QMO) at East Avenue Medical Center have been created in 2014 as the central office in charge of monitoring and evaluating the hospital Quality Management System and in preparing the hospital for its accreditation to ISO 9001: Quality Management System. Since then, the function of the Office has evolved to spearhead the accreditation of the hospital to QMS (ISO 9001:2008 and ISO 9001:2015).

               QMO has transformed to the Office of the Strategy and Quality Management (OSQM) on January 13, 2021 to align and comply with the needs of Performance Governance System (PGS). OSQM is responsible for ensuring alignment of all plans, systems and process to the goals and objectives of East Avenue Medical Center through its PGS Strategy Roadmap and Quality Management System and reporting directly to the Medical Center Chief.  It is primarily responsible for the conduct of strategic, special and policy studies and the management of cross-functional processes related to governance and strategy management to ensure the effective implementation of East Avenue Medical Center Strategic Objectives.

               The following are the functions and responsibilities of the office:

1. Internal Quality Audit – To formulate a systematic, standardized and efficient Internal Quality Audit; policies, programs, procedures and guidelines that conforms to the regulations of ISO 9001:2015. Monitor and ensure the strict implementation of the organizational process and compliance to regulatory and regulatory requirements in relation to the Quality Management System. Conduct internal audit to determine whether the Quality Management System is effectively conforming, implementing and maintaining, the set standards and requirements of the International Organization for Standardization. Assist in the conduct of External Audit by the Certifying Body. Follow-up the process owner and submit to the certifying body all documentary requirements needed for the non-conformity / observations by the External Audit. [ Other additional information in Appendix B (QM-QMS-IQA-001)]
2. Customer Experience – To monitor healthcare needs of all customers through internal and external strategy. The Internal Strategy for customer satisfaction constitutes feedback loop to incorporate customer comments and complaints into the planning process to the quest for continual improvement of EAMC product and services. This strategy is pursued through: Customer Survey Feedback and Customer Complaint Resolution Strategy from internal and external portals. [ Other additional information in Appendix C (QM-QMS-CRU-001)]
3. Records Management – To formulate a systematic, standardized and economical Records Management policies programs, procedures and guidelines in the Record creation, dissemination, maintenance, storage, protection, retrieval, retention, preservation and disposal of Records. Reinforce the strict implementation and compliance of all regulatory and statutory requirement in relation to Records Management. [ Other additional information in Appendix D (QM-QMS-REC-001)]
4. Workplace / Quality Assurance – To formulate a systematic, standardized and efficient Occupational (Workplace) Health- Safety and Environmental Health policies, programs, procedures and guidelines that conform to the regulations of ISO 9001:2015, ISO 45001 and ISO 14001. Reinforce strict implementation and compliance of all regulatory and statutory requirements in relation to Occupational (Workplace) Health- Safety Standards and Environmental Health Standards to foster a safe and healthy work environment.
5. Performance Governance System (PGS) – (TWG) To develop the EAMC Charter Statement and formulate the Scorecard. To cascade the Charter Statement and Scorecard to the different divisions. To effectively and effectively implement the EAMC Communications Plan for PGS. To lead in Strategy Refresh and Strategy Review of the EAMC Scorecard. To prepare the Medical Center Chief Performance Reporting and Public Governance Revalida. [ Other additional information in Appendix A (QM-QMS-PGS-001)]
6. Risks and Opportunities Management

“Clause 6.1.1 When planning for the quality management system, the organization shall consider the issues and the requirements and determine the risks and opportunities needed to be addressed to:  

1. give assurance that the quality management system can achieve its intended result(s)  
2. enhance desirable effects
3. prevent, or reduce undesired effects
4. achieve improvement.

Clause 6.1.2 The organization shall plan:

1. actions to address risks and opportunities
2. how to: 1. Integrate and implement the actions into its quality management system processes 2. Evaluate the effectiveness of these actions.

Actions taken to address risks and opportunities shall be proportionate to the potential impact on the conformity of products and services. Options to address risks can include avoiding risk, taking risk in order to pursue an opportunity, eliminating the risk source, changing the likelihood or consequences, sharing the risk, or retaining risk by informed decision. Opportunities can lead to the adoption of new practices, launching new products, opening new markets, addressing new customers, building partnerships, using new technology and other desirable and viable possibilities to address the organizations or its customer’s needs. (Refer to PNS ISO 9001:2015)” 

(See Appendix E – Risks and Opportunities Management)

7. Never Event / Sentinel Event Documentation and Handling

National Quality Forum (NQF), “never events” are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.

Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

Sentinel events are defined as “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof.” The NQF’s Never Events are also considered sentinel events by the Joint Commission. The Joint Commission mandates performance of a root cause analysis after a sentinel event.

7 CATEGORIES OF NEVER EVENTS/SENTINEL EVENTS

1. Surgical or Procedural Events
2. Product or Device Events
3. Patient Protection Events
4. Care Management Events
5. Environmental Events
6. Radiologic Events
7. Criminal Events

The forms/templates can be downloaded from the East Avenue Medical Center website-https://eamc.doh.gov.ph/