Healthcare Quality

2009 ANNUAL REPORT

Raising the Bar in

THE MEDICAL CItY: TOWARDS SERVICE AND LEADERSHIP The Medical City (TMC), a tertiary health care institution owned and operated by Professional Services, Inc. (PSI), has been operational since 1967. Through the years, it has learned to integrate the science of medicine with that of business management. Hence, TMC boasts of its world class standards of care, while remaining one of the most nancially sound health care organizations in the country. Its history reects the collective aspiration and experience of its forerunners, which has in turn shaped its character, and enabled it to stay the course towards its vision and mission. The Vision To be a leader in shaping how Filipinos think, feel and behave about health and how health services are accessed by and delivered to them, and to use such leadership to serve equity in health, life and development. The Mission The pursuit of our vision is animated by the passion to keep our patient on center stage and deliver service of greater worth, engaging strategic partners who share our vision and passion, constantly proceeding from what we do best. In the process of carrying these out, we align the interests of our employees, our professional staff and our shareholders with the interests of those we serve. CORPORAtE VALUES Excellent and compassionate service We aspire to excellence and compassion in the provision of our services, achieving increasingly superior performance through organizational synergy and continuous innovation. Client partnership We forge sustainable partnerships with enlightened and empowered clients - our patients, physicians and payors - systematically creating opportunities for active engagement, informed participation, and shared responsibility. Primacy of the human resource We invest in the personal and professional development of our staff, providing them with the requisite technology, capacity and voice to exercise their primacy as a resource in serving our customers and creating value for our shareholders. Integrity We uphold personal and institutional integrity, consistently seeking alignment between the values that we espouse, and the strategies, decisions and actions that we pursue.

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TABLE OF CONTENTS

02 Executive Message 09 Financial Performance Feature Articles: 12 The New Intensive Care Paradigm 18 Prepared in Times of Crisis 24 A Solution to Every Problem 28 Managing the Supply Chain 30 Board of Directors 34 Executive Committee 36 Senior Management 37 Vice Presidents 37 Medical Directors 38 Assistant Vice Presidents 39 Financial Report

2009 ANNUAL REPORT

EXECUTIVE MESSAGE

07

At The Medical City (TMC), our vision of leadership is founded on a commitment to service excellence, which is, in its most fundamental sense, a commitment to quality and safety in patient care.

LivinG Out a Commitment to Service EXcellence

This commitment is enlivened by a culture that has, over time, taken root at all levels of the institution, and across the various functions within. This culture, in turn, has been developed and enriched over years of shared values and experience, and has ultimately been concretized in TMCs Quality Improvement and Safety (QuIPS) Program.

Augusto P. Sarmiento, MD Chairman

Alfredo R. A. Bengzon, MD, MBA President and CHIEF EXECUTIVE OFFICER

THE MEDICAL CITY

This ability to rapidly form and effectively work as teams across disciplines, ranks and units distinguishes and has distinguished TMCs culture of quality.
TMCs QuIPS Program aims to achieve good patient outcomes by continuously improving the quality and safety of patient care processes, and ensuring the safety of staff and facilities. It does so by designing systems and building capacity directed at high service quality and reliability, with particular focus on those areas that have the greatest impact on the wellbeing of patients and staff: care of high-risk patients; prevention of hospital care-related infections; medication safety; device use safety; surgical safety; anesthesia safety; blood safety; laboratory safety; radiation safety; facilities safety; and staff health. Using a bottom-up approach, departmentlevel and cross-functional teams are regularly organized as appropriate to address specic challenges in both medical and administrative areas. In delity to our partnership philosophy, we have also engaged patients and patient groups to be part of these teams. The teams undertake the Plan-Do-CheckAct (PDCA) cycle when pursuing continuous quality improvement in their spheres of concern. Performance improvement projects are prioritized based on clinical and strategic importance. An action plan is formulated and implemented to achieve the desired outcomes. Quality indicators are then measured and monitored to assess project success in objective terms, as well as to identify opportunities for further improvement. This ability to rapidly form and effectively work as teams across disciplines, ranks and units

2009 ANNUAL REPORT

EXECUTIVE MESSAGE

07

By far, the most signicant testament to TMCs service quality was our reaccreditation by the Joint Commission International (JCI) in November 2009.
distinguishes and has distinguished TMCs culture of quality. Senior management, department managers, clinical chairs and staff at all levels are all jointly accountable for leading and accomplishing the QuIPS Program. However, the organizational unit directly charged with overseeing program execution is the QuIPS Council. Headed by the Manager of the Systems and Quality Department (SQD), and operating under the supervision of the Director of the Medical Quality Improvement Ofce (MQIO), the QuIPS Council is composed of representatives from the Medical Services Group, Patient Services Group, Finance and Administrative Services Group and Strategic Services Group. The Council institutes quality and safety policies and programs, supervises implementation, and evaluates their impact and effectiveness. Through its work, the Council promotes such quality improvement principles as patientfocus; improvements based on correct information and current evidence; prevention rather than correction; and the shift from a culture of blame to a culture of innovation.

Quality Acclaimed Our endeavors have not gone unnoticed. The Philippine Health Insurance Corporation (PHIC), which administers the National Health Insurance Program of the Philippines, has awarded TMC with the Pasasalamat sa Partners Award, in appreciation of our efforts in promoting continuous quality improvement. PHIC has recognized TMC as a Center of Excellence, the highest hospital accreditation level based on the enhanced quality standards of the PHIC. TMC has also been tapped to collaborate with PHIC in operationalizing a radically new system for billing and reimbursement that is based not on itemized inputs, but on episodes, complexity and outcomes of care.

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By far, however, the most signicant testament to TMCs service quality was our reaccreditation by the Joint Commission International (JCI) in November 2009. Widely recognized as the most prestigious accrediting body of international healthcare organizations, JCI prescribes compliance with 14 chapters involving 323 standards and 1,193 measurable elementscovering all aspects of hospital organization and operations. Preparations for reaccreditation were systematic, rigorous and thorough. As early as 2007, even as we had just successfully hurdled our rst accreditation process, the JCI Compliance Committee was established to ensure sustained adherence to

all Joint Commission standards. In 2008, the Committee recommended the formation of Task Forces to be focused on four of the most challenging functional concerns: Medication Safety, Team Communication, Documentation, and Patient Education. Composed of medical, allied medical and administrative staff, the Task Forces worked tirelessly to lead the hospital towards JCI-readiness. The Medication Safety Task Force reviewed and reformed medication management systems and processes. It likewise offered training courses for TMC physicians, nurses, pharmacists and other staff on such important issues as medication safety, rational drug use, formulary use, medication reconciliation, and adverse drug reaction monitoring.

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EXECUTIVE MESSAGE

The Team Communication Task Force designed programs and mechanisms to promote effective communication between the members of health care teams, especially those deployed in high-risk areas such as the Surgery Suite, Delivery Suite, Ambulatory OR, Emergency Department and Intensive Care Unit. The Documentation Task Force recommended policies and processes to improve the generation and management of information contained in the patient chart. It conducted regular assessments of the content, completeness, accuracy, legibility and timeliness of the patient chart. It also oversaw quality improvement activities related to patient chart documentation. The Patient Education Task Force directed its efforts towards developing policies, programs and associated materials responsive to our patients need for information and education; as well as towards capacitating TMC staff in their implementation. Of particular concern were programs on patient and family rights, informed consent, advance directives, and disclosure of adverse events. In addition, special programs were introduced in response to specic quality and safety concerns. Based on a root-cause analysis of all patient

falls over a twelve-month period, TMCs Falls Prevention Program calls for all patients to undergo a falls risk assessment upon admission, upon transfer to another unit within the hospital, after a change in status, after a fall, or on a regular basis, as needed. Depending on the patients fall risk, a specic Falls Prevention Protocol is carried out. The program also encourages the participation of patients and their families in fall prevention. TMCs Get Wet Campaign was introduced to educate staff on proper hand hygiene, and to encourage its practice at appropriate times in the care process. Hand washing has long been recognized as the most effective way of controlling and preventing the spread of infection in a hospital setting, although it has been notoriously difcult to perform consistently. On a weekly basis, the CEO and other senior managers conducted walkabouts around selected areas of the hospital. Tagged as Leadership Rounds, these walkabouts served as the means to evaluate service levels rst-hand, while communicating top-level emphasis indeed, insistenceon quality. Mock surveys were carried out at strategic time intervals to assess compliance with standards,

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spot areas of weakness, and propose necessary corrective action. Mock surveyors were selected from among the internal staff, and the process mimicked the actual survey. This enabled a realtime evaluation of hospital performance while also allowing personnel to practice relating and responding to the surveyors.

The actual accreditation survey came upon us quickly. Early on, we had adopted the slogan Tested. Acclaimed. Ready. Now. and we were. As before, the survey was conducted by a seasoned team composed of a nurse team leader, a physician and a hospital administrator. The surveyors were meticulous and methodical. During the ve-day period, they reviewed documents, inspected facilities, observed operations, consulted patients, and interviewed staff at all levels from the Chairman of the Board to the janitors and security guards. Over the course of the survey, the team commended TMC on numerous best practices, including our use of clinical practice guidelines and pathways, our quality monitors, our infection control program, our patient

Finally, organizational development initiatives were undertaken to support and reinforce the hardcore process and policy changes. The Quality Award was launched to achieve broadbased awareness on the quality and safety policies of the hospital, and to celebrate those units which have adopted and consistently adhered to these policies. Similarly, a TMC Superheroes Event was organized to encourage staff to be Quality Superheroes in their own specic work settings.

2009 ANNUAL REPORT

EXECUTIVE MESSAGE

In the end, as we did in 2006, we performed with distinction, garnering perfect scores in standards on Patient and Family Education, and Governance, Leadership and Direction, as well as superior marks in standards on Quality Improvement and Patient Safety, Prevention and Control of Infection, and Anesthesia and Surgical Care.
education materials, our environment of care plan, our information management system, and our acute stroke program, among others. In the end, as we did in 2006, we performed with distinction, garnering perfect scores in standards on Patient and Family Education, and Governance, Leadership and Direction, as well as superior marks in standards on Quality Improvement and Patient Safety, Prevention and Control of Infection, and Anesthesia and Surgical Care. Furthermore, TMCs sentinel event policy has been featured in a Joint Commission publication on understanding and preventing sentinel events. We now look forward to the next accreditation process with excitement and anticipation. JCI consistently demands from us only the best that we can bring forth, and this best, we owe to our constituents, as well as to ourselves. More than ever, we are convinced of the rightness of our direction. Quality in The Medical City is not just a way of doing; it is our way of being. As we raise the bar of quality for ourselves, so too do we for our industry, our sector and our country, all for the benet of the patient partners who remain our true north.

Augusto P. Sarmiento, MD Chairman

Alfredo R. A. Bengzon, MD, MBA President and CHIEF EXECUTIVE OFFICER

THE MEDICAL CITY

PROFESSIONAL SERVICES, INC. AND SUBSIDIARIES

2009 FINANCIAL PERFORMANCE

Patient Services Revenue Gross Profit Margin EBITDA Margin Operating Profit Margin After TaX Profit Margin 2009 3,381.9 39% 26% 17% 14% 3,222.9

2008

2007 2,686.9 35% 22% 13% -15%

38% 25% 16% 13%

Our reputation for service quality served as the platform for another year of solid nancial performance. TMC registered a respectable revenue growth of 5%, despite the global economys sluggish recovery from the recession. More importantly, all protability metrics have demonstrated consistent improvements, as aggressive marketing and sales initiatives, together with investments in service development and enhancement, have been accompanied by robust and effective cost management.

2009 ANNUAL REPORT

financial PERFORMANCE

3500 3000 2500 2000 1500 1000 500 0

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financial PERFORMANCE

To facilitate year-to-year comparisons, 2007 Earnings per Share was adjusted to exclude the one-time loss on sales of investment property. Associated Income Tax Rate was estimated at 30%.

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The NeW Intensive Care ParadiGm

TMCS NEW ADULt INtENSiVE CaRE mODEL ENHaNcES caRE REGimENS aND OUtcOmES iN aND OUt OF tHE ICU.

In 2007, TMC began development of a new model for its Adult Intensive Care Service, which is the rst of its kind in the Philippines. TMC Intensivist (Intensive Care Specialist), Dr. Jose Emmanuel Jep M. Palo, who had completed his residency in Internal Medicine, and had undergone fellowship training in Critical Care Medicine at the Chicago Medical School of Franklin University (U.S.A), had been exposed to this model while training abroad. Upon his return, he proposed that TMC take the lead in its adoption. Akin to Emergency Care (ER), Intensive Care is a unit-based or area-based specialty rather than an organ-based specialty, explains Dr. Palo. ER doctors are expected to take care of anything that happens in the ER. Similarly, we at Intensive Care are expected to be capable of providing support whether the problem is neurologic, cardiovascular, pulmonary, etc. Given their compromised conditions, ICU patients are especially vulnerable to a wide range of life-threatening conditions collapsed lungs, multiple organ failure, cardiac arrest, and others. Our training prepares us to care for the sickest patients from all specialties.

Despite the Intensivists broad scope, integrating their practice into day-to-day medical management remains a challenge, as treatment still revolves around organ-based specialties at present. In truth, the role of the ICU Specialist is not yet well understood or appreciated. Intensive Care Medicine is not yet mature in the Philippines, says Dr. Palo. Only a few Adult Intensive Care Specialists practice here. But this was not a deterrent. Partnering with Dr. Jude Erric L. Cinco, a Canadian-trained Intensivist, and working alongside Dr. Mediadora C. Saniel, then-Director of TMCs Medical Services Group, ICU Director Dr. Donato R. Maraon, and a specially-assembled consultant team of Intensivists composed of Dr. Luis Martin I. Habana, Dr. Raymundo F. Resurreccion, Dr. Celina Z. Ancheta and Dr. Geraldine B. Jose, Dr. Palo designed a pilot Semi-Closed Adult Intensive Care Program, directed at improving the survival rates of TMCs most critical patients by increasing the Intensivists involvement in care. First off, the patients were classied into 2 groups, based on the severity of their illnesses as dened by international ICU guidelines. Care protocols for each group were then formulated. Co-

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management by the Attending Physician and the Intensivist was prescribed for patients in Category 1, who were in more serious conditions. On the other hand, referral to the Intensivist for those in Category 2 was left to the discretion of their Attending Physicians. This departed from the open ICU model then in place, where involvement of the Intensivist in care was completely optional, regardless of the patients state. We knew from studies abroad that engaging Intensive Care Specialists in the ICU increased patient survival rates by about one and a half times that of the baseline performance, says Dr. Palo. We needed similar results in our ICU to prove that the Semi-Closed model would work better than the previous open model arrangement. This rate thus became the benchmark for the Services performance. The pilot was implemented in both the ICU and Acute Stroke Unit for the next two months. Data was collected from September 2007 onwards, while 2006 baselines were

established to facilitate comparison. The results were very impressivethanks to the Service, survival rates of the ICU actually doubled, despite an increase in the average severity of the case mix. With this initial data validating the success of their model, the team acquired the leverage and credibility to spearhead other measures to further maximize the effectiveness of TMCs Adult Intensive Care Service. First, coverage of the Adult Intensive Care Service in identifying and co-managing the hospitals highest-risk patients was expanded. At rst, it was involved mainly in cardiology, pulmonary and sepsis cases, but it was soon engaged in the management of patients suffering from such threats such as Inuenza A(H1N1) and leptospirosis, as well as those under the new liver transplant program. Second, the Service introduced new therapies and protocols and trained staff accordingly. Therapeutic

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The NeW Intensive Care ParadiGm

The Medical City INTENSIVE CARE UNIT StandardiZed Mortality Ratio

September 2007 to December 2009

Standardized Mortality Ratio (SMR)

14

ICU Mortality (%)

This chart shows ICU performance using standardized mortality ratios (SMR). The mortality rate (blue columns) predicted through a standard scoring system reects the severity of illness among admitted patients. The increase over time implies that more severe cases are being seen at our ICU. In contrast, the actual mortality rate (red columns) remains relatively constant. The standardized mortality ratios (green dots) are the ratio of actual and predicted mortality; the lower, the better. The regression line (solid green line) shows a downtrend in the SMR, indicating improvement in performance over time.

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hypothermia protects the neurologic functions of patients who have suffered cardiac arrest by lowering their body temperatures and temporarily placing them in a managed comatose state. Without it, most comatose survivors of cardiac arrests are unable to fully recover. TMC is now the rst and only Philippine hospital to offer therapeutic hypothermia routinely, and has provided this lifesaving service to twenty one patients (21) since its introduction in September 2007. The Service has worked with the Philippine Heart Association and other hospitals, encouraging them to adopt the procedure as well. Advanced mechanical ventilation procedures were also introduced for patients whose lungs are

so compromised that no oxygen can enter their bloodstream. Prone positioning was rst tried in TMCs ICU in 2007, and the procedure saved the life of a patient with severe double pneumonia. This and other techniques, such as lung recruitment maneuvers (that shock open uid-lled collapsed lungs with short bursts of high pressure) and Airway Pressure Release Ventilation (which allows a patient with severe lung injury to breathe at alternately high and low pressures to improve air exchange), are increasingly being offered by TMCs ICU Intensivist team. The Sepsis Alert Protocol, based on early goaldirected therapy for sepsis, was developed by a multidisciplinary team led by Dr. Irmingarda P.

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The NeW Intensive Care ParadiGm

Gueco, Section Head of Nephrology. Early goaldirected therapy for sepsis stops the onset of major inammation borne from infection that leads to various complications and, ultimately, multi-organ failure. The University of the Philippines-Philippine General Hospital (UP-PGH) has since adopted a similar protocol, following TMCs example. Third, multidisciplinary rounds were instituted. This entailed the medical, nursing and ancillary personnel, who were involved in the patients day-to-day care, to convene on a daily basis. For each patient, current problems were reviewed and emerging threats were identied, care recommendations and contingency plans were formulated, and checklists were used to ensure that each patient received appropriate care. These rounds also served as a regular venue for teaching the principles of critical care to trainees of all levels. Fourth, the Service assisted the ICU Clinical Director and Nurse Manager in reviewing and improving ICU policies and protocols. The Sedation Protocol for patients undergoing mechanical ventilation was revised in accordance with international guidelines.

Patient monitoring documentation was updated to better capture all the elements of complex care. Measurement of illness severity in relation to patient survival was also continued, as this was essential in monitoring the most important metric of an ICUits ability to save lives. Lastly, in advancing the paradigm that Intensive Care is a process, and not just a room, the Service enhanced hospital-wide resuscitation and rescue services by providing high-delity simulation training for housestaff and nurses, and by supervising medical trainees during real crises, wherever the patients were located. TMCs Intensivist service proved invaluable in caring for the victims of 2009s various health crises - the pulmonary patients of the Inuenza A(H1N1) pandemic, and the kidney- and other organ-failure patients of the leptospirosis outbreak following Typhoon Ondoy (international name: Ketsana) and contributed signicantly to the impressive outcomes achieved by the hospital, which were better compared to the national averages.

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After two-and-a-half years and 2,500 admissions, survival rates continue to remain steady even as the Service takes on increasingly difcult cases. Simply put, more and sicker patients are being saved.
The Adult Intensive Care Service continues to build on its achievements. Dr. Palo has since been named Chairman of the Code 99 Committee, the hospital unit that ensures proper and prompt resuscitation procedures. In April, a workshop was completed to lay the groundwork for a Rapid Response System that mobilizes a multi-disciplinary team to care for critically-ill patients outside the ICU. The goal of this system is to reduce unexpected, preventable deaths to zero. The countrys very rst Critical Care Fellowship is also underway, under the stewardship of Dr. Jude Erric L. Cinco. Two post-residency trainees are now learning the principles, techniques and procedures of multidisciplinary critical care. These rst candidates are expected to graduate in 2012. All in all, the value of the reforms implemented in TMCs ICU has been amply validated. After twoand-a-half years and 2,500 admissions, survival rates continue to remain steady even as the Service takes on increasingly difcult cases. Simply put, more and sicker patients are being saved. Many ICUs all over the world have a specialist approach to care: Cardiology Units take care of heart patients, Neurology Units have stroke patients, and so on, says Dr. Palo. But what about patients who have problems with more than one organ system? What about those with sepsis, which hits various organs at the same time; or cardiac patients whose other organs fail after their heart stops? When a hospital has Intensive Care Specialists working in and out of the ICU, all these patients are promptly and effectively served; and this really makes a world of difference.

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Prepared in Times of Crisis

TMCS HOSPitaL INFEctiON CONtROL COmmittEE DEmONStRatES FORESiGHt, ViGiLaNcE aND iNNOVatiON amiDSt 2009S HEaLtH cRiSES.

On April 29, 2009, the World Health Organization (WHO) reported a signicant clustering of u-like illnesses associated with exposure to swine, and promptly warned the public of a pending epidemic in Mexico and the US. This development alerted the TMC Section of Infectious Diseases headed by Dr. Maria Fe R. Tayzon, who is likewise the Chair of its Hospital Infection Control Committee (HICC). The HICC immediately commenced close surveillance of patients at TMCs Emergency Room (ER) and the Medical Arts Towers doctors clinics. It also launched a comprehensive awareness campaign to educate TMC frontline healthcare workers, in anticipation of the A(H1N1) strain reaching our country. True enough, the Department of Health

(DOH) reported the appearance of the deadly strain a few days later, and Dr. Tayzon combined forces with Nurse Victoria I. Ching, TMCs Infectious Diseases Surveillance Coordinator, to formulate and initiate a masterplan for dealing with the virus. Two immense tasks were at handalerting the public on the impending outbreak, and preparing TMC to respond effectively to the A(H1N1) cases in the days and months to come. My concern was to keep the virus from spreading and causing panic among the patients and staff of the hospital, says Dr. Tayzon. On May 4, TMC launched its rst A(H1N1) forum,

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Oplan Sagip Bayan, inviting speakers from key agencies, including Dr. Jade F. del Mundo, then Undersecretary of Health, Dr. Enrique A. Tayag, Head of National Epidemiology under the DOH, Dr. Remigio M. Olveda, Director IV for the Research Institute of Tropical Medicine (RITM) and Dr. Nerissa N. Dominguez, National Professional Ofcer for Communicable Disease Surveillance and Response of the Philippine WHO ofce in the Philippines. Before an audience composed of local hospitals administrators, business and community leaders, and the media, Dr. Tayzon and the speakers relayed information on the disease, the magnitude of the crisis, and the associated pandemic preparedness plan. On May 12, an Inuenza A(H1N1) Pandemic Preparedness Task Force was organized, under the stewardship of Mrs. Virginia B. Alano, Senior Vice President Patient Services Group and Dr. Eugenio F. Ramos, Head Medical Services Group. The Task Forces duties and responsibilities were as follows: Draft and implement policies for managing Inuenza A(H1N1) cases in TMC and its satellite clinics Act as the oversight committee and conduct audit of Inuenza A(H1N1) cases managed at TMC

Coordinate with the different departments and units involved in the management of Inuenza A(H1N1) cases Coordinate and network with the Department of Health, Local Government Units and other nongovernment agencies involved in the evaluation and management of Inuenza A(H1N1) Gather and analyze conrmed cases Educate the internal and external community

The WHOs algorithm of key medical and safety procedures was adopted. Use of protective gear was strictly required of all staff directly involved in patient care. Special triaging and isolation strategies were implemented to manage patient trafc and limit exposure. Proper collection and handling of specimens was also emphasized. During the rst days of the alert, testing of all specimens was centralized with the RITM. As the demand for testing began to overwhelm the RITM, Dr. Raul V. Destura, Consultant Director of TMCs Microbiology Laboratory, set up and secured approval from the DOH for an in-house A(H1N1) testing lab, the only such private facility in the country at the height of the pandemic between June to July 2009.

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Prepared in Times of Crisis

On the whole, TMCs pro-active approach to facing the threat of A(H1N1) resulted in signicantly better patient outcomes. Case fatalities were limited to 0.63%, substantially lower than the global rate of 4-7%.

Even as manuals were being developed on policies and procedures in A(H1N1) management, interim guidelines were issued in response to new and evolving knowledge about the virus. A dynamic, nimble and decisive organization was critical in managing the complex situation, and TMCs HICC operated as such. At rst, the virus was limited human-to-human transmission; then in a matter of three weeks, fullblown community outbreaks were conrmed, Dr. Tayzon explains. In the beginning, the guidelines prescribed admission for everyone who showed symptoms of A(H1N1). Soon, however, the hospital approached full occupancy. To address these capacity limitations, we identied and prioritized the population segments which were at greatest risk. We managed this by constantly reviewing and updating our guidelines in response to the transmission patterns we observed. A Fever Clinic was established to serve adult

and pediatric A(H1N1) cases under observation, thereby protecting other ER patients from exposure to the virus. The Fever Clinic was run by specially-trained ER doctors, nurses and health care workers, who also coordinated admissions with the hospitals Intensive Care Unit as the patients conditions warranted. A Communications Center was set up to respond to telephone queries, facilitate admissions, receive and release A(H1N1) test results, and provide home care instructions to individuals who had inuenza-like symptoms and patients for discharge. The Center served a critical role in disseminating accurate and timely information on A(H1N1) as the virus spread throughout the country. A series of forums was organized, each forum focused on a specic target audience patients and family members, corporate clients, and school ofcials. The latter group beneted especially from the forums, as schools became hot beds for the

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virus. TMC shared with the schools its algorithms for managing cases under observation, helped schools administration in creating guidelines for parents on how to manage conrmed and suspect cases, and guided them in setting up their own Communications Centers to serve students, faculty and staff. On the whole, TMCs pro-active approach to facing the threat of A(H1N1) resulted in signicantly better patient outcomes. Case fatalities were limited to 0.63%, substantially lower than the global rate of 4-7%. The organizational, policy formulation, process design and staff development initiatives pursued in line with the A(H1N1) pandemic helped the HICC to respond to the other health crisis that hit Metro Manila, this time in September 2009. Typhoon Ondoy (international code name: Ketsana) caused a months worth of rain to fall within 12 hours, leaving many locations underwater. As large numbers of people were forced to struggle through, and even

MEmBERS OF THE A(H1N1) PanDEmIC PREpaREDnESS TaSK FORCE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Dr. Maria Fe P. Raymundo-Tayzon Hospital Infection Control Committee Ms. Cristela A. Villa-Real Nursing Services Ms. Victoria I. Ching Hospital Infection Control Committee Dr. Mediadora C. Saniel Infectious Disease Specialist Dr. Marissa M. Alejandria Infectious Disease Specialist Dr. Raul V. Destura Infectious Disease Specialist and Microbiology Lab Dr. Regina P. Berba Infectious Disease Specialist Ms. Aura J. Guinto Special Services, Ambulatory Mr. Alejandro M. Calado, Jr. Housekeeping Ms. Jovita San Diego Medical Arts Tower (Administration) Ms. Melita C. Perez Marketing Ms. Nina V. Posadas Corporate Communications Dr. Florianne F. Valdes Center for Patient Partnership Mr. Edmongino J. Camacho Center for Patient Partnership Ms. Judith S. Betita Human Resource Dr. Blesilda E. Concepcion Professional Staff Development Ofce Dr. Rolando A. Balburias Emergency Room and Center for Wellness & Aesthetics Engr. Mary Ann E. Artates Safety Dr. Liza Mary P. Palencia Emergency Room (Resident) Dr. Alejandro G. Dela Cruz Emergency Room (Resident) Dr. Chairmaine D. Calianga Emergency Room (Resident) Engr. Philip L. Tan Facilities Mr. Samuel A. Carbonel Security

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Prepared in Times of Crisis

TMC A(h1n1) performance (May December 2009)

UNILAB Refused Positive Not Applicable No Result Negative Cancelled

No. of CUOs

1,940 1,291 (66.54%) 624 (48.33%) 4 (0.63%) 49 (1.35%)

Cases Under Observation (CUOs) Swabbed Cases Under Observation Positive Cases TMC Case Fatality (versus Global Rate of 4 7%) TMC HCWs Positive for A(H1N1) (versus Global Rate of 25 38%)

No Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week data 1 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 50 51 52 53 UNILAB Refused Positive Not applicable No Result Negative Cancelled 9 35 1 2 6 2 2 5 1 5 2 9 1 12 1 87 5 85 1 23 36 48 80 36 30 34 22 21 2 2 5 9 149 223 50 51 35 1 1 1 37 104 35 150 19 181 10 51 4 38 1 15 2 25 4 11 15 19 15 12 6 6 2 4 4 5 3 3 2 2 1 2 1 1 5 1 3 6 1 2 1 1

live around, unsanitary ood waters, a leptospirosis outbreak ensued. The inux of patients was unparalleled in TMC history as many locations within its catchment area were submerged. There was growing concern over the strain on hospital operations and resources. The HICC, together with TMCs Infectious Diseases and Nephrology specialists headed by Section Chief Dr. Irmingarda P. Gueco, quickly formed another Task Force to establish and monitor hospital care protocols, requiring that all potential leptospirosis cases be assessed by both an Infectious Disease Specialist and a Nephrologist.

This multi-disciplinary assessment enabled physicians to act within a crucial six-hour window to stabilize the patient and decide on initiation of renal replacement therapy. Such early intervention averted the need for dialysis in many patients and was central to TMCs success in leptospirosis management. The team also introduced innovations in dialysis prescription. The initial cases were so severe and so unique that Dr. Gueco and her team of Nephrologists came up with their own care protocol. The regular dialysis regimen was revised to address the specic conditions of the

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leptospirosis patients. The shortened but more frequent treatments also served to maximize the capacity of TMCs Hemodialysis unit. It was a unique strategy, continues Dr. Tayzon. We didnt just copy what everybody else was doing. The team saw the need to revise the standard protocol and adapt it to our specic needs. This innovation in care management, borne from the A(H1N1) experience, resulted in signicant positive patient outcomes; kidney failure was preempted, and recovery was quick for those who were dialyzed very early. As a result, TMCs success rate in treating leptospirosis patients bested national performance: a 5% mortality rate in TMC compared to the national average of 10%.

In support of local government disaster management efforts, TMC signed a Memorandum of Agreement with the City of Pasig to set up a special Charity Ward. TMC took in referrals from the local hospital network of patients suffering from acute diarrhea, dehydration, pneumonia, bacterial wounds, simple fractures, viral and skin infections, and other Ondoy-related malaises. Indeed, thanks to the foresight, cooperation and commitment of its staff, TMC has certainly proven that it can address the greatest of challenges, responding efciently and effectively to the publics need for quality health care, even in times of overwhelming crisis.

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A Solution to Every Problem

TMCS CaRDiOVaScULaR CENtER imPROVES SERVicE EFFiciENcY tHROUGH ENtERPRiSE aND iNNOVatiON.

Nurse Bethzaida C. Faylogna, Assistant Manager of TMCs Cardiovascular Center, had long been aware of a recurring problem in her department: the delay in the release of echocardiogram results to patients. On a daily basis, the Center releases patient test reports from four service areas: Treadmill, Vascular, 24 hours Holter and Ambulatory Blood Pressure Monitoring, but despite their best efforts, 20% of nal reports could not be released to their patients earlier than 5 days after the procedure. These delays caused great inconvenience to the patients, stress for the staff, and reected in the Departments inefciency. The problem was not just long-standing; it was worsening, as the Centers patient volumes increased over time. Decisive and effective action was clearly required. As a rst step, Nurse Faylogna reviewed her units workow in an effort to understand the problem better. She uncovered that the main cause for delay was the manual and tedious process of report generation, approval and nalization.

PREVIOUS RESULT GENERATION PROCESS Step 1: Test is conducted. Step 2: Technician encodes the values in the computer and prints the report. Step 3: Technician delivers the worksheet (with printed report values and the DVD recording of test) to Cardiology Fellow in the reading room. Step 4: Cardiology Fellow views the study and manually writes interpretation. Step 5: Cardiology Fellow places interpretation in the designated folder of the Cardiology Consultant. Step 6: Cardiology Consultant views the study, reviews the initial interpretation of the Cardiology Fellow, and signs the report. Step 7: Cardiology Fellow forwards the signed manual report to the Centers Clerk. Step 8: Center Clerk encodes the report. Step 9: Center Clerk delivers nal report to Cardiology Fellow for signature. Step 10: Cardiology Fellow reviews and signs the report. Step 11: Transport Orderly les nal reports, pending release to patients.

24

THE MEDICAL CITY

If upon review, the Cardiology Fellow and/or Consultant uncovered an error in the report, the process would have to be repeated in part or in whole. The entire process would have taken two days to complete, provided all went well, but in reality, some cases could drag on for up to ve days. Nurse Faylogna thus initiated two major process changes. She collaborated with the hospitals IT Department in designing and implementing an automated system for storing, retrieving and updating all diagnostic test results. These electronic les were much easier to generate, access and edit compared to their hard-copy counterparts. The second change was a far greater challenge. To streamline the process ow even further, she would have to persuade Consultants and Fellows to encode the readings themselves. She feared that the doctors would consider this task menial and beneath them. She was even more concerned about the likely negative reaction of the doctors to receiving this directive from a nurse like herself. Having worked in the health care sector for many

years, Nurse Faylogna was painfully aware of the less-than-subtle hierarchy that was operative here rst the doctor, and then everyone else. Yet, Nurse Faylogna gathered up her courage and pushed forward with resolve. Over a period of six months, she worked with the doctors in learning and adopting the new network system. To further simplify the result-generation process, electronic result templates were created. Doctors could simply copy and paste text from the result templates onto the nal report, and encode additional descriptions as needed. In time, all 46 of the Centers doctors had transitioned to the new system. The process changes freed Center staff to attend to other important administrative duties, such as responding to customer inquiries, organizing procedure schedules, and managing unit documentation. As use of paper and printing were kept to a minimum, supply costs were reduced. Most importantly, reports were nally released to patients in a more timely manner 2 working days after the tests vs. 5 working days after the tests. In fact, the department used to receive about 20 customer calls a day just to follow up on the release

2009 ANNUAL REPORT

25

A Solution to Every Problem

AVERAGE PATIENT WAITING TIME - CLAIMING OF RESULTS (in minutes)

40 20 0
Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Average 2007 35 29 36 32 35 28 28 24 25 21 21 20 28 2008 30 27 25 24 20 20 22 10 9 8 5 5 7 2009 5 8 7 3 4 2 4 3 3 3 2 2 3

Generation of Official Results at CARDIOVASCULAR CENTER BEFORE 20% of procedures not interpreted on the same day Average of 4 complaints per month due to delayed release Average of 30 minutes of waiting time when picking-up results AFTER 2% of procedures not interpreted on the same day 1 complaint received in the last 6 months Average of less than 5 minutes waiting time when picking-up results Average of 4 corrections by Cardiology Fellows per day Operating Expense equivalent to 16% of Gross Revenue 99% of results released within target time of two working days after procedure

Average of 20 corrections by Cardiology Fellows per day Operating Expense equivalent to 18% of Gross Revenue 80 % of results released within target time of two working days after procedure

26

THE MEDICAL CITY

The endeavor clearly demonstrated to Nurse Faylogna and her team the value of process improvements in terms of productivity and service quality.
of reports; now it rarely receives such calls, and the number of complaints about delays has dwindled to near-zero. Nurse Faylogna admits that the planned changes took quite some time to take root, but as doctors became comfortable with the system and experienced its benets, especially in terms of increased patient and staff satisfaction, resistance slowly but surely fell away. A little respectful assertiveness also goes a long way, Nurse Faylogna quips. The endeavor clearly demonstrated to Nurse Faylogna and her team the value of process improvements in terms of productivity and service quality; its success has made her even more conscious of other processes that could be enhanced. Presently, her team is working on reducing the waiting time for patients slated to undergo echocardiograms. A digital archiving system that makes diagnostic images accessible anywhere in the hospital has also been introduced. Remote report generation is now fully implemented as well. In the end, Nurse Faylognas success is a rousing example of the TMC staffs initiative and innovation. As an industry leader, TMC encourages and nurtures these qualities, as it seeks to offer everhigher standards of quality and safety. There is a solution to every problem when organizational vision meets individual enterprise.

2009 ANNUAL REPORT

27

ManaGinG THE SUPPLY CHAIN

StREamLiNiNG TMCS SUPPLY cHaiN RESULtS iN maJOR GaiNS FOR tHE HOSPitaL aND itS PatiENt-PaRtNERS.
A hospital as large as TMC has formidable purchasing and warehousing requirements that necessitate efcient and cost-effective management. TMC serves thousands of inpatients and outpatients yearly, and associated demand for medicines and medical supplies is tremendous. Too much stock leads to rising inventory costs and storage problems. Too little stock could mean acute shortages, and consequently, delays in and even failure of care. TMCs Medication Management and Use Task Force, consisting of members from the Hospital Therapeutics Committee; as well as the Pharmacy, Purchasing, Warehouse and IT Departments, was organized in February 2008 to review and ensure hospital compliance with JCIs comprehensive and stringent standards, which cover all aspects of medication drug selection, purchasing, prescription, dispensing, administration, documentation, patient education and disposal. Appreciating the opportunities to streamline processes, and reduce prices for patients, the Task Force took on the daunting task of redesigning TMCs supply chain management system.

28

THE MEDICAL CITY

TMC decided to share these benets directly with its patient-partners. In June 2009, the hospital announced a major price rollback, offering a 20% discount for a wide range of medicines.
As it does every year, the Therapeutics Committee performed its review of TMCs formulary, the denitive list of medicines stocked in the hospital pharmacy. The drugs are listed under three categories: essential drugs, as dened by the World Health Organization (WHO); life-saving drugs or drugs which are used in resuscitation; and specialty drugs, which TMCs clinical departments recommend as essential to the practice of the various specialties and subspecialties. The Therapeutics Committee then engaged the leadership of TMCs medical staff in encouraging doctors to limit their prescription drugs in the formulary. Simultaneously, the Task Force decided on a policy to limit the number of brands purchased per drug to a maximum of two, as opposed to the previous maximum of four. The Pharmacy and Purchasing Departments, which monitored historical drug consumption, dened the necessary inventory and order quantities per drug. The Purchasing Department then implemented contract procurement and competitive bidding strategies to increase efciency of the purchasing process and boost negotiating power with suppliers. The Department maximized the cost benets by securing lower prices, and included provisions on price protection in contracts with vendors. The IT Department was engaged to in automating the requisition process, specically the purchase requests made by the Material Management (Warehouse) Department, and the purchase orders processed

ImprovinG Supply Chain ManaGement (in million pesos)

Purchases 400,000,000 300,000,000 Savings 336.58M

18%
savinGs
33.04M 2008

20%
savinGs
67.39M

200,000,000 188.63M 100,000,000 0

2009

by the Purchasing Department. This automation eliminated the need for tedious and duplicate manual efforts and reduced physical paperwork. Resulting gains were substantial. By year-end 2008, TMC had saved P24,781,798 in procurements costs, 18% of the total. Actual savings for 2009 amounted to P67,387,449 or 20% of the total amount spent on supplies. TMC decided to share these benets directly with its patient-partners. In June 2009, the hospital announced a major price rollback, offering a 20% discount for a wide range of medicines. This was in addition to the price reductions already mandated under the Medicine Price Reduction Act of 2009. The success of TMCs Medication Management and Use Task Force is clear proof that good medicine and good management do mix and in this mix, both hospital and patient win.

2009 ANNUAL REPORT

29

BOARD OF DIRECTORS

Augusto P. Sarmiento, MD
Chairman

Alfredo R. A. Bengzon, MD, MBA

PRESIDENT AND CEO

Mitos Sison
ADVISER

Jose Xavier B. Gonzales

TREASURER
30 THE MEDICAL CITY

Juan Y. Fuentes, MD
ADVISER

Atty. Ma. Romela M. Bengzon

CORPORATE SECRETARY

Francis P. Hernando
Director

Pote P. Videt
director

Blesilda E. Concepcion, MD Venancio I. Gloria, MD

DIRECTOR director
2009 ANNUAL REPORT 31

BOARD OF DIRECTORS

Herminio J. Germar, MD
DIRECTOR

Rev. Fr. Roberto C. Yap

director

Mediadora C. Saniel, MD
DIRECTOR

Eugenio Jose F. Ramos, MD

director
32 THE MEDICAL CITY

Rolando B. Hortaleza, MD
director

Mona Lisa B. dela Cruz

Director

Alberto L. Buenviaje
Independent director

Teodoro L. Locsin, Jr.

Independent director
2009 ANNUAL REPORT 33

EXECUTIVE COMMITTEE

Alfredo R.A. Bengzon, MD, MBA

president AND ceo

Atty. Ma. Romela M. Bengzon

corporate secretary

Augusto P. Sarmiento, MD
chaiRman

Benita J. Macalagay
SVP, FINANCE, ADMINISTRATIVE AND MANAGEMENT SERVICES
34 THE MEDICAL CITY

Virginia B. Alano
svp, patient services group

Margaret A. Bengzon
head, strategic services group

Jose Xavier B. Gonzales

board member
2009 ANNUAL REPORT 35

senior manaGement

Alfredo R. A. Bengzon, MD, MBA

president AND ceo

Benita J. Macalagay
svp, finance, administrative AND management services

Eugenio Jose F. Ramos, MD

head, medical services group

Margaret A. Bengzon
head, strategic services group

Virginia B. Alano
svp, patient services group
36 THE MEDICAL CITY

vice presidents

Cristela A. Villa-Real
nursing services DIVISION

Lina A. Maranan
corporate planning and network development

medical dIRECTORS

Mercedes G. Gonzales, MD

Jose M. Acuin, MD

Medical quality medical management AND services development improvement office office

Blesilda E. Concepcion, MD
professional staff development office

2009 ANNUAL REPORT

37

ASSISTANT VICE PRESIDENTS

Aura J. Guinto
Special services division

Herminia F. Fresnoza
Administrative services division

Judith S. Betita
human resource divison

Marilyn R. Atienza
special services division (flagship programs)

Sylvia R. Nacpil
finance services division
38 THE MEDICAL CITY

Leticia E. Carolino
nursing services division

2009 ANNUAL REPORT

Concept and Design: Portrait and Operational Photography: Additional Operational Photography:

K2 Interactive (Asia), Inc. and The Medical City Corporate Communications Erik Liongoren Miguel C. Bernardo, Jr.

We would like to acknowledge Dr. Eric S. Pascual for his participation and Shangri-La Plaza Corporation for the use of their facilities.

THE MEDICAL CITY

ORTIGAS AVENUE, PASIG CITY, METRO MANILA PHILIPPINES. TEL. NOS. (632) 635-6789, (632) 631-86-26 EMAIL: MAIL@MEDICALCITY.COM.PH WEBSITE: WWW.THEMEDICALCITY.COM