UPCM AHEAD Proposal v4 - Revised Nov 8 2018

VISION
To make Ospital ng Makati

into a state of the art hospital providing
ultimate health care service.
MISSION
To ascertain the evolution of
Ospital Ng Makati
into a world class hospital through
delivery of an efficient, quality and affordable
health care served in a humane and compassionate
manner that ensures client satisfaction.
QUALITY POLICY STATEMENT

We, the officials and employees of
Ospital Ng Makati, are
committed to provide quality health care service to
our customers and other relevant interested parties [rev. 1]
with promptness and effectiveness and to
improve our quality management system at all times.
DEPARTMENT OBJECTIVES
To effectively deliver quality health care through
caring and highly competent personnel utilizing
world class technology.
1 Version 4. November 8, 2018

Department of Science and Technology
RMDD-PRJ- F1
Rev 0/11-20-09

PHILIPPINE COUNCIL FOR HEALTH RESEARCH AND DEVELOPMENT
DETAILED RESEARCH PROPOSAL
Date: July 27, 2017 (revised December 17,2017; November 22, 2018*)
Title of the Study: Assessment of Performance Measures and Indicators of Patient

Safety in Select Government and Private Hospitals in the Philippines Study Number:
Author(s):
Agnes D. Mejia, MD
Telephone numbers: 526-4170/525-0299
Email: admejiamd@gmail.com, agnesmejiamd@gmail.com
Implementing Agency:
University of the Philippines-Manila College of Medicine

*Amendment/clarifications are in blue text; highlighted items are bolded and/or underlined

(2) Table of Contents
Introduction 3
Project title 5
Project leader 5
Implementing agency 5
Cooperating agency 5
Significance of the proposal 6
Literature review and Conceptual Framework 7
Objectives 10
Expected output(s) 11 (62)
End-users/target beneficiaries 14
Project duration 14
Methodology 14
Plans for data processing and analysis 22
Work plan schedule 24 (54)
Ethical clearance 25
Research utilization/dissemination 26
Estimated budgetary requirements 28
Endorsement from agency head (UP Manila) 28
Curriculum vitae 29

Declaration of Conflicts of Interest 41
Bibliography 41
Duties and Responsibilities 43
Line Item Budget 46

Appendices 48

(3) Introduction

Patient safety may be simply defined as “the avoidance, prevention and amelioration of adverse
outcomes or injuries stemming from the process of healthcare. 1” It is a belief that most individuals,
whether they are recipients or providers of healthcare, seem to understand and value. However,
its true concept is broader, more complex and more important than what it seems. Its attainment
is even more elusive. When healthcare results in harm, more often than not, it is predictable,
avoidable and results from breakdown or the lack of systems that should respond or prevent the
adverse event. As healthcare becomes more complex, so does the need to build methods and
networks to manage the complexity and keep patients at harm’s way.
This is probably the reason why the past decades have seen a tremendous shift towards viewing
patient safety as a global health priority. While adverse events have been reported in the 1950s
and perceptions on preventable medical harm began in the 1970s and 1980s, the pivotal turn
happened after the release in 1999 of the Institute of Medicine report, “To Err is Human: Building
a Safer Health System.2” The report revealed that 44,000 to 98,000 Americans died due to medical
errors. Several other researches in Australia, United Kingdom and Northern Ireland reported
similar findings. This paved the way for global discussions that culminated in the creation of the
World Alliance for Patient Safety during the 55th World Health Assembly of the World Health
Organization (WHO) in 2002. The World Health Organization urged its member countries “to pay
the closest possible attention to the problem of patient safety and to establish and strengthen
science-based systems, necessary for improving patients’ safety and the quality of health care,
including the monitoring of drugs, medical equipment and technology.3” Since then, more countries
including members of the Organization for Economic Cooperation and Development (OECD) have
taken a closer look at the problem of harm in healthcare and have made significant steps towards
solving it.
It is important for organizations to have a strong sense of what safety issues are, as well as use,
well-defined and appropriate measures to document, analyze and monitor improvements with the
ultimate goal of safe and quality healthcare. This reinforces one of the main research thrusts of
the World Alliance for Patient Safety that was articulated in their 2006-2007 report – the need to
establish the nature and extent of harm attributable to medical care in developing and transitional
countries as well as strengthening capacity for research on patient safety. 4

In 2008, the Department of Health (DOH) directed more attention towards patient safety, through

its Administrative Order 2008-0023 that aims “to ensure that patient safety is institutionalized as a
fundamental principle of the health care delivery system in improving health outcomes.5” The policy
emphasized building a culture of patient safety and implementing patient safety programs in
facilities that are in accordance with policies and standards developed by the DOH National Patient
Safety Committee and the Philippine Health Insurance Corporation (PHIC) Benchbook on Safe
Practice and Environment. The directive also designated the National Patient Safety Committee
to establish a pro-active reporting system for events that will foster learning from experience. Risk
reduction strategies, professional development and patient empowerment are also embedded in
the said document. While the Administrative Order called for an “effective and efficient monitoring
system that will link all patient safety initiatives,5” an overall assessment of the many interventions
done from the publication of the policy and its actual impact on the status of patient safety in the
country is still lacking. There are no explicit targets and indicators specified to measure success
and to provide benchmarks that qualify and quantify whether efforts are effective and helpful. Now
with almost a decade from the passage of this administrative order, are our patients safer?
Safety is almost always seen as part of the broader context of healthcare quality. Quality ensures
that care is delivered to produce the intended effect while safety deals with how systems can fail
to function towards said delivery of care.6 Because of the intimate relationship of these concepts,
it may be difficult sometimes to label inconsistencies in practices as quality issues versus safety
issues. When a blood product is mislabeled and transfused erratically to a patient causing a
hemolytic reaction, it can clearly be regarded as a safety issue. However, when a patient with a
heart attack is discharged without aspirin and soon after succumbs to another heart attack, the
safety issue is less clear-cut even when it is regarded as poor quality of care. It is therefore
imperative that a clear sense of safety issues surrounding medical care be consistently defined
and ultimately used to stimulate discussions on creation and improvement in hospital processes
and protocols. Improper labeling of safety issues may result to wastage of resources, false sense
of security among patients and staff, and a demoralized working environment.
True to the mandate of the University of the Philippines “to lead as a public service university by
providing various forms of community, public and volunteer service, as well as scholarly and
technical assistance to the government, the private sector and civil society while maintaining its
standard of excellence7” and in response to the call of WHO and DOH as mentioned above, the
University of the Philippines College of Medicine (UPCM) adopted the national healthcare quality
and patient safety as a priority flagship project in November of 2012. This has led to the proposed
creation of the Center for Healthcare Quality and Patient Safety in June 2013 whose vision is “safer
healthcare for Filipinos”. This vision is the driving force for its mission of being a “center with high
level of expertise and state-of-the-art facilities to develop the clinical competencies of health
professionals; promote research development, policy formulation through transdisciplinary
approach towards safer patient care and better health outcomes. 8”
The eventual creation of the Center for Healthcare Quality and Patient Safety shall seek to
strengthen and complement the government’s health programs by helping ensure that every
Filipino, not only gains access to healthcare, but also to a healthcare of highest quality and safety
comparable to recognized international standards. Furthermore, it shall provide opportunities to
empower and engage patients in managing their own health. The Center shall also serve as an
academic hub that shall partner with stakeholders (health professionals, educators, policy makers,
private sector, and patient groups) in the delivery of quality care and ensuring patient safety. It is
envisioned that the end result of all these endeavors is the improvement in healthcare outcomes
for Filipinos. The Center shall provide a system and mechanism for integration, coordination and
implementation of patient safety strategies.

The short and medium term plans of the Center, aptly called “Research for Patient Safety”, aim to

develop the knowledge, attitudes and skills of health professionals in the conduct of patient safety
studies and to use the research outcomes and evidence to improve safety in healthcare,
particularly safe care of patients. A more thorough assessment of the patient safety “landscape”
shall be achieved through research, training-workshops, and extension projects.
Laying the ground work for the said endeavor were projects on modernization of the basic science
departments, strengthening of the clinical skills simulation laboratory, virtualization of medical
education and conduct of translational researches on biomedical devices, medication errors,
infection control and the patient safety culture. To date, 3 of eleven researches conducted as early
as 2012, were published in Acta Medica Philippina.
Capacity-building towards patient safety has been carried out through recruitment of faculty from
UPCM and other colleges in UP Manila, such as the UP College of Nursing. Several faculty
members have attended international workshops/conferences on patient safety including one that
was organized by British Medical Journal (BMJ) and the Institute for Healthcare Improvements.
Using the TeamSTEPPS® (Team Strategies and Tools for Enhancing Performance and Patient
Safety) curriculum, the Center has trained several healthcare professionals and administrators on
effective communication and team-based approaches to reduce harm in the workplace.
Furthermore, part of the medium-term goal is to support at least 5 faculty members who will
undertake master’s and/or doctorate degree in patient safety and health systems management.
The long-term plans of the Center involve “Education for Safer Care” and “Patients for Patient
Safety”. In this regard, initiatives towards refined health professional curricula where patient safety
is emphasized and the engagement of patients as partners will be undertaken.
This proposal will fit into the medium-term plans of the Center. Through this project, the current
status of patient safety interventions in the country and their performance measurements and
indicators will be assessed. The information will serve as important foundations for continuing
work, not only by the Center, but also by policy-makers and various stakeholders in enhancing
patient safety initiatives. More sophisticated and integrative measures pertaining to training,
curricular development and patient-centeredness can then be further studied.
(4) Project title: Assessment of Performance Measures and Indicators of Patient Safety in
Select Government and Private Hospitals in the Philippines
Research Area: Health Metrics (Setting Standards and Ensuring Accountability)
(5) Project leader: Dr. Agnes D. Mejia, Dean, UP College of Medicine
(6) Implementing agency: University of the Philippines-Manila College of Medicine

(7) Cooperating Agencies: Department of Clinical Epidemiology UP College of Medicine,
Health Facility Development Bureau (HFBD) of the Department of Health, Philippine Health
Insurance Corporation (PHIC)

(8) Significance of the Proposal

The study will describe the current status of patient safety and its performance measurements in
select government and private hospitals in the country with two main purposes. Firstly, it will unify
strategies and programs on patient safety towards clear and common targets. Secondly, it will
serve to enhance the culture of safety that is centered on consistent cycles of measurement,
analysis, execution and monitoring. Improvements in patient safety are anchored on information
management systems. Therefore, there is a need to describe the current capabilities and needs
of hospitals in this regard. Inherent to this project is capacitybuilding, both for the project team and
health professional staff of the participating hospitals, and collaborative work towards addressing
the identified gaps in the context of information technology and safety culture.
The study will analyze if differences in data collection and reporting exist in these hospitals.
Literature suggests that these inconsistencies in data may be seen due to multiple data sources,
differences in operational definitions and imprecise systems. Such differences not only distort the
truth but also make it impossible to use a uniform language in patient safety. However, if
performance measures and monitoring systems are identified, optimized, and harmonized,
appropriate comparisons between hospitals can be made. Such comparisons can foster
institutions’ accountability, transparency and eventually be drivers for improvement. This study can
also be a starting point for the development of patient safety indicators (PSIs) - gauges that indicate
that safety has been achieved in healthcare. The said indicators should be relevant and responsive
to the different characteristics of all hospitals and other healthcare facilities in the country.
This project will assist the Department of Health, PHIC and other stakeholders in gaining access
to good data so as to formulate evidence-based policies and standards for hospitals nationwide. It
is important to highlight that for effective and judicious policy-making, data should have these
characteristics: reliable (produces the same reading regardless of who does the measuring or
when and where the measurement is taken), valid (determines what it intends to measure) and
standardized (whether definitions of data elements, collection process, and analysis are precise
and comprehensible so they can be understood and applied in the same way regardless of who
refers to or applies them).9 Another important dimension that these performance measures should
possess is patient-centeredness that encompasses qualities of compassion, empathy, and
responsiveness to the needs, values and preferences of the individual patient. This ensures that
the patient’s and family’s rights are upheld and is a step towards equity and satisfaction in
healthcare delivery. The study will examine performance measures in hospitals in terms of
reliability, validity, standardization and patientcenteredness. These 4 criteria will cover the other
characteristics of a good indicator based on other literature sources and will sum up the significant
characteristics of an indicator; for instance, “intelligible and easily interpreted” will fall under
“standardized” while timeliness will be under “reliable” and so forth. While this project is only
confined to select government and private hospitals, information gathered including best practices
in metrics may be relevant and useful for other types of healthcare facilities that complete the
service delivery network in the country.

(9) Literature review

Safety is a key element in ensuring quality of healthcare. However, there are still challenges that
may hinder delivery of quality healthcare. A 2001 IOM report identified existing gaps in the
provision of quality healthcare. Firstly, the current healthcare system could not cope with the
growing complexity of healthcare, lacking the ability to translate knowledge into practice and to
apply new technology safely and appropriately. Secondly, the public’s health needs have shifted
from acute, episodic care needs to chronic illnesses due to the aging population, and emerging
health diseases due to environmental changes. Lastly, the healthcare delivery system is complex
and uncoordinated, leading to wasted resources, unaccountable voids in coverage, and loss of
information.10 These gaps present as barriers to patient safety. The mentioned long standing
issues related to patient safety are still present and were reiterated in the 2016 report entitled
“Patient Safety 2030.11”
A systematic literature review on patient safety and quality of care in developing countries in
Southeast Asia was published in 2015. The review stated that “unsafe medical care is a major
contributor to poor patient outcome globally, presenting a particular challenge for low- and middle-
income countries that have fewer resources.” The four major inter-related quality and safety
concerns recognized in developing countries are: (1) risk of patient infection in health care delivery;
(2) medication safety; (3) quality and provision of maternal and perinatal care; and (4) overall
quality of healthcare provisions. The review recognized the need for “largescale epidemiological
patient safety and quality of care research” and sharing of expertise and experiences among Asian
countries in order to generate a better and more complete picture of the challenges.12
While providing safe healthcare for all patients seems like a formidable and elusive goal, the
development of evidence and consensus around measurement of patient safety has proven to be
an equally daunting task. The Agency for Healthcare Research and Quality (AHRQ) in the United
States commissioned the Evidence-based Practice Center (EPC) at the University of California
San Francisco and Stanford University (UCSF-Stanford) in collaboration with the University of
California Davis in 2002 to develop one of the most widely used patient safety indicators
internationally.13 These are grouped into provider-level and area-level indicators that have
consistently undergone updating according to the latest scientific evidence and internal monitoring
by AHRQ. Some countries have taken on a broader, more comprehensive approach through
multinational and multidisciplinary programs on patient safety standards and measurement. The
European Society for Quality in Healthcare (ESQH) through its SImPatIE - Work Package 4
created a patient safety vocabulary that has been adapted by all member nations to simplify
comparisons and standards setting. It also listed down its own patient safety indicators that were
developed on a framework they designed called Stepwise Assessment Framework Approach
(SAIFA).5,14 This work entailed evidence search and appraisal, consensus-building through expert
consultation from its members and other partner organizations.
Review of literature also showed several key dimensions and domains that can be adapted to
assess patient safety performance in organizations. 15,16 Common domains are safe
evidencebased clinical practice, integration and learning, leadership and commitment. Construct
validity has been established for many of the patient safety indicators across many settings so the

focus now of this study is understanding and implementation by hospitals – with their attendant
promotive and prohibitive influences.

In the Philippines, the PHIC developed core standards and criteria in quality health care.
Examples of these standards relate to leadership and management, medication management,
surgical and anesthesia care, and infection control. These standards are being used to assess
performance of hospitals applying for Center for Excellence accreditation under the National
Health Insurance Program. In its 2nd edition of the Benchbook manual, the agency enhanced the
standards adopting concepts on patient safety, sentinel events, risk management, international
benchmarks of quality and safety, among others. 17 In the same manner, other regulatory
agencies such as the Department of Health, through its licensing and accreditation bureaus will
have a distinct set of core standards as well.
ADDENDUM:
Upon review, our team noted that the Philippine Society for Quality in Healthcare (PSQua) is a
non-stock, non-profit organization that was established to promote quality management,
assurance and improvement of healthcare services in the country. They have been conducting
training seminars on quality improvement in hospitals. Of note is a 5-day seminar they conducted
last 2011 entitled the 1st Healthcare Indicators and Performance Measures in the Hospital: Settin
the Roadmap to Quality Certification/Accreditation in the Hospital. Specific details about the
target and actual participants (public vs private) and on coordination with local regulators (DOH g
and PHIC) are lacking but our team will reach out to the said organization whose current and
past works may contribute to this research. Particularly, we would like to investigate how the
said indicators and measures were selected and implemented.
Safety culture assessments have been found to be useful tools in assessing patient safety.
These tools have been validated to measure organizational environment, particularly how
healthcare personnel feel about their organization. The indicators are used to measure
conditions that can lead to adverse events and medical errors. They can also be used for
developing and evaluating safety improvement interventions in healthcare facilities. 11,18
However, the choice of instruments for assessing safety culture will depend on the purpose, the
target population, validity, reliability and other considerations. 19

Conceptual Framework
Themes common to the above efforts underscore the need for a unified language in
measurement and the development of standards in assessing patient safety. The researchers
believe that in order to move forward in the initiatives towards attainment of safety of provision
of health care, we must strive to develop measures and targets that can be efficiently
implemented at a national level. The project team anticipates that findings from this research
will prove valuable in creating and modifying existing poli cies on standards, accreditation,
financing and service delivery. While hospitals vary in the complexities of care delivered, their
clientele and amount of resources available, we believe that a minimum set of valid, reliable
and standard indicators can b e identified – against which we can benchmark and provide
meaningful and fair comparisons. Data collection using standards are essential to provide
11
evidence to show that change is necessary and to measure progress and improvement.
However, the challenge goes beyond using not only critical appraisal of evidence for these
measures but also engagement of stakeholders in consensus -building. Adherence to
continued measurement and improvement in patient safety relies upon institutional
commitment and engagemen t as well as positively influenced by performance -based
incentives. In resource -limited environments such as ours, finding the right balance between
achieving the best outcomes using reliable, efficient processes for delivery and monitoring at
minimal cos t across different levels of care (in this case, for different hospitals) is critical and
is a key step towards value -based care. Observation from other countries show that
performance -based incentive can pave the way for provision of quality and timely care as well
as ensure equity and universal access especially in low - to middle -income countries. All of
these initiatives are founded on capitalizing on health information technology, emphasis on
continued monitoring and feedback as well as a uniformly eng aged environment and culture
for patient safety. While the project involves hospitals as the study population , the expected
outputs are intended to contribute to broader discussions on systems issues on patient safety
measurement and implementation.
(10) Objectives
Research Question: How do select government and private hospitals choose and utilize patient
safety performance measures and indicators to achieve the six international patient safety
goals?
The researchers expect that throughout the course of this project, we will also be able to
identify and hopefully answer questions on accuracy and security of data sources of the
hospitals; finding the delicate balance between transparency in reporting and data privacy;
varying approaches and perceptions between and across different provider types (e.g. doctors,
nurses, paramedical staff); and administrative, logistic, economic and cultural barriers to
evaluation and monitoring on patient safety and quality - even if these are not explicitly stated
in our research question. This expectation comes from the fact that this project is first in its
kind locally and will be allowed (or even intentionally be made) to run an exploratory and
though-provoking course.
Objectives
General Objectives:
1. Assess the reliability, validity, standardization and patient centeredness of
performance measures and indicators utilized by government and private hospitals in
the achievement of the following international patient safety goals (IPSGs)20:
 Identify patients correctly
 Improve effective communication including patient-doctor interactions
 Improve the safety of high-alert medications
 Ensure correct-site, correct-procedure, correct-patient surgery
 Reduce the risk of healthcare-associated infections
 Reduce the risk of patient harm resulting from falls
2. Recommend a dashboard of reliable, valid, standardized and patient-centered

measures for hospitals
AMENDMENT:
3. Facilitate and describe improvement initiatives on patient safety using data on
performance measures and indicators
Specific Objectives:
 Identify relevant performance measures utilized by government and private hospitals
focused on the six IPSGs;
 Categorize the identified performance measures into structural, process and outcome
measures;

 Evaluate reliability of performance measures identified using methodological triangulation
by document/protocol review and key informant interviews;
 Evaluate validity of performance measures identified by comparing against relevant local
and international measures e.g. PhilHealth Benchbook17, Agency for Healthcare Research
and Quality Patient Safety Indicators21 (AHRQ PSI), OECD measures, etc.;

 Evaluate standardization of performance measures identified by document/protocol review

and key informant interviews;
 Appraise if patient-centeredness is emphasized in all aspects of measurement and
improvement in patient safety;
 Describe the patient safety culture among hospital personnel with emphasis on knowledge-
building and continued measurement;
 Characterize and recommend best practices in data collection, analysis and dissemination
observed during the study.
 Build capacity around the use, reporting, monitoring and research of patient safety and
quality performance measures and indicators
(11) Expected Outputs (see details under Appendix I)

1. A dashboard of reliable, valid and standardized performance measures that are
considered necessary for hospitals assessment and monitoring will be generated.
The measures will be grouped according to structural, process and outcome measures. 6 Structural
measures consist of parameters that assess the organization’s capacity and the conditions in
which care is provided. These include organization’s staff, facilities, or health information
technology systems such as existence of a manual of procedures in all admitted patients. Process
measures are parameters that gauge how services are provided. Example of a process measure
is whether a patient is assigned a unique identifier upon admission. Outcomes measures are
those that determine the result of health care such as the percentage of all patients assigned a
unique identifier upon admission. Use of diverse tools that include all types of measures will create
a more comprehensive assessment of the institutional performance. Gaps and differences in
available measures in the said groupings will be highlighted.
Currently, there are no explicit and unified patient safety indicators that will signify success or
considerable improvement in patient safety. The researchers recommend harmonizing and
institutionalizing patient safety performance measures and indicators as guided by the
International Patient Safety Goals on a nationwide scale with their evaluation using the four
dimensions mentioned as a starting point. Ultimately, the project intends to create a list of more
streamlined, useful and appraised measures and indicators from the current mix of DOH, PHIC,
JCI and other standards that are possibly too many, overlapping, redundant and not applicable for
all hospital settings.
CLARIFICATION:
2. Models of Quality and Patient Safety Initiatives to emphasize Measurement and
Monitoring in Sentinel Hospitals

The project intends to conduct facilitative sessions called Plan-Do-Study-Act (PDSA) cycle

sessions in selected sentinel hospital sites. The sites will be chosen based on results of initial
quantitative and qualitative data analysis. The sessions are meant to provide the sentinel
hospitals with summary of collected and analyzed data from the study and create opportunities
for discussion of the implications of the said data in planning, implementing and monitoring
strategies for patient safety by the institutions. The project team is expected to facilitate these
discussions and synthesize important actionable items with the implementing hospital. These
PDSA cycle sessions will be written up as case studies and presented as models for improvement
for consideration of adoption by individual hospitals or on a wider scale by DOH or PhilHealth. See
SUMMARY OF EXPECTED OUTPUTS vis-à-vis
OBJECTIVES in the succeeding page
LIMITATIONS OF THE STUDY

The project has a number of delimitations. Firstly, the project covers hospitals only since the
investigators have found substantial amount of literature and consensus around patient safety
standards in the said level of care. The same cannot be said for primary care facilities for which
evidence is still being gathered and appraised even in developed countries. With its results and
eventual broadening of safety standards in primary care facilities, this proposal aspires to embark
on a more expansive study involving the entire service delivery network in the next few years.
Secondly, the focus of this study is measuring performance in the achievement of the six
International Patient Safety Goals (IPSGs) based on the Joint Commission International (JCI)
Accreditation Standards for Hospitals 2011, which are some of the more common patient safety
issues encountered in hospitals and have evidences for system-wide measurement and solutions.
The decision to use the IPSGs as the starting point is for its simplicity, familiarity amongst
institutions, focus on patient safety and being used as reference by the DOH and PHIC standards.
Issues outside of these six IPSGs can later on be covered once processes employed highlighted
in this project are scaled up. Thirdly, while the measurement of safety inherently involves
measuring quality, other aspects of quality such as individual assessment and communication of
health risks to patients regarding specific illnesses and their treatment are also not included.
These concepts would need their own separate discussions, in that, these will require investigation
of more general contexts and details outside of hospital processes.

Objective Strategies/Activities Participants/Resources Relevant Outputs
Identify relevant performance measures Literature search Hospital database and protocols Dashboard of PS measures and
utilized by government and private Hospital survey indicators
hospitals focused on the six IPSGs
Administrators, patient safety (PS) specific
personnel, frontliner staff including Hospital Policy briefs, infographics
Coordinator
Categorize the identified performance Literature search Hospital Hospital database and protocols Dashboard of PS measures and
measures into structural, process and survey indicators
outcome measures
Administrators, PS-specific personnel,
frontliner staff including Hospital Policy briefs, infographics
Coordinator
Assess the reliability, validity, Literature search Hospital database and protocols Dashboard of PS measures and
standardization and patient centeredness Hospital survey “Consensus- indicators
of performance measures and indicators for building workshop”
the 6 international patient safety goals Administrators, PS-specific personnel,
(IPSGs)2 frontliner staff including Hospital Policy briefs, infographics
Coordinator
Describe the patient safety culture among Patient safety culture personnel Hospital clinic staff (doctors, nurses, Expanded pool of experts and
hospital personnel with emphasis on survey pharmacists) advocates in PS
knowledge-building and continued
measurement
Infographics
Characterize and recommend best Data analysis Administrators, PS-specific personnel, Case studies describing models of
practices in data collection, analysis and “Benchmarking sessions” frontliner staff including Hospital best practices and identified gaps
dissemination observed during the study “PDSA cycles” Coordinator (sentinel hospitals)
Consultant experts in quali/quanti analysis
Build capacity around the use, reporting, “Onboarding workshop” Hospital Coordinators Expanded pool of experts and
monitoring and research of patient safety Data collection proper Online Project team advocates in PS measurement,
and quality measures and indicators and onsite training courses monitoring, feedback and
research
SUMMARY OF EXPECTED OUTPUT vis-à-vis OBJECTIVES
Lastly, certain aspects of safety in the workplace such as infrastructure requirements,
hazardous waste management and sanitation are also not covered. While these are
important issues that need to be addressed, these are probably better seen in the light of
facility safety and hazard risk reduction and not safety during medical management of
patients per se.
(12) End-users/Target Beneficiaries

 DOH: as the regulatory and supervising agency of these hospitals that will formulate
evidence-based standards and policies on patient safety
 PHIC: refine and update incentive programs for institutions and professionals to be
evidence-based, inclusive, responsive and streamlined to influence outcomes and
not just processes
 Participating hospitals that will include administrators, patient safety
committees/officers and front-line staff: application of these measures not only for
compliance to regulatory standards and reimbursement procedures but also for
continuous internal quality improvement and organizational accountability
 Other hospitals and facilities: the results will serve to identify and develop best
practices on measurement, monitoring and analysis that can be useful guide and
reference for other public and private institutions.
(13) Project Duration

The project is expected to cover a period of 30 months from the formalization of the research
contract up to the writing and dissemination of the project report.
(14) Methodology
Study Design. This is a descriptive, cross-sectional study that will look at performance
measures and indicators, and data collection processes around said measures/indicators.
Composition of Project Team. The project team will be composed of two groups who will be
responsible for the main aspects of data collection. One group will be involved in the
quantitative evaluation of available measures for validity, reliability and standardization
through review of procedure manuals, hospital databases, adverse event reporting, trends
data among others, as well as, conduct of hospital survey. The other group will look into
qualitative aspects of the said measures such as understanding and acceptability within the
hospital patient safety committee and strategies of implementation that will be uncovered
during key informant interviews. The quantitative team will be composed of medical and
paramedical faculty and researchers mainly from the UP College of Medicine with support
from representatives from DOH and PHIC while the qualitative team will be experts in
qualitative analysis from the Institute of Clinical Epidemiology of the National Institutes of
Health – University of the Philippines Manila with possible support from social scientists from
the College of Arts and Sciences in UP Manila or College of Social Sciences and Philosophy

in UP Diliman. The teams underscore the value of a multidisciplinary and collaborative
approach towards patient safety. The research associates and research assistants are young
faculty and professionals who are preferably enrolled in or plan to undertake graduate or

postgraduate courses aligned towards patient safety and health quality measurement as a
strategy for capacity-building in the said fields .
Composition of Project Team
Sampling Frame for Hospitals Included . A total of 60 hospitals will be included from al l (16)
regions in the country and will include PGH, private hospitals with JCI accreditation as well as
DOH-retained and LGU hospitals – sampled based on proportion of hospitals per region .
Levels 2 to 3 hospitals will be included to obtain a broader picture of patient safety status
across varying complexities of healthcare and to gain insights around differences in needs
and patient safety strategies. A combination of proportionate random and purposive sampling
will be employed in selec ting participant hospitals in this study to capture a nationally
representative picture. Proportionate sampling will be done at the regional level for DOH-
retained and LGU hospitals taking into consideration the level of hospital classification. Rough
calculation of the hospital sample size based upon the intended 18 indicators/outcomes (3
types of measures for each of the six IPSGs) will give us an allotment for about 54 hospitals .
Purposive sampling will include the Philippine General Hospital being a national university
hospital as well as for four to five private hospitals that have JCI accreditatio n to be able to
collect information on possible best practices that are employed in these institutions that
merited such accreditatio n.
CLARIFICATION:
We randomly selected using the RAND function in Microsoft Excel 50 gene ral hospitals (52%
of the total public level 2 and 3 hospitals; 83% of the total sample) and 4 specialty hospitals
(4% of the total public level 2 and 3 hospitals; 7% of the total sample ). Purposive sampling
was done for PGH as the national university hospital
37 and the 5 Version
JCI -accredited hospitals
4. November 8, 2018
(8.33% of the total sample ) namely Makati Medical Center, St Luke’s Medical Center, Asian
Hospital and Medical Center, The Medical City and Chong Hua Hospital)
Upon discussion with our consultant statistician from the Institute of Clinical Epidemiology, the
sample size of hospital participants should be revised. The initial sample size computation
was based on the assumption of intended 18 indicators or items in the questionnaire (3 types
of measures for each of the six IPSGs) with aactor
f of 3 selected to come up with 54. However,
the final version of the hospital questionnaires includes 134 items which will entail possibly
recruiting as many level 2 and 3 hospitals as possible (for our budget and timeline) to be able
to measure validity and reliability of the indicators. Currently, there are 85 general and 11
specialty hospitals that comprise the total 96 public level 2 and level 3 hospitals in the country;
the complete list can be seen in Appendix K: Level 2 and 3 hospitals .
A summary of the computation for the total number of participating hospitals is seen below:
Total Number of Levels 2 and 3 Hospitals:

85 General + 11 Specialty = 96 hospitals
6 IPSGs x 3 dimensions (structural, process, outcome) x

3 indicators/dimension: 54 hospitals
+ 6 from purposive sampling
Total number of hospitals = 60
Comment [MOU1]: The spec ialty hospitals should go under

proportionate sampling since we did not include all specialty
Proportionate sampling Purposive sampli ng hospitals.
per region
Private Hospitals
Number of DOH and LGU sampled proportionate to existing
with JCI
numbers in the region (including specialty hospitals)
Accreditation
Luzon 50% n=25 Visayas 20 % n=12 Mind anao 30 % n=13 PGH (National
CAR, NCR, Regions 1 -5 Regions 6 -8 (Regions 9-12 ; ARMM,
University Hospital)
Caraga)
Sampling Frame for Hospitals Included
Participants. Key informants will be the hospital patient safety officer or selected members of
the patient safety committee and/or information systems manager who are knowledgeable
and directly involved in the monitoring and reporting of patient safety measures. These key
informants should be directly involved in monitoring and recording patient safety indicators
and has been in that capacity for at least 1 year . These hospital staff will be recruited fo r the
key informant interviews on patient safety and performance measures and indicators . They
will also be the contact persons for the hospital survey data collection. Eligible respondents
will be taken from review of the documents outlining the current organizational structure and
verified by hospital administrator.
On the other hand, estimation of the respondent sample size for the patient safety culture
survey, involving hospital personnel allots for 384 respondents per region based upon the
finding of Paguio et al about 50-70% baseline knowledge scores on patient safety culture. 21
Inclusion criteria for respondents are as follows: doctors, nurses, pharmacists from list of
regular employees; at least employed in the hospital for 5 years; from major departments
(pediatrics, internal medicine, obstetrics-gynecology, surgery, ICU) and in-patient
involvement. Proportional sampling of respondents will be done per region and per hospital.
Participants are expected to complete the survey and key informant interviews in less than
one day, most probably for only one to two hours. They may also be invited to attend training
courses (1-2 days generally) and workshops (1-day) on a voluntary basis.
Computation of the number of respondents is as follows:
N = P(1-P) Z!/2)2 = (0.50) (0.5) (1.96)2 = 384

∆2 (0.05)2
Recruitment of study hospitals and participants will be initiated in the orientation

(onboarding) workshop for participating hospitals. Training of study surveyors at the start of
the study will be made sure to cover utmost respect, confidentiality and scientific rigor for
this study, including those related to securing the informed consent. Special and vulnerable
populations are not expected to be participants of this study.
ADDENDUM:
Hospitals who refuse to participate at the outset, those who withdraw their participation
during study implementation and non-responders will be replaced as other hospitals give
their consent to participate. Non-responders are those who have no reply to the project team
after 3 attempts at follow-up through mail courier, email and telephone call. Only those
hospitals with conforme slips received by December 15, 2018 will be accommodated in the
study – this will allow sufficient time should the individual ethics review boards will require
their individual review.
Methods for Data Collection. There will be three sources of data, namely, hospital records,
patient safety officer or committee member, hospital administrators/managers, and health
personnel. Data collection strategies include review of relevant documents, surveys and key
informant interviews.
The first method of data collection is document review of hospital databases, protocols on
reporting and manuals for information gathering regarding patient safety. Key informant
interviews of select hospital administrators, patient safety officer, frontline staff, and
representatives from patient groups will be conducted in situations where gaps and best
practices were identified during the conduct of the documents review. Information on hospital
characteristics will be taken using a hospital profile survey and will be related to the findings
on performance measures. The said survey will also include items on acceptability, possible
barriers to implementation, and alternatives to the index set of patient safety indicators and
measures that will be listed down at the start of the study. This information, along with other
data collected during the entire study duration, will be used to guide consensus-building on
the indicators and measures when we convene the workshop with DOH, PhilHealth and expert
panel consisting of leaders and advocates in patient safety. A hospital-wide survey using a
validated interview questionnaire on patient safety culture will be conducted among randomly
selected health personnel from different disciplines, such as doctors, nurses, and
pharmacists. Summaries of the data collection methods for quantitative, qualitative and
integrative analyses vis-à-vis the study objectives and resources are located in the succeeding
page.
The tools for data collection will be developed by the project team during a writeshop session
at the beginning of this project. The questionnaires will include items that will cover structural,
process and outcome measures, as well as, descriptors on patient-centeredness. In the said
writeshop, the survey questionnaire on patient safety culture will be developed from the tool
used by Paguio et al21 on knowledge and perceptions of healthcare workers on patient safety
culture on that has been validated locally and largely based on the internationally accepted
survey from the Agency of Healthcare Research and Quality (AHRQ). A summary of the
methods that will be employed in this study are detailed below.
Summary of Data Collection Methods (Quantitative)

Strategies/ Participants Data to be Collected; Data Specific Objective/s
Participants Analysis
Literature search Research Team PhilHealth Benchbook for Identify relevant

Accredited Hospitals, 2nd ed performance measures
utilized by government
hospitals focused on the
JCI Accreditation Standards for six IPSGs
Hospitals 2011
Other relevant internationally

accepted measures (AHRQ,
OECD, etc)
Data Analysis: Initial listing of all

relevant performance
measures to be evaluated
Documents Patient safety Reporting of never events Categorize the identified

review (Hospital officer/committee (based on National Quality performance measures
database and into structural, process
member, Forum), near-misses, adverse information
relevant
procedures system event rates and AHRQ patient manager and/or and outcome measures
manuals) safety indicators
administrator
Information on data collection,
analysis, recording and monitoring Evaluate validity, reliability,
on patient safety standardization
measures and indicators of performance measures
Data Analysis: Frequency of

reporting vs non-reporting
hospitals per performance
measure; description of protocols
used
Survey (2) Patient safety Hospital profile survey Encourage the culture of
officer/committee patient safety through
member, information emphasis on
system manager Patient safety culture survey knowledgebuilding and
and/or administrator (based on AHRQ survey) continued measurement
Data Analysis: Descriptive

statistics for respondents’
profiles; regressions between
characteristics and patient safety
culture scores
*see page 20 for details on data analysis plans

Summary of Data Collection Methods (Qualitative)

Strategies/ Participants Data to be Collected Specific Objective/s
Activities
Key informant Patient safety Information on data collection, Evaluate validity, reliability,
interview officer/committee analysis, recording and standardization of
member, information monitoring on patient safety performance measures
system manager
measures and indicators
and/or administrator
Data Analysis: summary of

common themes from
responses, methodological
triangulation, case study
*see page 20 for details on data analysis plans
CLARIFICATION
Summary of Data Collection Methods (Integrative)
Strategies/ Participants Data to be Collected or Specific Objective/s

Activities Presented
Workshops
“Benchmarking
Hospital Summary of data gathered Characterize and
sessions”
representatives in the during documents review, key recommend best practices
region; 1 per region informant interview for feedback in data collection, analysis
during study generation and dissemination
observed
during the study
Facilitate discussions with

Selected sentinel Selected based on findings of representatives from
“PDSA cycle hospitals quantitative surveys and sentinel hospitals that use
sessions” engagement from hospital findings of the study to plan
representatives – an explicit improvement strategies on
interest in implementing a patient safety and quality
quality improvement initiative is
required
Data Analysis: Case study

Build consensus on patient
safety measures and
“Culminating Representatives Comprehensive analysis of data
indicators to be nationally
Consensus- from all participating gathered throughout study and
implemented
building workshop” hospitals DOH, scientific evidence on patient
PHIC, stakeholders safety measures and indicators
including patient
groups
Workshops will be conducted to cover the following:

(1) Training and orientation workshop among the members of the project team.
The workshop will include lectures and skills training on the principles and concepts of
patient safety and methods for the assessment of measures and indicators; this will involve
participation of the project team along with representative from relevant units in the
Department of Health Health Facility Development Bureau (HFDB) and PhilHealth.
(2) Writeshop among members of the project team.

The purpose of the writeshop will be to develop the different tools that will be used for
data collection, particularly the guide questions for the surveys and key informant
interview questionnaire for health personnel, hospital profile survey and data collection
checklist. After the said activity, a list of relevant and useful indicators from the three
domains of quality (structure, process, outcome measures) for the 6 IPSGs will be
created based on appraisal of best available evidence for their validity. These will be the
index indicators which will be observed if used by the study hospitals and evaluated for
reliability and standardization. This will be the venue for mentoring research associates
in developing appropriate tools for specific endpoints. We will be convening an expert
panel consisting of members from public and private institutions as well as select
members from stakeholder organizations that include the DOH HFDB and relevant units
in PhilHealth.
(3) Workshops for participants/stakeholders.

First, orientation meetings called the “Onboarding Workshops” that will include the
research team and regional representatives from hospital partners will be organized to
introduce the project and to elicit participation and commitment from selected hospitals.
Informed consent will be taken by the surveyors trained in qualitative and quantitative
methodologies during the training writeshop with the assistance of hospital coordinators.
The details on the actual conduct of the project will be explained and inputs will be
solicited from the representatives and hospital study coordinators. Endorsement from
DOH through letters from the Secretary of Health for public hospitals and AHEAD
Program Leaders and engagement letters for private hospitals will be presented –
conforme signifying their intent to participate will then be collected. The Onboarding is a
critical element to facilitate data collection and to cultivate a sense of collaboration and
engagement that is necessary for consensus-building later. While this strategy may
unintentionally give participating hospitals due preparation for the research team visits
and prohibit blinding, the team intends to make data collection accurate by training our
data collection on triangulation methods and verification of information.
CLARIFICATION:
Second, three regional workshops that will summarize quarterly findings on data
collection and analysis will be held – these are called “Benchmarking Sessions”. Key
findings will be presented to the hospital representatives from the region to encourage
immediate feedback and correction/action for quality improvement.
Third are the PDSA cycle sessions, that will utilize the Plan-Do-Study-Act (PDSA)
approach. The project team will provide technical support in the analysis of their dynamic
PDSA outputs and outcomes. These hospitals will be followed for a year, and will be
written as case studies to highlight implementation models that can be relevant to other
institutions. The case studies will showcase success stories from hospitals who will be
observed to have efficient and accurate systems for patient safety measurement and an
enabling patient safety culture. These will also offer deeper insights on barriers and
sociocultural determinants that affect achievement of patient safety goals. Workshops on

how to conduct and monitor quality improvement projects will also be offered to interested
hospitals.
(4) Consensus-building
A culminating workshop will be convened with DOH and PhilHealth as well as an expert
panel of patient safety leaders and advocates from patient groups to build consensus
around the patient safety indicators and measures based on data gathered and lessons
learned from the entire conduct of the project.
Data to be Collected. Use of specified performance measures as described by the PhilHealth

Benchbook, HFDB from DOH and JCI Accreditation manual will be recorded. These will then
be categorized into structural, process and outcome measures. Evaluation of the validity,
reliability, standardization and patient-centeredness will be done for all relevant performance
measures listed at the start of the study (as agreed upon during the writeshop) and those
observed to be undertaken by hospitals from data collection. An important strategy for the
said evaluation is methodological triangulation which has been used in many health
systemsrelated researches. Methodological triangulation involves using more than one kind
of method to study a phenomenon – a blended qualitative and quantitative approach.
Investigators intend to compare the key findings in the quantitative review of documents,
protocols and surveys vis-à-vis those that will be uncovered qualitatively in the key informant
interviews. Differences in reporting, perspectives and methods of monitoring and surveillance
of the performance measures will be noted. This is a unique but comprehensive approach to
attempt to describe and summarize best practices and gaps in the use of patient safety
measures and indicators. This underlies the importance of engaging experts in quantitative
and qualitative techniques as well as accurate documentation of this process which may be
considered novel in the local setting. The definitions and methods for evaluation of the four
mentioned dimensions are summarized in the table below. Information regarding methods of
assessment of said measures and deviances from protocols on measurement will be reported.
Hospital characteristics such as fiscal management, level (according to DOH definitions), bed
capacity, staffing, PHIC reimbursement, Health Facility Enhancement Program (HFEP)
support, accreditation status, availability of electronic medical record, patient safety officer
and/or committee will be noted. Reporting of never events, near-misses, adverse event rates
and AHRQ patient safety indicators22 will be recorded. “Never events’ are shocking medical
errors that should never occur and now consists of 29 events grouped into 7 categories:
surgical, product or device, patient protection, care management, environmental, radiologic,
and criminal according to the National Quality Forum (please see page 46). Recording of the
AHRQ patient safety indicators (please see page 47) will be noted.

Methods of Evaluation for Dimensions of Performance Measures

Dimension Definition Method of Evaluation
Validity Determines what it intends to Comparing against relevant local and
measure international measures e.g. PhilHealth
Benchbook7, Agency for Healthcare
Research and Quality Patient Safety
Indicators8 (AHRQ PSI), OECD measures,
etc
Reliability Produces the same reading Methodological triangulation by
regardless of who does the document/protocol review and key
measuring or when and where the informant interviews
measurement is taken
Standardization Whether definitions of data Methodological triangulation by

elements, collection process, and document/protocol review and key
analysis are precise and informant interviews
comprehensible so they can be
understood and applied in the same
way regardless of who
refers to or applies them
Patientcenteredness Encompasses qualities of Methodological triangulation by

compassion, empathy, and document/protocol review and key
responsiveness to the needs, informant interviews based on standards in
values, and expressed preferences the PhilHealth Benchbook under
of the individual patient “Patient’s rights and Organizational Ethics”
Key informant interview involving

representatives from patient groups
A number of parameters for the hospital personnel survey questionnaire will be adopted from
the AHRQ hospital survey23 and on patient-centered care recommendations from the Institute
for Family-Centered Care in collaboration with the Institute for Healthcare Improvement 24. It will
cover the following domains, among others: staffing, teamwork, organizational learning,
perceptions, communication, events monitoring, responses to adverse events and
patientdoctor interactions.
(15) Plans for data processing and analysis.
Descriptive evaluation of the performance measures and indicators will be performed. Both
quantitative and qualitative methods will be employed. The core of the study is to determine
qualitatively possible deviances and gaps in measurement of these patient safety indicators.
The reliability, validity and standardization of the said measures and indicators will be subjected
to triangulation against key informant interviews that will be conducted as well as against
international and local consensus on the definitions of the measures and indicators. Common
themes will be identified when analyzing the information gathered during the key informant
interviews. Quantitative methods will include a scoring system to be developed by an expert
panel that will assign numerical values to the 3 domains of an indicator – namely structural,
process and outcomes and other factors deemed necessary by the panel during the writeshop.

The project will not come up with new indicators, but we will evaluate the existing indicators
as to the 4 characteristics across hospitals as how these indicators are uniquely implemented
with their attendant barriers and successes based on the aforementioned qualitative and
quantitative methods. We intend to look at associations between these and hospital
characteristics as well as identify surrogate/proxy outcomes should the monitoring of known
PSIs be deemed not feasible in the local setting. The health personnel survey will be
processed using descriptive statistics, specifically frequencies of responses and percent
positive response scores. These scores will be analyzed across the hospitals such as between
and among types (e.g. DOH-retained vs LGU-retained vs private), level and other relevant
variables. Case studies that will integrate results from quantitative and qualitative analyses
will be written up and presented using the planned dissemination strategies (see below under
Research Utilization and Dissemination).
The sample data collection tool summarizing the findings on performance measures on the
IPSGs and the hospital profile survey form and survey among hospital health personnel are
found in pages 43-45 and 48.
Data collected will be summarized and analyzed quarterly on a regional level and presented
in the regional feedback workshops mentioned above. This is to initiate quality improvement
and corrective measures based on information from the document reviews, surveys and key
informant interviews. Individualized feedback per hospital will also be done. Possible solutions
on patient safety gaps will be discussed in the PDSA cycles mentioned above.
ADDENDUM:
Preparation of the Dashboard
The following activities will be undertaken to develop the dashboard:
 Prepare draft/prototype of initial dashboard (4th quarter 2019)
 Presentation of draft dashboard in the Consensus-building workshop to be attended
by hospital participants, DOH and PhilHealth as well as an expert panel of patient
safety leaders and advocates from patient groups (1st quarter, 2020)  Finalize
revisions based on Consensus workshop (1st quarter, 2020)
 Pilot testing (1st quarter, 2020)
 Submission of final dashboard to DOH Health Facilities Development Bureau (2nd
quarter, 2020)
Capacity-building in patient safety and healthcare quality measurement is an important

thrust of this study and initiatives will be undertaken to enable the research team and
participating hospitals alike. The members of the project team as well as select hospital
champions will have opportunities to attend patient safety conferences locally and in Asia for
the purpose of learning from and sharing information with Asian neighbors on patient safety
experiences, particularly in the area of processing and analysis of data on patient safety as
well as on the PDSA cycles, root cause analysis and Team STEPPS that are within the scope
of the study topic. Another reason is to build international collaboration and partnership for
patient safety initiatives. Increasing the pool of patient safety experts as well as engaged and
committed partners within and outside of the health sector are vital to the success of the patient
safety and quality of health initiative in our country. We envision that this 30-month project will
highlight key measurement and monitoring processes that other institutions can undertake or
can be implemented for other areas in patient safety or otherwise. The members of the
research team and representatives from hospitals will be carefully selected on the basis of
merit and interest in patient safety/healthcare quality/measurements in health and will be
supervised under DOH, PHIC and UP Manila policies on capacity-building and personnel
training. A summary of the strategies for capacity-building are listed down below:
Strategy Participants Output/s
Orientation workshop Members of the project team Introduce principles of patient safety
and methods of performance
assessment of patient safety
Training writeshop • Members of the project team Develop patient safety data
• Technical experts collection tools
• Representatives from DOH • Key informant interview
HFDB and relevant units from questionnaire for health
PhilHealth personnel
• Hospital profile survey and data
collection checklist
• Survey questionnaire on patient
safety culture
Introduce met
Onboarding Workshop • Hospital Coordinators from Elicit participation and commitment

participating hospitals from selected hospitals
• Representatives from DOH and
AHEAD project Introduce concepts on patient safety
and quality measurement and
monitoring
Introduce research methods

applicable to patient safety
measurement and monitoring, both
quantitative and qualitative
Gathering inputs towards consensus-

building in patient safety

Training courses, Participating hospital Introduce research methods
among others: • coordinators applicable to patient safety
Team STEPPS (regional/provincial champions), measurement and monitoring, both
• ASEAN Patient Safety members of the project team, quantitative and qualitative
representatives from DOH HFDB
Congress
and relevant units from
• Online courses in BMJ PhilHealth Develop experts and advocates in
and Institute for field of Patient Safety and
Healthcare Quality
Healthcare
Improvement (IHI)
• Quality improvement
strategies (PDSA
cycle, root cause
analysis, case studies)
Building patient safety advocates and experts composed of young and emerging researchers
who are co-investigators of this project is an important element of the capacity-building as well.
These will include 4 University Researchers, 4 University Research Associates and consultants
that are intended to be developed in quantitative and qualitative aspects of patient safety,
quality improvement and measurement. It is recognized that success in patient safety will only
be guaranteed by a conglomerate of quantitative and qualitative skill sets - these include data
analysis, database maintenance and interpretation, critical appraisal of evidence base
and logical data correlations as well as socio-cultural determinants, acceptability,
patient-centeredness, efficient communication and workplace dynamics respectively.
These are areas that are expected to be will be developed in the participants from this
project internally - with the project team as well as the 60 participating hospital
coordinators and externally with stakeholders. Several papers will be written out from this
project and these will be written by these young and emerging patient safety team members.

(16) Work Plan Schedule: (see page 53)
(17) Ethical Considerations

Ethical clearance for this research has been granted by the UP Manila Research Ethics Board.
The proposal is expected to comply with the ethical standards set by the University in so far
as there is no direct participation from patients and that the information to be collected are
hospital aggregated data that have no identifiers pertaining to the individual patients. With
regards the survey among hospital health personnel, an informed consent will be obtained
and the name of participant will be optional in the form. The research team will be enforced to
comply with all measures directed towards data security and proper conduct of research. All
participating hospitals and respondents will be assigned individual codes to anonymize
information and ensure data privacy. Only the principal investigators and co-investigators will
have access to the identity of the participating hospitals and respondents. All data collection
tools and instruments will be kept in a designated and secure cabinet and office within the UP
College of Medicine.
ADDENDUM: The project will request sentinel ethics review boards (ERB) to facilitate
supervision and monitoring of the research protocol implementation. One sentinel ERB each
will be assigned for NCR, Luzon, Visayas and Mindanao that will cover all the enrolled DOH
hospitals; LGU and private hospitals will be under UP Manila REB or their respective ERBs
as appropriate.
Benefits of the Study to the Participants

There are no direct benefits (compensation/reimbursements/entitlements) for participants
joining the study. Participating hospitals will be provided with feedback on important quality
improvement gaps and strategies. Workshops to address these concerns will also be
available. The study will be writing a compendium of best practices and strategies. These will
be shared to all participating hospitals. In doing so, hospitals will have the opportunity to
implement and monitor quality improvement measures.
We will provide tokens of participation for the respondents that will include UPCM
memorabilia/souvenir. Honoraria will be given to hospital coordinators; PhP 5,000/month for
9 months which is the estimated duration of data collection per hospital.
Potential Harm of the Study to the Participants

Administrative impunity may unfortunately be observed when hospital representative report
institutional gaps and weaknesses during the study but should be minimized by anonymizing
the respondents and ensuring utmost objectivity by reporting findings at the group level.
Respondents for inclusion will be sampled independently by the research team based on the
current organizational structure of the institution and as verified by hospital administrators.
Once identified by the administrators, data collection will be done without the presence of the
administrators and superiors (survey questionnaires will be sent out and collected from the
respondents directly) and with utmost confidentiality. We will provide opportunities and
guidance for hospitals to approach the need for quality improvement strategies with a

constructive and systems-based approach. Interviewers will also be trained by the consultants
from the Institute of Clinical Epidemiology (Medical Anthropology) will ensure cultural
sensitivity, gender sensitivity and workplace dynamics.
(18) Research Utilization and Dissemination

Regional workshops in Luzon, Visayas and Mindanao will be held quarterly or with end of data
collection for each region to summarize and analyze all data gathered, recommend strategies
and resources for improvement and emphasize the patient safety culture. This will also serve
as an opportunity to elicit suggestions and recommendations from participating hospitals on
scaling up and dissemination of the patient safety measurement initiatives and inter-agency
collaborations. All information gathered including best practices and gaps in measurement will
be reported and used in a consensus-building culminating workshop.
The results of the research project will also be presented in scientific conferences and fora,
inter-agency committee and DOH National Patient Safety Committee meetings. These are
expected to provide scientific and logistic background for policy-making by DOH, PHIC and
other stakeholders. The reports will be written in publication-ready format and will target
journals with high impact factor and relevance.
The project team plans to develop infographics and briefers for wider dissemination of the
research findings. This project also intends to form partnerships with health information
technology experts in exploring the possibility of creation of web-based applications to
streamline monitoring of performance measures as well as increase online presence of the
patient safety concept using webinars, website and social media.
Once these patient safety indicators are created and disseminated, designating hospitals to
be centers of safety or “Sentrong Ligtas” is one of the possible longer-term impact of this
project. This is envisioned to be performance-based signal or label on attainment of patient
safety, contingent upon use of recommended patient safety indicators and measures,
achievement of targets set by DOH/PHIC and employment of reliable and continuous
monitoring methods by these hospitals. The “Sentrong Ligtas” mark can serve as basis for
PHIC payments as well as inclusion in Health Facilities Enhancement Program (HFEP) of
DOH.
Data Management and Sharing

The data generated will be co-owned by both DOH and the investigators. Data analysis will
be shared to participating hospitals. Sensitive information, such as gaps and administrative
barriers will be shared only to the concerned hospitals. Best practices and solutions will be
shared to all participating hospitals. Researchers who want to do secondary data analysis will
need to ask permission from both DOH and the investigators.
Data Security
All data collected will likewise be managed with strict privacy and confidentiality. Accomplished
survey questionnaires will be returned in a sealed white envelope to the Hospital Coordinator of the
research project and will be collected by the assigned research assistants. All encoded data will be
password-encrypted to ensure anonymity and data security. After encoding, all survey forms, tapes
and transcripts of interviews will be kept in a designated and secured cabinet at the research
project office within the UP College of Medicine. The office is only accessed by the research
project team. The researchers intend to adhere fully to the provisions of the Data Privacy Act of
2012.
Collaborative Study Terms of Reference

The research team is expected to update the sponsoring/funding agency (DOH AHEAD
Program) regularly of the progress of the study with quarterly reports of findings and expenses.
Members of stakeholder agencies such as the Health Facilities Development Bureau of the
DOH as well as relevant units from PhilHealth are invited to participate in the study activities,
particularly the workshops and other training courses offered throughout, as part of capacity-
building towards patient safety. They are also enjoined to help write manuscripts, infographics
and briefers for dissemination and publication that will be generated from this study.

Estimated budgetary requirements:
Particulars Sources of Funds and Amount (PhP)
PCHRD Assistance Agency Counterpart Other Sources
I. Personal Services (PS)

a. Salaries
8,448,156.00
b. Honoraria Sub-
total for PS 594,000.00
Salaries:
9,402,156.00
9,832,872.00
II. Maintenance and Other
Operating Expenses (MOOE)
Direct Costs (DC):

a. Travel expenses
b. Training expenses
3,190,970.00 Office space:
c. Representation
expenses 80,000.00 272,025.00
d. Communication 307,480.00 Electricity costs:
180,000.00
expenses
e. Supplies & materials 105,000.00
f. Printing & binding 242,914.00
expenses
g. Other professional
200,000.00
expenses
h. Capacity Building
i. Research Utilization 4,600,276.00
& 553,066.20
Dissemination
Sub-total for Direct Costs
1,501,200.00
10,780,906.20
Indirect Costs (IC)
1,676,649.96 452,025.00
Sub-total for MOOE
(DC + IC)
12,457,556.16
III. Capital Outlay
Sub-total for Capital
Outlay
560,000.00 0
Grand Total 22,419,712.16 10,284,897.00

Endorsement from the agency head
Dr. Carmencita D. Padilla

Chancellor, University of the Philippines-Manila
(19)

(20)

(21) Curriculum vitae
(1) Full name and date of writing the CV

Dr. Agnes Dominguez Mejia (Principal Investigator)
18 July 2017
• Date and place of birth, nationality, current residence and contact details
4 May 1952, Manila, Philippines, Filipino
110-H B. Gonzalez, Xavierville, Quezon City
Telephone numbers: 426-0204, 426-5011 (Residence); 526-4170/525-0299 (Office)
Cellphone number: 0919-3298887
Email address: admejia@up.edu.ph, agnesmejiamd@gmail.com
• Education and degrees awarded: Degree title (most recent first), educational institution,
major subject, graduation date
Doctor of Medicine, University of the Philippines College of Medicine, 1977
BS Pre Med, University of the Philippines-Diliman, 1973
• Other education and training, qualifications and skills o Other studies aiming at a
degree, qualifications or supplementary education and training: name of educational or
training program, extent of education and training, organizer, start and completion date
of education or training
o Other skills
Fellowship in Hypertension, University of Michigan Medical center, Ann Arbor, MI,
USA, 1986-1989
Fellowship in Nephrology, University of Cincinnati Medical Center, Cincinnati, Ohio,
USA, 1982-1985
Residency in Internal Medicine, UP-Philippine General Hospital, 1979-1980
• Current position o Current position, employer and place of work, start and state of
employment relation
Professor 12, Department of Medicine, UP College of Medicine, full-time, permanent
Consultant, Section of Nephrology, Department of Medicine, UP College of Medicine
Dean, UP College of Medicine, 2012-present
• Previous work experience o Earlier secondary occupations, additional work

experience, other commitments and potential conflicts of interest relevant to the
application (e.g. commitments in a company)
Chairman, Department of Medicine, UP-PGH, 2004-2013
Head, Section of Nephrology, UP-PGH, 1992-1997
Chairman, Department of Adult Nephrology, National Kidney and Transplant
Institute, 2002-2003
Chairman, Philippine Society of Nephrology-Specialty Board, 2003
Chairman, PCP-Philippine Specialty Board in Internal Medicine, 2004
Course Director, Annual Review in Internal Medicine, 2009-2011
• Research funding as well as leadership and supervision o Major research funding
(grants and appropriations): Source of funding, funding period and amount of funding

An 8-week, double blind, randomized parallel group, multi center study to evaluate the

efficacy and safety of combination of Aliskerin 300 mg & Amlodipine 10 mg compared
to Amlodipine 10 mg in patients with moderate to severe hypertension. Agnes
Mejia, P.I. Sponsor: Novartis Healthcare Phils. 2009
(Protocol No. CSPA 100A2306)
A twelve-week, randomized double blind, parallel group study to evaluate the
prolonged efficacy and safety of aliskiren 300 mg compared to telmisartan 80 mg in
mild to moderate hypertensive patients with 24-hour ambulatory blood pressure
measurement after 1 week of treatment withdrawal. Agnes
Mejia, P.I., Sep 2009. (Protocol No. CSPP 100A2408)
A multi-national, multi-center, double blind, randomized parallel study comparing the
efficacy and safety of valsartan/amlodipine 160/5 mg to valsartan 160 mg alone in
patients with mild to moderate essential hypertension not adequately
controlled with valsartan 160 mg monotherapy. Agnes Mejia, P.I. Oct 2009
(Protocol No. CVAA 489A2317)
A Multicenter, Randomized, Double Blind Study to evaluate the Efficacy and Safety of
Sitagliptin vs Glipizide in patients with Type 2 Diabetes Mellitus and Chronic Renal
Insufficiencies who have inadequate Glycemic Control. Agnes Mejia, P.I.;
Sponsor: MSD. March 2011 (Protocol No. MK0431-PNO63)
Post Marketing Surveillance to evaluate the effectiveness and safety of Aliskiren
(Rasilez) 150 mg and 300 mg for Stage 1 and 2 essential Hypertension in the Asian
population. Francis M. Domingo, Antonio Sibulo, Agnes Mejia, Annette Borromeo. June 2011.
o Role in the preparation of funding applications for a research group (name of
principal investigator)
Program Manager: Healthcare Quality and Patient Safety Research and
Development Program (DOST/PCHRD funded)
• Merits in teaching and pedagogical competence o Pedagogical training and
competence
Students’ Evaluation (Medical students): Academic Years 2009-2017: 3.21-4.0 (Very
Good-Outstanding) o Teaching awards
Distinguished Teacher Award, Philippine College of Physicians, 2004
Special Award for Medical Education, Phil. Society of Nephrology, 2004
UPMAS Distinguished Teacher, UP Medical Alumni Society, 2008
Outstanding Teacher Award in Clinical Science, UPMASA Missouri Southern Illinois
Chapter, 100th Commencement Exercises & PGH’s Internship Program Closing
Ceremonies, May 17, 2009
• Awards, prizes and honors granted for scientific, artistic or research merits or on the
basis of the recipient’s academic career Diamond Jubilee Professorial Chair, 2005-2011
Dr. Alfredo T. Ramirez Professorial Chair, 2012 to present
Most Distinguished Senior Consultant, Department of Medicine Graduation, Feb 2012
• Other academic merits o Memberships and positions of trust in scientific and
scholarly societies
Chairman, Scientific Committee , Philippine College of Physicians, 1992 & 1993
Chairman, Scientific Committee, Philippine Society of Hypertension, 1993 Chairman,
Scientific Committee, Asian Colloquium in Nephrology, 2002
Chairman, Philippine Society of Nephrology-Specialty Board, 2003

Chairman, Philippine Specialty Board in Internal Medicine, 2004

Member, Philippine Society of Critical Care
Member, Philippine Lipid Society o Positions as editor-in-chief, editor, or
member of editorial boards of scientific and scholarly journals and publication series
Member, Editorial Board, UP Press, 2009
Member, National Book Development Board, 2011-present o Administrative
responsibilities at higher education institutions or at research organizations,
responsibilities in the higher education community
Dean, UP College of Medicine, 2012-present
Member, Technical Committee on Medical Education, Commission on Higher
Education
Chairman, Learning Unit VI Academic Committee, 2006-2008
Member, Professor Emeritus Committee, 2007-2009
• Scientific and social impact of research o Total number of publications and, e.g., 10
most important and/or most cited publications according to a relevant database
Total number of research publications: 6 in international journals, 7 in local journals o
Artistic works and processes
Series Editor, 12 Health Series Booklets, 2009, 2011, 2012 (Milflores Publishing, Inc.)

Dr. Lynn Crisanta del Rosario Panganiban (Supervising Investigator) 15 July 2017
10 January 1960, Iloilo City, Philippines, Filipino
Unit UG-B Gateway Garden Ridge, Barangay Barangka Ilaya, EDSA, Mandaluyong City
Telephone numbers: 706-5455 (Residence); 526-4248, 521-8251 (Office) Cellphone numbers:
0977-8394549, 0920-9174836, 0922-8961540
Email address: ldpanganiban@up.edu.ph, lynn_panganiban@yahoo.com
Doctor of Medicine, University of the Philippines-Manila College of Medicine, 1984
Bachelor of Science in Zoology, University of the Philippines-Diliman, 1980
• Other education and training, qualifications and skills
Holistic Foundations for Assessment and Regulation of Genetic Engineering and
Genetically Modified Organisms, August 2003, Norwegian Institute of Gene
Ecology, University of Tromso, Norway (Earned credit units in the Doctoral
programs at the Faculty of Medicine)
16th Annual Occupational Health and Safety Institute, Midwest Center for
Occupational Health and Safety, University of Minnesota School of Public Health,
1998, Summer Session II (Earned graduate credit units for the Masters in Public
Health)
DTCP-IDRC Special Course on Monitoring and Evaluation of Projects and Programmes,
United Nations Development Programme, Manila, April 1992
Diploma in Health Care Evaluation and Management Skills (Clinical Epidemiology),
University of Toronto, Ontario, Canada, May-July 1990

Training in Clinical Toxicology under Dr. Nelia Cortes- Maramba (Department of

Pharmacology, UP College of Medicine), 1989
Chief Residency in Family Medicine - Philippine General Hospital, 1989
Family Medicine Residency Training - Philippine General Hospital, 1986-1988
Postgraduate Internship - Philippine General Hospital, May 1984 – April 1985
employment relation
Professor 12, Department of Pharmacology & Toxicology, University of the
Philippines (UP)- College of Medicine, 1990, full-time, permanent
Consultant, National Poison Management & Control Center, UP College of
Medicine-Philippine General Hospital, 1990 o Secondary occupation, additional
work experience, other commitments and potential conflicts of interest relevant to the
application (e.g. commitments in a company)
Member, Pesticide Expert Panel, Food and Drug Administration, Department of
Health, March 2016-present
Technical Service Consultant, Center for Cosmetic Regulation & Research, Food &
Drug Administration, Department of Health, August 2016-present
• Previous work experience
Chair, Department of Pharmacology & Toxicology, UP College of Medicine,
September 2010-December 2015
Head, National Poison Management & Control Center, UP College of Medicine/
Philippine General Hospital, 2005-2010
Chair, Drug Committee, Philippine General Hospital, February 2015-December 2016
Member, Pesticide and Technical Advisory Committee, Fertilizer & Pesticide
Authority (FPA), 2014-2016
Technical Consultant and Evaluator, Pesticide Products (Toxicity Studies and
Occupational Exposures/Human Exposures) & Pesticide Manufacturing/
Formulating Plants, FPA, 1991-2007
Consultant, Environmental & Occupational Health Office, National Center for
Disease Prevention and Control, 1992-2015
Consultant, Department of Family & Community Medicine, 1990-2005
• Research funding as well as leadership and supervision o Major research funding
(grants and appropriations): Source of funding, funding period and amount of funding
Status of poison centres in the Western Pacific Region, January- March, 2017 (WHO-
Western Pacific Region Office; US $ 10,596.00)
Survey on Community Health Status and Environmental Exposures in Barangays
Bancal and Tugatog, Bulacan, 2015-2016 (Pure Earth/Asian Development
Bank; US $ 4,400.00)
Effects of Aqueous Quassia amara L. leaf extract on the behavior, locomotion and
coordination of albino rats, 2014-2016 (DOST funded; PhP 3,217,859.15) Effects of
Aqueous Quassia amara L. leaf extract on the cardiovascular and respiratory
functions of male Sprague-Dawley rats, 2014-2016 (DOST funded;
PhP 12,681,418.40 )
Managing Environmental Risks for Sustainable Food and Health Security in
Watershed Planning in Lake Laguna Region, Component 2, Phases 2-4

2012-2014 (Research Institute for Humanity and Nature/Yokohama National

University-funded; Php 1,929,200.00)
Rapid health assessment study among population groups exposed to conventional
and auto-LPG converted vehicles, 2012 (DOH-funded; PhP 420,920.00) Health
Assessment on Pesticide Exposure Among Public Health Workers, 2011
(DOH-funded; PhP 2,000,000.00)
Health Effects of Lead Exposure Among 6-7 year old Children in Barangays Tugatog,
Bancal and Banga in Meycausayan, Bulacan, 2010 (DOH/Blacksmith Institute-
funded)
Community monitoring on the effects of exposure to bunker oil spill among high risk
populations and the environment in Guimaras Province, 2008-2012 (DOH- funded; Php
8,050,000.00)
Determination of chemical-contamination of drinking water and the health status of
residents in Bauko, Mt. Province: Phase I, 2008 (SIDA/World Bank funded;
PhP 150,000.00)
Community-based surveillance on acute pesticide poisoning: a pilot study, 2004
(WHO funded; US $ 2,000.00)
Neurodevelopmental effects of mercury among children near the abandoned
mercury mines in the Philippines, 2004 (International Atomic Energy
Agency/DOH funded: PhP 299,850.00)
A Cross-sectional study on the health effects of ethylene bisdithiocarbamate
exposure among plantation workers, 2001 (DOH-funded: PhP 2,500,000.00)
Epidemiological study of pesticide poisoning in the Philippines, 2001 (WHO funded:
US $10,168.60)
Health and environmental impact of arsenic exposure among workers and residents of
a community near a battery recycling plant, Marilao, Bulacan, 2000 (DOH- funded)
Health and environmental impact of arsenic exposure among residents near Mt. Apo
geothermal plant 2001-2003 (DOH-funded: PhP 369,000.00)
Beta-testing of the INTOX Version 4 (WHO-IPCS collaborative project), June-
October, 2000 (WHO-funded)
Drug Utilization Studies in the Philippine (AusAid/DOH funded), 1993-1995 o Role
in the preparation of funding applications for a research group (name of principal
investigator)
Technical Consultant: TA 8458-REG: Mitigation of Hazardous Waste
Contamination in Urban Areas: Supporting Inclusive Growth (Principal
Investigator: Pure Earth), ADB-funded
Co-investigator: Effect of Aqueous Quassia amara L. leaf extract on the behavior,
locomotion and coordination of albino rats (Principal Investigator: Dr. Jose
Paciano Reyes), DOST-funded
Co-investigator: Effects of Aqueous Quassia amara L. leaf extract on the
cardiovascular and respiratory functions of male Sprague-Dawley rats
(Principal Investigator: Dr. Maria Concepcion Sison), DOST-funded
Technical Consultant: Development of an effective national chemical safety
program towards chemical poisoning prevention and control: Chemical
Safety Training and Other Related Programmes Component (Principal
Investigator: Philippine Department of Health), UNEP-funded o Leadership in
research work
Assumed role of project leader/principal investigator in the following:

Status of poison centres in the Western Pacific Region, January- March, 2017

Survey on Community Health Status and Environmental Express in Barangays Bancal
and Tugatog, Bulacan, 2015-2016
Managing Environmental Risks for Sustainable Food and Health Security in
Watershed Planning in Lake Laguna Region, Component 2, Phases 2-4
2012-2014
Rapid health assessment study among population groups exposed to conventional
and auto-LPG converted vehicles, 2012
Health Assessment on Pesticide Exposure Among Public Health Workers, 2011
Community monitoring on the effects of exposure to bunker oil spill among high risk
populations and the environment in Guimaras Province, 2008-2012 Determination of
chemical-contamination of drinking water and the health status of residents in Bauko,
Mt. Province: Phase I, 2008
Community-based surveillance on acute pesticide poisoning: a pilot study, 2004
Beta-testing of the INTOX Version 4 (WHO-IPCS collaborative project), June-
October, 2000 o Experience as officially appointed supervisor to
undergraduate and postgraduate students/doctoral students
Therapeutics 201 research adviser (Learning Unit IV College of Medicine)
• Merits in teaching and pedagogical competence o Pedagogical training and
competence
Integrated Faculty Development Program Modules
Students’ Evaluation (Medical Students): Academic Years 2013-2016: 3.72-4.0
(Outstanding)
o Involvement in curriculum planning and the implementation of courses:
subject, study hours, course level and duration Therapeutics 201: Medicine, Learning
Unit IV, 3 weeks
Therapeutics 202: Medicine, Learning Unit V, 2 weeks
Pharmacotherapeutics Conference: Medicine, Learning Unit VI, 2 semesters
Pharma 248 Toxicology, MS Pharmacology, 1 semester
Pharma 292: Clinical Elective in Pharmacology (Toxicology) Medicine, Learning Unit
VI/VII, 4 weeks
Postgraduate Course in Toxicology Administration and Management, Department
of Health physicians/nurses (Regional Offices), 6 months
o Development of teaching methods
Case Studies in Pharmacovigilance, 2015 (College of Medicine)
Self-instructional modules: Preventing Medication Errors (2007, 2012); Adverse
Reactions to Commonly-Used Antidotes for Poisoning (2001); Toxicokinetics
(2000); Toxicodynamics (1999); Drug Interactions (1998); Drug and Substance
Abuse (1996) (College of Medicine)
“Iwas Lason” (CD on poisoning prevention and first aid treatment of poisoning in
children), 2007 (UPM National Telehealth Center/US-AID funded) Management of
Pesticide Poisoning: Protocols and Resources (self-instructional
CD-ROM for physicians and nurses), 2003 (WHO-funded)
Poison Information Specialist Training Module ,1991, 2003 (National Poison
Management and Control Center) o Supervision of theses
MS Occupational Health, UPM-College of Public Health: Dr. Elinore Crisostomo,
1999-2000

MS Environmental Science, UP Diliman: Engr. Ana Rivera, 2011-2012 MS Pharmacology,

UPM-College of Medicine:
2008-2014: Dr. Abraham Cruz, Mr. Francis Capule, Ms. Mona Flores
2016-present: Dr. Laura Aguinaldo, Dr. Nerissa Dando, Mr. John Paul Pimentel
Ms. Melanie Salinas
o Teaching awards
Gawad Chancellor Award for Outstanding Teacher, 2016
• Awards, prizes and honors granted for scientific, artistic or research merits or on the
basis of the recipient’s academic career
One UP Professorial Chair for Research and Public Service, 2016
International Publications Award (2004, 2006, 2013)
Professorial Chair Award (2003, 2011)
Centennial Faculty Award, 2008
Jewels Award (National Poison Management & Control Center), UP Manila , 2005
Outstanding Health Research Award: Impact of the Poison Control & information Service
Network Project on the Health Care Delivery System (Co- investigator/Assistant
Project Leader), PCHRD, March 1998
• Other academic merits o Memberships and positions of trust in scientific and
scholarly societies
Fellow & President, Philippine Society of Clinical & Occupational Toxicology, Inc,
2016-present
Diplomate, Philippine Academic of Family Physicians
Member, Asia-Pacific Association of Medical Toxicology
Member, Roster of Faculty, Committee on Medical Education, Philippine College of
Occupational Medicine
Member, Philippine Society of Experimental and Clinical Pharmacology o Membership in
national or international expert groups, evaluation or steering committees, as well as
other expert duties
Temporary Adviser/Consultant, World Health Organization (1992-2016)
Chair, Technical Working Group, Bids and Awards Committee 1 (Medicines and
Devices)
Member, UPM-NIH FDA Review Panel, 2015-present
Reviewer, Research Proposals, UPM-National Institutes of Health and the
Philippine Council for Health Research & Development (Toxicology)
Member, Health Human Risk Assessment (HHRA) Expert Panel to the IACEH Expert
Panel, Bangkal Oil Spill (2013-2014)
Member, Steering Committee/Technical Working Group, Development of the
National Action and Implementation Plan for the National Chemical Safety
Management Program, DOH, 2013
Member, Technical Working Group on health and environmental effects of auto- LPG,
2013
Member, Steering Committee, APEC/CTI/Chemical Dialogue/Regulators Forum
Regulatory Cooperation, 2012
Member, Task Force MV Princess of the Stars, 2008 (Chair, Subtask Force on
Hazardous Materials), 2008
Member, Occupational Health & Safety Committee, UP Manila, 2006-2010 o
Positions as editor-in-chief, editor, or member of editorial boards of scientific and
scholarly journals and publication series
Member, Editorial Board/Reviewer, Journal of Health and Pollution o Referee for

scientific and scholarly journals
Reviewer, Acta Medical Philippina o Administrative responsibilities at higher
education institutions or at research organizations, responsibilities in the higher
education community Assistant Associate Dean for Faculty and Students, UP College of
Medicine, 2012- present
Member, Dean’s Advisory Committee, 2010-present
Chair, Committee on National Center on Healthcare Quality and Patient Safety,
2016-present
Chair/Co-Chair, Learning Unit IV Academic Committee, 2010-2015
• Scientific and social impact of research o Total number of publications and, e.g., 10
most important and/or most cited publications according to a relevant database
Number of published articles/researches: 15
Number of published abstracts: 7
Number of published books, chapters in books: 20
Number of citations (Google Scholar): 181; h-index 5; i10-index 4 Most cited publications:
1. Environmental and human exposure assessment monitoring of communities near
and abandoned mercury mine in the Philippines: A toxic legacy (56) 2. Correlation between
blood ethylenethiourea and thyroid gland disorders among banana plantation workers in
the Philippines (46)
3. Health and environmental assessment of mercury exposure in a gold mining
community in Western Mindanao, Philippines (38)
4. Rhabdomyolysis in isoniazid poisoning (27) o Merits related to the production
and distribution of research results and research data research dissemination grants:
Oral Presentations: Health risk assessment of environmental lead exposure
among children in four Villages in Santa Rosa City, Laguna (August 12), Association
between blood lead level and neurodevelopmental status in children in four lakeshore
villages in Santa Rosa City, Laguna, Philippines (August 13)
5th Biennial Conference of the International Association for Ecology and Health,
University of Quebec, Montreal, August 2014
Oral Presentation: Biologic monitoring of pesticide exposure among vector-control
workers in four regions of the country, 12th Asia-Pacific Association of Medical
Toxicology Congress, Hong Kong, December 2012 Oral Presentation: Follow-up health
and environmental assessment of communities exposed to bunker oil in Guimaras
Province 15 months after the Spill, 11th Asia-Pacific Association of Medical Toxicology
Congress, Penang,
Malaysia, November 2011 o Merits in science communication and expert
assignments in the media
Resource person/interviews in the areas of pharmacology & toxicology: ABS-CBN, Agila Net
25, Al-Jazeera, ANC Channel, CNN Philippines, GMA-7, PTV-4, Channel 5, Philippine Center
for Investigative Journalism, Health & Lifestyle Magazine, etc.
• Positions of trust in society and other societal merits o Significant positions of trust,
expert duties and assignments (also research-based policy advice tasks)
Member, Interagency Committee on Environmental Health, DOH, 1992-2010

Post Graduate: University of the Philippines College of Medicine
Doctor of Medicine 2002 - 2007
Graduated Cum Laude and Class Valedictorian
Philippine General Hospital Internship Program
May 2006 - April 2007
College: University of the Philippines Manila College of Public Health
Bachelor of Science in Public Health 1998 - 2002
Graduated Cum laude and Valedictorian

High School: Manila Science High School 1994 – 1998, silver medalist
Elementary: Justo Lukban Elementary School 1989 – 1994, valedictorian

Member, INTOX Poisons Control Centre Working Group, IPCS-WHO (1992-2009)

Dr. Diana Rivadelo Tamondong-Lachica (Research Associate II)
27 September 2017
10 August 1982, Dagupan City, Philippines, Filipino
Unit 1521 Sorrel Residences, Sociego Street, Sampaloc, Manila 1008
Telephone numbers: 573-2765 (Residence)
Cellphone numbers: 0998-5474182
Email address: drtamondonglachica@up.edu.ph, dtlachica@gmail.com
Residency Training Department of Medicine - Philippine General Hospital 2008-2010
• Other education and training, qualifications and skills Chief Resident, Department of
Medicine 2011-2012
employment relation
Clinical Associate Professor, Section of Adult Medicine, Department of Medicine,
UP College of Medicine – Philippine General Hospital o Secondary occupation,
additional work experience, other commitments and potential conflicts of interest
relevant to the application (e.g. commitments in a company)
Chief Medical Officer, QURE Healthcare, Inc. (US-based results-driven research and
consulting firm committed to furthering health care quality) Faculty, Asia Pacific Center
for Evidence-based Healthcare
• Previous work experience
Visiting Consultant, Department of Internal Medicine, The Medical City Ortigas
Lecturer, Ateneo School of Medicine and Public Health, Ortigas Avenue, Pasig
Lecturer and Part-time Assistant Professor I, Department of Physiology and
Department of Medicine, San Beda College of Medicine, Mendiola, Manila
Lecturer, Topnotch Board Prep
Consultant, Interim Support Group (Quality of Care), Sept 2012-2013, Health
Policy Development Program, UP School of Economics
Vice-Chair, Clinical Pathways and Guidelines Committee, The Medical City, Oct
2012-April 2014
• Other academic merits o Positions as editor-in-chief, editor, or member of
editorial boards of scientific and scholarly journals and publication series
Editor-in-Chief, Journal of the Association of Philippine Medical Colleges, ISSN 25078496

• Scientific and social impact of research o Contributor, “The Challenge of Reaching the

Poor with a Continuum of Care: A 25year Assessment of the Philippine Health Sector
Performance”. UPecon-Health Policy Development Program (HPDP), Queon City Philippines,
In press.
o Shimkhada R, Solon O, Tamondong-Lachica D and Peabody JW. “Misdiagnosis of
obstetrical cases and the clinical and cost consequences to patients: a crosssectional
study of urban providers in the Philippines”. Glob Health Action 2016, 9:
32672 - http://dx.doi.org/10.3402/gha.v9.32672 o Timothy Kubal, Doug G
Letson,Alberto A Chiappori, Gregory M Springett, Riti Shimkhada, Diana Tamondong
Lachica, John W Peabody. Longitudinal cohort study to determine effectiveness of a novel
simulated case and feedback system to improve clinical pathway adherence in breast, lung
and GI cancers. BMJ Open
2016;6:e012312. doi:10.1136/bmjopen-2016- 012312 o John Williamson Peabody,
Trever Bradley Burgon, Diana Tamondong-Lachica, Lisa DeMaria. “Evaluation of Clinical
Practice among Urologists Caring for Patients with Early Stage Prostate Cancer.” 2015 ASCO
Annual Meeting , May 29 - June 2, 2015. Abstract accepted; In press.
o Kubal T, Letson D, Fields K, Levine R, Andrews C, Hamm J, Tamondong-Lachica
D, Shimkhada R, Peabody JW. “Building a Provider Network Based on Quality: the Moffitt
Oncology Network Value Initiative.” American Society of Clinical Oncology
(ASCO) Quality Care Symposium, October 17-18, 2014. Abstract accepted; In press.
o Fields KK, Soliman HH, Friedman EL, Lee RV, Acelajado MC, Tamondong-Lachica D,
Peabody JW. “Measuring Clinical Pathway Compliance Using a Simulated Patient
Approach with Clinical Performance and Value (CPV®) Vignettes.” J Clin Oncol 31 (suppl
31; abstr 96), 2013
• Positions of trust in society and other societal merits o Significant positions of trust,
expert duties and assignments (also research-based policy advice tasks)
Fellow, Philippine College of Physicians
President and Member of Board of Trustees, Philippine Society of General Internal Medicine
Member, Residency Training Program Committee, Philippine College of Physicians 2013-
present
Member, Advocacy Committee, Philippine College of Physicians 2014-2015
Member, Annual Convention Scientific Committee, Philippine College of Physicians 20142015
(4) Full name and date of writing the CV Bryan Albert Lim (Research Associate I)
27 September 2017
Date and place of birth, nationality, current residence and contact details
Birth Date: April 12, 1984
Place of Birth: Cebu City
Temporary Address: Rm 402 1851 Summit Apartment Maria Orosa St. Malate, Manila
Permanent Address: 336 Valencia St. Villa Del Rio, Bacayan, Cebu City, Cebu
Cell Phone Number: 09173201502
Email: bryanalbertlim@gmail.com
Civil Status: Single
Citizenship: Filipino
Language: English, Cebuano, Tagalog, Fookien
Education and degrees awarded: Degree title (most recent first), educational institution, major
subject, graduation date

Clinical Fellow, Infectious Diseases (Chief Fellow)

University of the Philippines – Philippine General Hospital
Department of Medicine, Section of Infectious Diseases
June 2016-June 2018
Diplomate in Internal Medicine
Graduated December 15, 2015
Masters in Development Economics (candidate)
University of the Philippines Diliman, School of Economics
Doctor of Medicine
University of the Philippines College of Medicine
Graduated May 23, 2010
Straight Internship in Internal Medicine at the Philippine General Hospital
Outstanding Intern in Internal Medicine
Graduated May 23, 2010
College: BS Biology - University of the Philippines in the Visayas College of Cebu Magna Cum Laude
and Valedictorian of Class 2005 of UP Visayas
High School: Cebu Eastern College - Valedictorian
Elementary: Cebu Eastern College - 2nd Honors
Current position
Clinical Fellow, Infectious Diseases (Chief Fellow)
Department of Medicine, Section of Infectious Diseases
June 2016-June 2018
Previous work experience

January 2016- May 2016 – Consultant, Department of Health, Office for Health Regulations
March 2016-June 2016 – Consultant, Valenzuela City Health System, Manual of Operations
Harmonization
Dec 16, 2015 – March 31, 2016: Project Consultant “Compilation and Modelling of Best Practices
in Community-based Diabetes Management Programs”. Sanofi
2013-2015: Medical Officer III, Philippine General Hospital
2015. Consultant/ Co-organizer. Global Forum for Health Research and Innovation. Oct 2015 to
present - Co-investigator: Efficacy, immunogenicity, and safety study of Clostridium
difficile toxoid vaccine in subjects at risk for C.difficile infection. Sanofi Pasteur
2012-2013: Principal Investigator “Pharmaceutical Transparency Through Technology”. Philippine
Business for Social Progress
2011-2013: Consultant, Asian Institute of Management – Dr. Stephen Zuellig Center for Asian
Business Transformation
2008-present: Member/Researcher, Universal Health Care Study Group, University of the
Philippines, National Institutes of Health
2010-2012 – House Physician/ER Physician, San Pablo Doctors’ Hospital.
2011-2012 - Project Head, Health Financing Documentary, World Health Organization, Western Pacific
Regional Office.
2010-2011 – Founding Program Coordinator, Asian Institute of Management – Dr. Stephen
Zuellig Center for Asian Business Transformation
Member, DOH Task force for the control and prevention of non-communicable diseases. Member, UP
College of Medicine Steering Committee, Center for Patient Safety
Co-organizer – ThinkOpenHealth. A Hackathon for Health, led by DOH, DOST and SMART Co-
founder/President- Health Sector Catalyst, a company which incubates creative, multisectoral and
innovative solutions to institutions involved in health.

Co-proponent- Health System Shapers. A year-long multisectoral, nationwide consultation on issues
concerning the implementation of Universal Health Care
Proponent – Secretary’s Cup. An 8-month long nationwide advocacy campaign to promote

Universal Health Care. Activities involve debates, townhall meetings, community consultations, health

talk series by former DOH secretaries, social media campaigns, and roundtable discussions with
journalists
Researcher/advocate– 2008 to 2010 Universal Health Care Study group, UP- National Institutes of
Health
Project Head/Documentary Director-Interviewer, Creative Team of the UP Presidential
Symposium on Universal Health Care organized by the UP President
Facilitator/Co-organizer – Health Young Leaders’ Congress, a 3 day event which brings together
various youth leaders from the health care-related courses. Participants are exposed to the national
health situation and to possible solutions. A venue for partnership, and inspiration.
Organized by Zuellig Foundation.
Project Consultant: 2nd Quisumbing-Escandor Film Festival for Health and Film Caravan
Project Head and Proponent: 1st Quisumbing-Escandor Film Festival for Health (February 2008) - A
nationwide film making contest that tackles issues in health, aimed at raising awareness to the
public. Films are shown to communities and schools to educate and mobilize. A project that
won the “Ten Accomplished Youth Organizations Award
Project Consultant: Establishment of a Health Center in Calauan Laguna for the relocation site of
Ondoy victims. Project with Bayer, ABS-CBN and Mu Sigma Phi Medical Fraternity
Project Proponent: Bayernihan Para sa Kalusugan
- A 3-year joint project of Mu Sigma Phi, ABS-CBN and Bayer Philippines, geared towards
training Barangay Health Wokers in Villa Espina Quezon.
Bearer of the Staff (Service Chair Person) (2007-2008), Mu Sigma Phi Fraternity - organizes relevant
service activities for various communities.
Research funding as well as leadership and supervision

• The epidemiology and burden of disease of infections due to Extended-spectrum Betalactamase
(ESBL) – producing organisms and methicillin-resistant Staphylococcus aureus (MRSA) of
patients admitted in sentinel hospitals of the Antimicrobial Resistance
Surveillance Program (ARSP) of the Philippine Department of Health: a pilot study (ongoing)
• Principal Investigator/Awardee Grand Challenges Canada Stars for Global Health- Pharmaceutical
Transparency through Technology. A mobile and web-based application designed to connect
consumers to drugstores.
• Co-investigator: Efficacy, immunogenicity, and safety study of Clostridium difficile toxoid vaccine in
subjects at risk for C.difficile infection. Sanofi Pasteur
• Fausto, A, Gabat, J & Lim, B. Comparison of the efficacy of sevelamer and calcium carbonate in
reducing coronary artery calcification among adult patients with chronic kidney disease. 2014
(unpublished)
• Lim, B & Lasco, G. Predictors of CPR Outcomes in the Internal Medicine Wards of the Philippine
General Hospital: A retrospective Study. 2010. (unpublished)
• Castillo, S, Lim, B. et al. Antitumor activity of Clostridium perfringes to colon carcinoma
xenografted in immunosuppressed mice 2006 (unpublished)
• Lim, B. Comparative Study on the Diversity of Meiofauna Collected from Sand and Mud. 2005
(unpublished)
• Lim, B. Verdolaga, R, Bermejo, M, and J. Mendoza. Manual of Operations of the Valenzuela City
Health System. 2016 (ongoing)
• Lim, B, Jumangit, A, Ricarte, J, & Canero, J. Usability of a mobile and web application for drug
information among community health workers: a pilot study. 2015 (unpublished)
• Lim, B, Gabat, J, & Loyola, A. Factors influencing compliance to premium payment among
individual-paying Philhealth members seen at the PGH Department of Medicine. 2015
(unpublished)
• Domingo, E, Lim, B. Insights from the Health System Shapers Program: A multi-sectoral
consultation on Universal Health Care. 2015 (ongoing)
• Consultant: Reconfiguring primary health care within the context of Kalusugan Pangkalahatan
2015 (ongoing)

• Romualdez, A, Lim, B, & Lasco, G. Universal Health Care in the Philippines. Journal of the
ASEAN Federation of Endocrine Societies. 27(2). 2012
• Contributor- Universal Health Care for All Filipinos, Acta Medica Special Edition. Feb 2011
Declaration of Conflicts of Interest
All of the above members of the research team namely the Principal Investigator, Supervising
Investigator, Research Associate II and Research Associate I, hereby declare no conflicts of interest
arising from financial, familial or proprietary considerations from this study.
(22) Bibliography:
1Vincent C. Patient Safety (2nd ed). Chichester: A John Wiley and Sons, Ltd Publications; 2010.
2Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human:
Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS (eds). Washington (DC):
National Academies Press (US); 2000. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK225182/doi: 10.17226/9728
3
World Health Organization 55th World Health Assembly A55/13 Provisional Agenda Item 13.9
23 March 2002
4World Health Organization. World Alliance for Patient Safety Progress Report 2006-2007.
WHO-IRIS: Geneva; 2008.
5 Department of Health issued Administrative Order 2008-0023 National Policy on Patient Safety
6Kristensen S, Mainz J, and Bartels P. (2007). Establishing a Set of Patient Safety Indicators:
Safety Improvement for Patients in Europe, SImPatIE - Work Package 4. ESQH-office for Quality
Indicators.

7Republic Act No. 1870: An Act for the Purpose of Founding a University for the Philippine Islands,
Giving It Corporate Existence, Providing for a Board of Regents, Defining the Board’s
Responsibilities and Duties, Providing Higher and Professional Instruction, and For Other
Purposes.
8UP College of Medicine. National Center for Healthcare Quality and Patient Safety; August 2016 9U.
S. Department of Health and Human Services Health Resources and Services Administration.
Quality Improvement. April 2011.
https://www.hrsa.gov/quality/toolbox/methodology/performancemanagement/index.html
10
Institute of Medicine (US) Committee on Quality Health Care in America. Crossing the Quality
Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press
(US); 2001. Available from: http://www.nap.edu/catalog/…/crossing-the-quality-chasma-new-
health-system-for-t…
11Yu A, Flott K, Chainani N, Fontana G, Darzi A. Patient Safety 2030. London, UK: NIHR Imperial
Patient Safety Translational Research Centre. 2016
12
Harrison R, et al. (2015). Patient safety and quality of care in developing countries in Southeast
Asia: a systematic literature review. International Journal for Quality in Health Care; 1-15. doi:
10.1093/intqc/mzv041.
13
McDonald K, Romano P, Geppert J, et al. Measures of Patient Safety Based on Hospital
Administrative Data – The Patient Safety Indicators. Technical Review 5 (Prepared by the
University of California San Francisco-Stanford Evidence-based Practice Center under
Contract No. 290-97-00131. AHRQ Publication No. 02-0038. Rockvilled, MD: Agency for
Healthcare Research and Quality. August 2012.
14Kristensen S, Mainz J, Bartels P. (2009). Selection of indicators for continuous monitoring of
patient safety: recommendations of the project ‘safety improvement for patients in Europe’.
International Journal for Quality in Health Care; 21(3): 169-175.
15Vincent C, Burnett S, Carthey J. BMJ Qual Saf Published Online First: 24 April 2014
doi:10.1136/bmjqs-20130002757
16
World Health Organization Regional Office for the Eastern Mediterranean. Patient Safety
Assessment Manual; WHO-EMRO; 2011.
17The Philippine Health Insurance Corporation. The Hospital Benchbook Survey Manual and Self-
Assessment Tool 2nd edition.
18Nieva VF, Sorra J. (2003). Safety culture assessment: a tool for improving patient safety in
healthcare organizations. Qual Saf Health Care; 12 (Suppl II): ii17-ii23.
19Singla AK, Kitch BT, et al. (2006). Assessing Patient Safety Culture: A Review and Synthesis of
the Measurement Tools. J Patient Safety; 2:105-115.
20Joint Commission International. International Patient Safety Goals. Available at:
http://www.jointcommissioninternational.org>Improve with JCI
21
Paguio JT, Sy ADR and Co, H. Patient Safety Culture and Perceptions on Event Reporting in the
National University Hospital. Final report March 2017 UP College of Medicine. With permission
from author.
22Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators.
https://www.qualityindicators.ahrq.gov/Modules/psi_resources.aspx

23Rockville W., et al. (2016). AHRQ Hospital Survey on Patient Safety Culture: User’s Guide. Agency
for Healthcare Research and Quality, U.S. Department of Human and Health Services.
24Johnson B, Abraham M, Conway J, Simmons L, Edgman-Levitan S, Sodomka P, et al. Partnering
with Patients and Families to Design a Patient and Family-Centered Health Care System:
Recommendations and Promising Practices. Besthesda, Cambridge: Institute for Patient- and
Family-Centred Care and Institute for Healthcare Improvement, 2008

Roles and Responsibilities Capacity Building
Principal Investigator - Ensures that the conduct of the study - Attends workshops and
(1) adheres to the protocol. Any training on patient safety and
inevitable protocol deviations will be health care quality
discussed and deliberated with the evaluation and monitoring
team
- Training in the use of
Discusses preliminary findings with
- DOH and PCHRD statistical software for both
qualitative and quantitative
Supervising - Assists the Principal Investigator in analysis
Investigator (1) meeting the targets of the study
Represents the Principal - Attends lectures and short

- Investigator courses on essential and
basic hospital management
- Formulate strategies on how to

implement the protocol in the most
efficient manner
University Researcher - Coordinates with the research

III (1) team
Arranges the work plan

-
- Monitors the progress of the team in
terms of meeting the targets and
research milestones
Ensures the integrity of the data by

doing oversight
-
University Researcher - Designs and conducts the training of
II (3) the research team prior to fieldwork
-
Leads the research teams in the field
work
Writes the paper together with the
study leads
-
- Identifies further research ideas that

could emerge during the conduct of
the research

University Research - Collects the necessary data during - Training in doing field
Associate (4) the field work interviews
-
Transcribes proceedings of meetings - Training in writing policy briefs
and interviews during the conduct of
the study - Orientation in basic hospital
structure and patient safety
- Encodes data according to the
statistical requirements of the data - Training in the use of
analysis statistical software
Researches, curates, summarizes, - Training in monitoring patient

- documents relevant literature safety indicators

(23) Duties and Responsibilities of Project Personnel

Project - Manages the research office - Training in basic hospital
Assistant/Administrative structure and management
Officer (1)
- Ensures that needs of the research
team are met eg. office supplies, - Orientation on patient safety
research materials, etc. indicators and challenges
- Arranges and schedules meetings with
the research team and consultants. - Training in the use of statistical
Takes and documents software
all meeting proceedings
- Facilitates and coordinates site visits.

This includes, but are not limited to,
coordination with hospital staff,
arranging transportation, procuring
necessary materials for the research
team
- Arranges all necessary paperwork and

documentation during the course of the
research
- Curates and stores all documentation

materials and study data

Consultants (4) Quantitative analysis expert NA
(Statistician)
- Designs the data collection protocol for
quantitative analysis
- Assist in the design, identification and
evaluation of indicators
Qualitative analysis expert (Medical

Anthropologist)
- Facilitates key informant interviews
- Trains the research associates in
conducting interviews
- Aids and guides the team in analyzing
qualitative data
Hospital administration expert

(MHA)
- Provides technical advice in selecting
best practices in patient safety
- Provides training to interested research
coordinators in implementing and
monitoring
patient safety strategies
Patient safety monitoring expert (ISO

or JCI)
- Provides technical advice on hospital
accreditation
Hospital Project - Point persons of the research team - Training on TeamSTEPPS

Coordinator (60) for patient safety strategies
(optional)

- Arranges the necessary logistics for - Training on patient safety
the team visit to the site (eg. meeting monitoring and evaluation
rooms, participants) Participates in the (optional)
- activities of the research team
Receive training on patient safety
-
Science Research - Processes the data to needed graphs NA
Analyst (Statistician) and statistical analysis
Computer Operator - Collates data from the research - Training on the use of
(Encoder) associates statistical software in the
study
-
Converts datasets to the format
conducive for statistical and qualitative
analysis
-
Maintains the database of the study
-
Maintains the internet connection, and

provide troubleshooting services
Fund Manager (Book - Coordinates with the funding agency NA
Keeper) and the UP Manila for fund release
and bookkeeping

(24) Line Item Budget (Proposed Revisions in Blue Font)
PARTICULARS Phase 1 Phase 2
12 months 18 months
I. Personal Services 3,735,662.40 5,923,252.80*
A. Salary 3,379,262.40 5,325,652.80
1) Project Development Officer III 1@ ₱42,831.60/mo. x12 months; 18 months 513,979.20 822,636.80
2) Science Research Specialist II 3@ ₱36,052.80/mo. x12 months; 18 months 1,297,900.80 2,058,372.00
3) Science Research Specialist I 4@ ₱27,908.4/mo. X12 months; 18 months 1,339,603.20 2,092,953.60
4) Project Assistant I 1@ ₱18,981.60/mo. X12 months; 18 months 227,779.20 351,691.20

B. Honoraria 356,400.00 597,600.00
1) Project Leader 1@ ₱8,800/mo. x12 months; 18 months 105,600.00 158,400.00
2) Project Staff (Level 3) 1@ ₱7,500/mo. x12 months; 18 months 90,000.00 135,000.00
3) Training Resource Person (Lecture) 2@ ₱1400/hr. x6 hours 16,800.00 -
4) Training Resource Person (Lecture) 3@ ₱1400/hr. x12 hours - 50,400.00
5) Training Resource Person (Lecture) 3@ ₱1400/hr. x9 hours - 37,800.00

6) Consultants 4@₱3,000.00/consultancy/mo. x12 months; 18 months 144,000.00 216,000.00
II Maintenance and Other Operating Expenses 5,332,716.69 7,126,150.71
A. Traveling Expenses 1,466,460.00 1,938,330.00 **
B. Training Expenses 80,000.00 -
C. Representation Expenses 122,020.00 316,018.00**
D. Communication Expenses 35,000.00 70,000.00
E. Supplies and Materials 162,743.79 80,170.21
F. Printing and Binding Expenses 100,000.00 100,000.00
G. Other Professional Services 2,298,826.00 3,237,233.20 **

H. Capacity Building 369,666.90 183,399.30
I. Research Utilization & Dissemination 698,000.00 1,201,000.00**
Indirect Cost 578,883.32 1,097,766.64

Administrative Overhead Cost 578,883.32 1,097,766.64
Research Grants Administrative Office (50%) -
- UPM REB Review Fees 30,000.00 -

- Internal Operating Expenses 274,441.66 548,883.32
Research Generating Units (50%) - -
- Internal Operating Expenses 274,441.66 548,883.32
III. Capital Outlay 560,000.00 -

Laptop 6@₱60,000/unit 360,000.00 -
Software and programs 200,000.00 -
Total 10,207,262.41 14,147,170.15***
Grand Total 22,419,712.16
*Based on 2018 salary rates

**Includes budget for carry-over activities from Phase (Yr) 1
***As of December 2017, budget for Year 2 was set at PhP 12,212,449.75
The deficit of PhP 1,934,720.40 will be taken from balance of
Phase (Yr) 1 budget
Appendix A: Plans for Data Processing and Analysis: Sample Data Collection
Tool
International Patient Safety Goal #1: Identify patients correctly

JCI Accreditation PhilHealth Hospital Benchbook Hospital #1 Hospital #2 Hospital #3
Standards
Structural Policies and procedures Policies and procedures require
measures support consistent that at least two (2) unique
practice in all situations identifiers are given to every √ (JCI, PHIC) √ (JCI, PHIC)
and locations. patient as they are registered,
admitted or born in the hospital.
Process Patients are identified The unique identifiers may include

measures using two patient a hospital number, the patient's full
identifiers, not including name or the birth date √ (PHIC) √ (PHIC) √ (JCI)
the use of the patient’s
room number or location.

Patients are identified The patient’s unique identifiers are
before administering verified before any treatment,
medications, blood, or procedure or medication is √ (JCI, PHIC) √ (JCI, PHIC)
blood products. administered.
before taking blood and verified before any treatment,
other specimens for procedure or medication is √ (JCI, PHIC)
clinical testing. administered.
before providing verified before any treatment,
treatments and procedure or medication is
procedures. administered.
Outcome Not specified Not specified Not specified Not specified Not specified
measures
Never Events
Reported
Others/remarks
Appendix B: Plans for Data Processing and Analysis (Sample Hospital Profile Survey Sheet)
Profile Hospital #1 Hospital #2 Hospital #3 Hospital #4 Hospital #5

Fiscal management
(Private,
DOHretained, LGU)
Level (1,2, 3)
Bed capacity
Number of staff
Medical
Nursing
Ancillary
Administrative
Presence of Patient
Safety
Officer/Committee
Availability of
Electronic Medical
Record (Y/N)
If yes, specify type or

software
Presence of
Information Manager
(Y/N)
Referral hospital/s

Referring hospital/s
PHIC
Reimbursement
Amount for 2016
Health Facility
Enhancement
Program (HFEP)
recipient (Y/N)
JCI Accreditation
Other
Accreditation/s
Reporting of Never
Events
Reporting of
Nearmisses
Reporting of AHRQ
PSI
Adverse Events
Rate

Appendix C: Table of Never Events

Appendix D: Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators

Appendix E: Plans for Data Processing and Analysis (Sample Hospital Survey on Patient Safety - Adapted from AHRQ form)
For Positively Worded For Negatively Worded Total Number of Percent Positive
Dimensions Items, # of “Strongly Items, # of “Strongly Responses to Items Response to Item
Agree” or “Agree” Disagree” or “Disagree” (Excluding Missing
Responses Responses Responses)
A. Items measuring
overall perceptions of
safety
A1.
A2.
….
B. Items on adverse
event reporting
B1.
B2.
….
C. Items on team work
C1.
C2.
…..

Appendix F: Work Plan Schedule (Proposed Revisions in Blue Font)
Year 1 Year 2 Year 3

Activities 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th
QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR QTR
Administrative and Logistic
preparations (contract signing,
staff recruitment, etc)
Organization and orientation of
research team
Writeshop for development of
data collection tools
(questionnaire, document
review forms)

Recruitment of hospitals and
introductory workshop on
patient safety measurement
Attendance to patient safety
conferences
Enrollment in on-line courses
Data collection (documents
review, key informant
interviews, survey)
Data analysis
Conduct of training courses
Culminating workshop on Best

Practices and Patient Safety
with DOH, PHIC and expert
panel
Presentation of Results to
Stakeholders
Manuscript writing
Research dissemination
Dashboard development
Appendix G: Detailed Work Plan Schedule (Originally Approved last December 2017)

Year 1
Activities Expected Output % Work Output
First Quarter
(January 2018 – March 2018)
• Contract Signing
• Recruitment and Training of Research Staff • Signed MOA 5%
(Capacity Building) • Signed Contract of Service 10%
• Development and validation of data collection tools
• Selection & recruitment of hospitals • Documentation of writeshop and the tools 15%
• List of hospitals and agreements 20%
Financial Report of 1st tranche due on March 15, 2019
Second Quarter
(April 2018 – June 2018)
• Orientation of participating hospitals

• 25% of data collection: Documents review and • Documentation of orientation 30%
hospital survey; survey on patient safety culture • Preliminary data
• Online courses from Institute for Healthcare 50%
Improvement • Course report and certificate
1st Semiannual Report & Financial Report of 2nd

tranche due on June 15, 2018
55%

Third Quarter
(July 2018 – September 2018)
• 75% of data collection: Documents review and

hospital survey; survey on patient safety culture • Preliminary data 70%
(1st visit) • Financial/ Liquidation Report of the 2nd tranche
• Attendance to International Forum on Quality &
Safety in Healthcare (IFQSH), 2nd Patient Safety • Conference reports
Congress
• Conduct of 1st TeamSTEPPS Fundamentals • Course program, documentation, and evaluation
Course • Preliminary results
• Analysis of hospital survey/documents review data
Financial Report of 3rd tranche due on Sept.15, 2018
80%
Fourth Quarter
(October 2018-December 2018)
• 100% of data collection on patient safety culture

• Analysis of patient safety culture data • Preliminary data
• Conduct of feedback sessions and KII (2nd visit) • Preliminary analysis of data
• Conduct of sessions on Quality Improvement 90%
Strategies (2nd visit)
• British Medical Journal (BMJ) Learning Courses
• Session program, documentation, and evaluation
• Course report and certificate

100%
2nd Semiannual Report & audited Financial Report of

Year 1 due on December 15, 2018
Year 2
Activities Expected Output % Work Output

First Quarter
(January 2019 – March 2019)
10%
• Signing of Memorandum of Agreement 15%
• Conduct of feedback sessions and KII (2nd visit) and on • Signed MOA
• Documentation of sessions
Quality Improvement Strategies (2nd visit)
• Hospital survey report
Financial Report of 1st tranche due on March

15, 2019
Second Quarter
(April 2019 – June 2019) • Course program, documentation, and
evaluation
• Conduct of 2nd TeamSTEPPS Fundamentals Course, • Patient safety culture report
• Activity report and documentation
30%
feedback sessions (3rd trip), research dissemination
activities
1st Semiannual Report & Financial Report of
2nd tranche due on June 15, 2019
Third Quarter
(July 2019 – September 2019)
• Conduct of research dissemination activities • Preliminary results of the assessment 50%

• Preparation of journal articles
• Attendance to 4th IFQSH Conference
• Draft of articles
• Conference certificate and report
Financial Report of 3rd tranche due on

September 15, 2019

Fourth Quarter
(October 2019-December 2019)
• British Medical Journal (BMJ) Learning Courses

• Finalization and submission of journal articles • Course report and certificate 70%
• Conduct of research utilization activities and feedback
sessions • Journal articles
• Integration/triangulation of available data
• Activity reports and documentation
• Preliminary data analysis
2nd Semiannual Report & Financial Report

of 4th tranche due on December 15, 2019
Fifth Quarter
(January 2020-March 2020)
• Activity reports, proceedings, and
• Conduct of feedback sessions, research utilization documentation
activities, final consensus workshop 80%
• Presentation of project research output
• Draft of final report
due on March 15, 2020

Sixth Quarter
(April 2020-June 2020)
• Conduct of writeshop for final report writing, research

utilization activities • Terminal report with acceptance from PCHRD 100%
and DOH
• Submission of final report
• Audited Financial Report of Year 2 due on
July 15, 2020
Appendix H: Detailed Work Plan Schedule (Proposed Revisions to UPCM AHEAD Timeline)
Italics: Capacity-building activities
Year 1: 2018 EXPECTED ACCOMPLISHED

st
1 quarter  Development and validation of data collection tools  Development and validation of data collection tools
 Selection & recruitment of hospitals  Selection & recruitment of hospitals
2nd quarter  Orientation of participating hospitals  Orientation of participating hospitals Recruitment

 25% of data collection: Documents review and hospital  of hospitals
survey; survey on patient safety culture

Online courses from Institute for Healthcare
Improvement

3rd quarter  75% of data collection: Documents review and hospital  Orientation of participating hospitals
survey; survey on patient safety culture  Recruitment of hospitals
 Analysis of hospital survey/documents review data  25% of data collection: Documents review and hospital
survey; survey on patient safety culture
Attendance to International Forum on Quality & Safety in 

 Online courses from Institute for Healthcare
Healthcare (IFQSH) Improvement
Attendance to 2nd Patient Safety Congress 
 Attendance to International Forum on Quality & Safety in
Conduct of 1st Team STEPPS Fundamentals Course
 Healthcare
 Conduct of 1st Team STEPPS Fundamentals Course
4th quarter  100% of data collection on patient safety culture  Recruitment of hospitals
 Analysis of patient safety culture data  50% of data collection: Documents review and hospital
 Conduct of key informant interviews (KII) survey, survey on patient safety culture
 Conduct of Feedback Sessions
 Conduct of sessions on Quality Improvement Strategies  Online courses from Institute for Healthcare
 British Medical Journal (BMJ) Learning Courses Improvement
 British Medical Journal (BMJ) Learning Courses

Year 2: ORIGINAL REVISED/ADJUSTED
2019/20
1st quarter  Signing of MOA  Signing of MOA
 Conduct of key informant interviews (KII)  75% of data collection: Documents review and hospital survey,
 Conduct of Feedback Sessions using Plan- survey on patient safety culture
DoStudy-Act (PDSA) cycle
 Conduct of sessions on Quality Improvement Attendance to 2nd Patient Safety Congress


Strategies Online courses from Institute for Healthcare Improvement

Financial Report of 1st tranche due on March 15, 2019

2nd quarter  Conduct of Feedback Sessions using Plan-Do-  100% of data collection: Documents review and hospital
Study-Act (PDSA) cycle survey, survey on patient safety culture
 Research dissemination activities  Conduct of key informant interviews (KII)
 Conduct of Feedback Sessions using Plan-Do-Study-Act
(PDSA) cycle
Conduct of 2nd Team STEPPS Fundamentals  Conduct of 2nd Team STEPPS Fundamentals Course
 Course  Online courses from Institute for Healthcare Improvement
1st Semiannual Report & Financial Report of 2nd tranche due

on June 15, 2019

3rd quarter  Research dissemination activities  Conduct of key informant interviews (KII)
 Preparation of journal articles  Conduct of Feedback Sessions using Plan-Do-Study-Act
(PDSA) cycle
 Research dissemination activities
 Preparation of journal articles
  Online courses from Institute for Healthcare Improvement

Attendance to 4th IFQSH Conference
 Attendance to 4th IFQSH Conference
Financial Report of 3rd tranche due on September 15, 2019
4th quarter  Conduct of Feedback Sessions  Conduct of Feedback Sessions using Plan-Do-Study-Act
 Integration/triangulation of available data (PDSA) cycle
 Finalization and submission of journal articles  Integration/triangulation of available data
 Conduct of research utilization activities  Finalization and submission of journal articles
 Conduct of research utilization activities
 Prepare draft/prototype of initial dashboard
British Medical Journal (BMJ) Learning Courses

2nd Semiannual Report & Financial Report of 4th tranche due
on December 15, 2019

5th quarter  Conduct of Feedback Sessions  Conduct of Feedback Sessions using Plan-Do-Study-Act
 Research utilization activities (PDSA) cycle
 Final consensus workshop  Research utilization activities
 Presentation of project research output  Final consensus workshop
 Presentation of project research output
 Presentation of draft dashboard in the Consensus-building
workshop to be attended by hospital participants, DOH and
PhilHealth as well as an expert panel of patient safety leaders
and advocates from patient groups (1st quarter, 2020)
 Finalize revisions based on Consensus workshop (1st quarter,
2020)
 Pilot testing (1st quarter, 2020)
Draft of final report due on March 15, 2020
6th quarter  Conduct of writeshop for final report writing  Conduct of writeshop for final report writing
 Research utilization activities  Research utilization activities
 Submission of final report  Submission of final report
 Submission of final dashboard to DOH
Audited Financial Report of Year 2 due on July 15, 2020
Appendix I. Detailed Expected Outputs:
6Ps Research Capacity Building Policy Communication/Dissemination

People • Courses/Training Analysis of DOH program data on Documentation/proof of:
[TeamSTEPPS, BMJ patient safety • Skills building on oral and
Learning, Institute for • 10-year analysis of available written communication
Healthcare Improvement (IHI) program data • Professional networking
Open School] participated by • Mapping of such linkage with Google
university researchers and policy/pronouncement related Scholar, ResearchGate, IHI,
research associates and to patient safety program BMJ
selected personnel from RPI
• Research methods and data
usage regarding patient safety
indicators
Publication Three (3) manuscripts – drafts Three (3) manuscripts 1st authored • At least three (3) briefs) • Conference attended per
ready for submission by the university researchers • At least five (5) inputs to policy year: one (1) participant
• At least ten (10) evidence (international); two (2)
summaries using the HRD participants (local)
format • At least two (2) abstracts
• Participation in the NHRFA
Policies • At least three (3) briefs • Two (2) out of 3 briefs authored • Two (2) out of 3 briefs One (1) round table discussion
• At least five (5) inputs to by university researchers authored by university (RTD) conducted in DOH per year
policy • Seven (7) out of 10 evidence researchers
• At least ten (10) evidence summaries authored by • Seven (7) out of 10 evidence
summaries using HRD university summaries authored by
format
researchers/research university
associates researchers/research
associates
• One university researcher will
serve as coordinator/liaison

officer with the DOH unit
counterpart
Partnerships • One (1) international • Participation of RPI to courses At least one (1) input to policy by One (1) RTD co-hosted with the
counterpart (formal • RPI as co-author in case the RPI PNHRS regional consortium
membership to /linkage studies
with a patient safety • At least one (1) personnel from
organization) the RPI serving as hospital
• One (1) Research Partner coordinator
Institution (RPI) outside of
Metro Manila
Products Survey tools Transfer of technology (TOT) to DOH primary user
Key informant interview tools
Guidelines/briefs
Dashboard

LIST OF LEVEL 2 AND LEVEL 3 PUBLIC HOSPITALS
GENERAL
REGION LOCATION NAME LEVEL INCLUDED IN
RANDOM SAMPLE
Ilocos Batac City Mariano Marcos Memorial and Medical Center 3 No
Ilocos Laoag City Gov. Roque B. Ablan Sr. Memorial Hospital 2 Yes
Ilocos Vigan City Ilocos Sur Provinical Hospital Gabriela Silang 2 Yes
Ilocos Candon City City of Candon Hospital 2 Yes
Ilocos La Union La Union Medical Center 2 Yes
Ilocos San Fernando City Ilocos Training and Regional Medical Center 3 No
Ilocos Dagupan City Region I Medical Center 3 Yes
Ilocos San Carlos City Pangasinan Provincial Hospital 2 Yes
Cagayan Valley Tuguegarao City Cagayan Valley Medical Center 3 Yes
Cagayan Valley Santiago City Southern isabela General Hospital 2 Yes
Cagayan Valley Nueva Vizcaya Veterans Regional Hospital 2 Yes
Central Luzon Balanga City Bataan Provincial Hospital 2 Yes
Central Luzon Malolos City Bulacan Medical Center 3 Yes
Central Luzon Cabanatuan City Dr. Paulino J. Garcia Memoria; Research & Medical Center 3 Yes
Central Luzon San Fernando City Jose B. Lingad Memorial Regonal Hospital 3 Yes
Central Luzon Tarlac City Tarlac Provincial Hospital 3 No
Central Luzon Zambales Pres. Ramon Magsaysay Memorial Hospital 2 Yes
Central Luzon Olongapo City James L. Gordon Memorial Hospital 3 Yes
Southern Tagalog Batangas City Batangas Medical Center 3 No
Southern Tagalog Dasmarinas City Pagamutan ng Dasmarinas 2 Yes
Southern Tagalog Trece Martires City General Emilio Aguinaldo Memorial Hospital 3 No
Southern Tagalog Sta. Cruz, Laguna Laguna Medical Center 2 No

2 No
Southern Tagalog San Pablo City Laguna Provincial Hospital-San Pablo City District Hospital 2 No Appendix J: List of Level 2 and
Level 3 Public Hospitals in the
Philippines

2 No

2 No
Southern Tagalog Quezon-Lucena City Quezon Medical Center

Bicol Legazpi City Bicol Regional Training and Teaching Hospital 3 Yes
Bicol Camarines Norte Camarines Norte Provincial Hospital 2 No
Bicol Naga City Bicol Medical Center 3 Yes
Bicol Catanduanes Eastern Bicol Medical Center 2 No
Bicol Masbate Masbate Provinical Hospital 2 No
Bicol Sorsogon City Dr. Fernando B. Duran, Sr. Memorial Hospital 2 Yes
Western Visayas Antique Angel Salazar Memorial General Hospital 2 No
Western Visayas Roxas City Roxas Memorial Provincial Hospital 2 Yes
Western Visayas Iloilo City Western Visayas Medical Center 3 Yes
Western Visayas Iloilo City West Visayas State University Medical Center 3 No
Western Visayas Bacolod City Corazon Locsin Montelibano Memorial Regional Hospital 3 Yes
Central Visayas Tagbilaran City Gov. Celestino Gallares Memo. Hospital 3 No
Central Visayas Cebu City Vicente Sotto Memorial Medical Center 3 No
Central Visayas Dumaguete City Negros Oriental Provincial Hospital 2 Yes
Eastern Visayas Borongan, Samar Eastern Samar Provinical Hospital 2 Yes
Eastern Visayas Tacloban City Eastern Visayas Regional Memorial Center 3 Yes
Eastern Visayas Maasin City Salvacion Oppus Yniguez Mem Provincial Hosp 2 No
Zamboanga Peninsula Pagadian City Zamboanga del Sur Medical Center 2 No
Zamboanga Peninsula Zamboanga City Zamboanga City Medical Center 3 Yes
Northern Mindanao Bukidnon Bukidnon Provincial Hospital-Maramag 2 No
Northern Mindanao Malaybalay City Bukdnon Provinical Medical Center-Malaybalay City 2 Yes
Northern Mindanao Oroquieta City Misamis Occidental Provincial Hospital 2 No
Northern Mindanao Ozamis City Mayor Hilarion A. Ramiro, Sr. Regional Training and Teaching 2 Yes
Northern Mindanao Cagayan de Oro Northern Mindanao Medical Center 3 Yes
Northern Mindanao Marawi City Amai Pakpak Medical Center 2 No

2 No
Northern Mindanao Iligan City Gregorio T. Lluch Memorial Hospital 2 Yes

Southern Mindanao Tagum City Davao Regional Medical Center 3 Yes

2 No

2 No
Southern Mindanao Mati City Davao Oriental Provincial Hospital

Southern Mindanao Digos City Davao del Sur Provincial Hospital 2 No
Southern Mindanao Davao City Southern Philippines Medical Center 3 No
Central Mindanao Cotabato City Cotabato Regional and Medical Center 3 No
Central Mindanao Koronadal City South Cotabato Provincial Hospital 3 No
NCR Manila Ospital ng Maynila Medical Center 3 No
NCR Manila Jose R. Reyes Memorial Medical Center 3 Yes
NCR Manila Tondo Medical Center 3 Yes
NCR Manila Sta. Ana Hospital 2 Yes
NCR Caloocan Dr. Jose N. Rodriguez Memorial Hospital 2 No
NCR Quezon City AFP Medical center 3 Yes
NCR Quezon City PNP General Hospital 2 Yes
NCR Quezon City Quezon City General Hospital 3 Yes
NCR Quezon City East Avenue Medical Center 3 Yes
NCR Quezon City Veterans Memorial Medical Center 3 No
NCR Quezon City Quirino Memorial Medical Center 3 Yes
NCR Las Pinas City Las Pinas General Hospital & Satellite Trauma Center 2 Yes
NCR Makati City Ospital ng Makati 3 Yes
NCR Mandaluyong City Mandaluyong City Medical Center 2 No
NCR Marikina City Amang Rodriguez Medical Center 3 Yes
Yes
NCR Muntinlupa City Ospital ng Muntinlupa 2
NCR Pasay City Air Force General Hospital 2 No
NCR Pasay City Pasay City General Hospital 3 Yes
NCR Pasig City Pasig City General Hospital 3 No
NCR Pasig City Rizal Medical Center 3 No
NCR Valenzuela City Valenzuela Medical Center 3 Yes

2 No
CAR La Trinidad Benguet General Hospital 2 No

CAR Buguio City Baguio General Hospital and Medical Center 3 Yes

2 No

2 No
CAR Bauko, Mt. Province Luis Hora Memorial Regional Hospital

ARMM Maguindanao Maguidanao Provincial Hospital 2 No
Caraga Butuan City Butuan Medical center 2 Yes
Caraga Agusan del Sur D.O. Plaza Memorial Hospital 2 Yes
Caraga Surigao City Caraga Regional Hospital 2 Yes
SPECIALTY
NCR Manila Dr. Jose Fabella Memorial Hospital 3 Yes
NCR Manila San Lazaro Hospital 3 Yes
NCR Quezon City Philippine Orthopedic Center 3 No
NCR Quezon City National Children's Hospital 3 No
NCR Quezon City National Kidney and Transplant Institute 3 No
NCR Quezon City Philippine Heart Center 3 Yes
NCR Quezon City Lung Center of the Philippines 3 No
NCR Quezon City Philippine Children's Medical Center 3 Yes
NCR Mandaluyong City National Center for Mental Health 3 No
NCR Muntinlupa City Research Institute for Tropical Medicine 3 No
NCR Pasig City Pasig City Children's Hospital Child's Hope 2 No

2 No

Appendix K: Diagrammatic Work Flow (Legend - Blue: study proper; Black: activities internal to team and AHEAD)
Finalization of Research Protocol Create Final Report, Manuscript/s

including Ethics Approval for Publication , Briefers and
Infographics
Recruitment of Research Team

including technical consultants for Presentation of Results to
Qualitative and Quantitative teams Stakeholders
Orientation Workshop for Research

Team, Participating Hospitals and
Culminating Workshop with Expert
representatives from DOH and
DOH AHEAD Program Panel for Consensus -building
PHIC
Managers
Writeshop to develop Data Regular Quarterly Feedback Sessions with

Collection Tools Feedback Participating Hospitals
Reports
Data Collection Proper:

Hospital survey and documents review (all hospitals)
Survey on Patient Safety Culture (all hospitals)
Key informant interviews (select hospitals based on initial survey and documents review)
Data Processing and Analysis


UPCM AHEAD Proposal v4 - Revised Nov 8 2018

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UPCM AHEAD Proposal v4 - Revised Nov 8 2018

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VISION

To make Ospital ng Makati

QUALITY POLICY STATEMENT

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DETAILED RESEARCH PROPOSAL

Title of the Study: Assessment of Performance Measures and Indicators of Patient

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Significance of the proposal 6

Literature review and Conceptual Framework 7

Expected output(s) 11 (62)

Plans for data processing and analysis 22

Work plan schedule 24 (54)

Estimated budgetary requirements 28

Endorsement from agency head (UP Manila) 28

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Duties and Responsibilities 43

Line Item Budget 46

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Research Area: Health Metrics (Setting Standards and Ensuring Accountability)

(5) Project leader: Dr. Agnes D. Mejia, Dean, UP College of Medicine

(6) Implementing agency: University of the Philippines-Manila College of Medicine

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2. Recommend a dashboard of reliable, valid, standardized and patient-centered

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(11) Expected Outputs (see details under Appendix I)

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LIMITATIONS OF THE STUDY

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(12) End-users/Target Beneficiaries

(13) Project Duration

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Composition of Project Team

Total Number of Levels 2 and 3 Hospitals:

6 IPSGs x 3 dimensions (structural, process, outcome) x

Comment [MOU1]: The spec ialty hospitals should go under

Sampling Frame for Hospitals Included

Computation of the number of respondents is as follows:

N = P(1-P) Z!/2)2 = (0.50) (0.5) (1.96)2 = 384

Recruitment of study hospitals and participants will be initiated in the orientation

Summary of Data Collection Methods (Quantitative)

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Literature search Research Team PhilHealth Benchbook for Identify relevant

Other relevant internationally

Data Analysis: Initial listing of all