Republic of the Philippines

Department ofHealth
OFFICE OF THE SECRETARY

January 14, 2020

DEPARTMENT MEMORANDUM
No. 2020- 0013

FOR: MEDICAL CENTER CHIEFS, CHIEFS OF HOSPITALS,

AND ALL OTHER DOH UNITS CONCERNED

SUBJECT: Online Completion and Submission of Hospital Reports as

Basis for 2021 Maintenance and Other Operating Expenses
(MOOE) £

The Health Facility Development Bureau (HFDB) of the Department of Health (DOH) assumes
technical leadership on health facility development. The HFDB is mandated to develop plans,
policies, programs, projects, standards and strategies and to provide coordination, technical
assistance, capability building, consultations and advisory services related to health facility
development, planning, operation and maintenance.

In view of the aforementioned, the HFDB Hospital Database shall be regularly updated for
continuous improvement in the provision of technical assistance for health facility
development. The updated database shall also serve as basis for 2021 Maintenance and Other
Operating Expenses (MOOE).

In this regard, all DOH hospitals are requested to complete and submit the online hospital
reports and required attachments on or before February 28, 2020 through this link:
http-//bit.do/BHPIHOMPSAT. Attached
reference (Annex A).
is
the printed version of the required reports for your

For queries and clarifications, you may contact Mr. Roderick.M. Napulan, Division Chief, or
Mr. Andy Geo A. Reyes, Science Research Analyst, of HFDB
email at doh. hfdb.rpmd@gmail.com.
at
(02) 651-7800 local 1406 or

For strict compliance.

By Authority of the Secretary of Health:

LILIBETH C. DAVID, MD, MPH, MPM, CESO I

Undersecretary of Health
Health Facilities and Infrastructure Development Team

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1113, 1108, 1135
Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http:/Awww.dch.gov.ph; e-mail: fiduque@doh.gov.ph
Instructions: Please complete the required information below using hospital data as of Dec. 31, 2019 ANNEX A
I. GENERAL INFORMATION
Authorized Bed Capacity
Region
(ABC)
-
By law
Authorized Bed Capacity
Address
(ABC) - Based on licensing
Implementing Bed Capacity
Name of Hospital (IBC) - Actual Capacity

Hospital Level

Email Address Contact No.

Il. HOSPITAL OPERATIONS

Total Number of Inpatients Total Number of Deliveries
Total Number of
Senior Citizens
Normal Spontaneous
admitted (60 years old and above)
Total Number of Inpatient Bed Days Low Risk

High Risk

Total Number of Outpatient Visits C-Section

New Patient Other

Re-visit Average Length of Stay (ALOS)

Bed Occupancy Rate %
Medicine
(BOR)

Surgery
Total number ofreferral/s OB
from other Hospitals
Total number ofreferral/s
Pediatric
to other Hospitals:

Ill. Deaths
Total Number of Deaths
Total Number of Neonatal Deaths

Total Number of Maternal Deaths

Gross Death Rate (%)

Net Death Rate (%)

Prepared by: Vetted and approved by:

Additional Requirements:
1. License to operate as of Dec. 31, 2019.
2. CHD validated IHOMP Tool (validated by CHD Health Facility Development Unit (HFDU), assessed and conducted within Jun. 2019-Feb. 2020)
 Republic of the Philippine
DEPARTMENT OF
HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool
Standards Required
be in place
to Data Source Points of Emphasis Data Gathered Remarks
I.Clinical Governance
Governance (20) _

|
and 4 points
Leadership: Do you Director’s/COH © Hospital Order
conduct Office e Minutes of Yes No
e Execom Meeting) (1) Meeting on File
e ManCom Meeting (1)- Yes No
e Financial Management
e Attendance on
File
e How often?
Com Meeting (1)
e Gen Assembly (1) Yes No

Yes No
2 points
Is your Organogram Actual e Includes Key
displayed in a validation Officials (1) Yes No
conspicuous place e Pictures and names Yes No
and contact details
(1)
-
2 points
Is your hospital’s Actual Posted in a
Performance/Quality validation conspicuous place Yes No
Indicators Posted for
Public Information?
3 points
How
is
DOH Manual
compliance
of
to Management Policy on
monitoring Describe
Standards per service standards
area monitored? Monitoring results
Presence of
Policy
Manual per service area
Manuals
accessible per
5 points
©

Management
service area Yes No
Do you have an Management Covered by a 4 points
oversight of contracts? policy Yes No
How
is
it being done?
idpatient
Describe
i
1 point
Do you have policies Hospital Policies that Yes No
covering the beliefs and Institutional prevent Describe
culture of your patients? Manual of discrimination
Policies

HFDB Form 15 — Integrated Hospital Operations and Management Program (IHOMP) Self — Assessment Tool
Revision 1
July 19 2018

Page Lof9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any meansof reproduction of this tool, kindly seek approval of the HFDB prior use.
3
Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool

ate bein place Data Source Points of Emphasis Cathee d Remarks

points
Actual validation e Patients’ Rights
Posted in Yes No
conspicuous places
Actual validation (1)
e Anti-Deposit IRR Yes No
Actual validation posted in ER (1)
e Availability of
costs of medicines, Yes No
supplies and
procedures (1)
What are your CMPS © Policies 1 point
programs and
services that e Specific programs Describe
encourage patient and services
participation? implemented

3 points
Do you implement CMPS e Is the Psychosocial
holistic approach to information Yes No
patient care? available in the
chart? (1)
.

Yes No
e Do you conduct
Multidisciplinary
case management
conferences? (1) Actual Data

e Rate of Therapeutic
Dietary Counselling

1 point
Discharge Planning CMPS/Clinical e Rate of complete
Management/HIM discharge planning Actual Data
provided (Doctor,
Nurse, Dietician,
Social Worker) (1)

Page 2 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
1
Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool
Standards Required Data
Data Source Points of Emphasis Remarks
to be in place Gathered
point
Do you have a system QMS Management e Turnaround time
of responding to for resolving Actual Data
complaints? patients’
complaints (1)
point
Continuity of Care Nursing Manager e Rate of handovers
correctly done (1) Actual Data
e No. ofInteragency point
HIM referral to higher
and lower facilities Actual Data
()
e No. of referrals point
HIM accepted by the
hospital from Actual Data
lower or higher
facilities (1)
Accessibility and 2 points
Equity MSW e Policy on
Identifying Yes No
indigent patients
(1)
MSW/HIM « % of indigent Actual Data
patients w/
Philhealth and w/o
Philhealth (1/2)
MSW/HIM e % of indigent Actual Data
patient provided
with specialized
care (1/2)
Empathy HIM/QMS e Turnover time for 3 points
patient’s
registration and Actual Data
admission process
(1)
Actual Data
|

HIM/QMS e Waiting time for

consultation (1)
Institutional Policy e Presence of policy
on understanding
and satisfying Yes No
special request of Describe
patients and family
ie)
Page 3 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
 Republic of the Philippine
DEPARTMENT HEALTH OF
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool

to bein place Data Source Points of Emphasis Cathane

d
Remarks

Privacy and 2 points

confidentiality e Names of patients Yes No
Privacy Officer are not displayed
for public
information (1/2) Yes No
e Patient records are Describe
protected (1/2)
Actual validation ¢ Confidentiality is Yes No
observed in
clinical How?
areas and
administrative
areas where
patient’s
information is
taken (1)

2 points
Do you implement QMS Team e Documented Yes No
quality improvement Initiatives (1)
initiatives? e % of staff involve Actual Data
in the Quality
improvement
initiative of the
hospital (1)
Utilization/workload 2 points
Are the following Management/HIM measures Yes No
indicators monitored e No. of inpatients Actual Data
and analysed? (1/2) Actual Data
e No. of outpatients
Actual Data
(1/2)
e No. of procedures
(1/2) (surgical etc) Actual Data
e No. of diagnostic
tests(1/2)
Efficiency measures 2 points
Management/HIM je
Average length of Yes No
stay (1/2)
¢ Bed occupancy Provide
rate (1/2) actual data
e Day case rate (1/2)
_

e Operating theater
utilization (1/2)
Page 4 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
2
Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool
a
iatobein plece Data Source. Points of Emphasis Cathe d Remarks
QMS/HIM Quality/outcome 5 points
measures
e Unplanned Yes No
readmission
rates<xx days Provide
e Infections (e.g. actual Data
MRSA and
Clostridium
Difficile)
e Patient falls
e Unplanned returns
to operating theater
e Needle-stick
injuries
e Pressure sores
e Complications rate
e Caesarean rate
e Deaths
e Sentinel Events

Patient and Family 1 point

Experience QMS/management e Patient complaints Yes No
e Patient satisfaction Actual Data
e Commendation
1 point
System of
monitoring, Description
frequency :

Management How
are these data
analysed and utilized
2 points
Describe
for decision making?

Presence of a Patient Safety Policy 2 point

Committee Committee Head Yes No

Do you conduct 5 points

CMPS clinical Audit? (1) Yes No
Documentation? (2) Describe
Infection Prevention Overall hand hygiene points
and Control compliance Actual Data
Coordinator
Page 5 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
2
Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool

ato bein place Data Source Points of Emphasis Gathune

d
Remarks
What data are you 5 points
Infection collecting to reduce Describe
Prevention and risks to patient?
Control - ADR
Coordinator - Medication
Error
- Others (please
specify)
Quality 4 points
Nursing and HIM Documentation? Yes No
(i.e FDAR) Describe
e Are meals served points
Actual validation on time, at proper Yes No
temperature, Describe
attractive and
acceptable?
Actual validation ¢ Food is protected
from contamination
and spoilage

a
Do you have risk
Management Plan? QMS Unit
ocumentation
available (1)
1
Yes
point
No
Health Emergency 1 point
and Disaster Disaster management Yes No
Management Unit/ Plan is available (1)
Emergency Dept.
Nutrition and Presence of Health 1 point
Dietetics Emergency Feeding Yes No
Department Plan (1)
1 point

Institutional Policy
Do you have
on how to address
a
policy
Yes No
patient or visitor who Describe
became violent? (1)

Do you have a Institutional 1 point

Preventive Policy/Engineering Policy available (1) Yes No
Maintenance and Facilities
program? Management
Institutional 2 points
Policy/Engineering Is there a system of Yes No
and Facilities reporting equipment Describe
Management failure (2)

Page 6 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
 Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool

Standards Required Data

Data Source Points
:
of Emphasis
‘
Remarks
to be in place Gathered
Healthy Environment 3 points
e Cleanliness of the Yes No
Actual validation environment
(inside and outside
hospital premises)
(1)

Actual validation e comfortable Yes No

seating
arrangement in the
waiting area
provided (1)

Actual validation e wheelchairs and Yes No

elevators provided
as necessary (1)

Do you conduct 1 point

budget utilization
review?
Management/CMPS | Documentation
available (1)
is Yes No

Do you conduct 1 point

performance review Documentation is Yes No
Management/ available (1)
,

Hospital wide Planning office

Service level
Department/ division
Level
Section/ Unit level

Finance Service 3 points

Are the following e Charging System Yes No
Financial System in Yes No
|

e Billing System
place: e Costing and Rate Yes No
Charging System setting
Billing System Procedures
Costing and Rate
setting Procedures

Page 7 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
 Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool

Stato bein place Data Source Points of Emphasis Cathene

d
Remarks
Financial Finance Service 1 point
Performance and e Cost per patient Actual Data
condition per day (1/2)
e Cost of
pharmaceutical in Actual Data
relation to the
total MOOE (1/2)
1 point
Availability of Pharmacy e % of filled Actual Data
Medicines? Department prescription (1/2)
e % of unfilled
prescription (1/2)

e Emergency cart 1 point

Emergency have complete Yes No
Department medicine (1/2)
Nutrition and e Compliance to 1 point
Dietetics the Php Yes No
Department 150/patient/day
meal allowance
q)
Finance Service e % of income 1 point
Income from Phil Health Yes No
(1)
2points
Wastage Nutrition and e Total amount of Actual Data
Dietetics wastage from
Department medicines, food,
reagents (1/2)
Pharmacy, © Do you havea Yes No
Laboratory and system of
Radiology, ND reducing
pilferage? (1/2)
e Do you practice Yes No
unit dosing? (1/2)
e Is inventory
management in Yes No
place? (1/2)
e Ratio of 1 point
Computer hardware IHOMU computers to Actual Data
admin support
staff (1)

Page 8 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
 Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool
Standards Required Data
Data Source Points
‘
of Emphasis‘ Remarks
to be in place Gathered
Personnel Section e Rate of Turnover 2 points
Compliance to health of nurses (1/2)
human resource e Doctors(1/2) Actual Data
standards e % of unfilled
positions (1)

Other significant concerns for technical assistance:

Name of
Address:
Hospital:

Contact No. +639-

Email Address

Please submit the accomplished tool together with the following documentary evidences:
1. Institutional Manual
2. Hospital Statistical Report for the last three years
3. Other reports and documents supporting data gathered.

Page 9 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
Any meansof reproduction of this tool, kindly seek approval of the HFDB prior use.