Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

January 10, 2023

DEPARTMENT MEMORANDUM
No. 2023-_DO0I0

FOR : ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES OF

THE FIELD IMPLEMENTATION AND COORDINATION TEAMS:
DIRECTORS OF CENTERS FOR HEALTH DEVELOPMENT:
HIEF F MEDICAL ENTER: HOSPITALS, AND
SANITARIA, AND OTHERS CONCERNED

SUBJECT : Implementation of the 2022 Hospital Scorecard Rating Scale

The Hospital Scorecard is a performance and reporting tool that is used to measure and
track the performance of all Department of Health (DOH) hospitals, consistent with the
commitment and goals of the DOH’s strategic thrust to achieve Universal Health Care, the
FOURmula One (F1 Plus) for Health.

Since the implementation of Hospital Scorecard in 2019, its Rating Scale is crafted
annually based on the progressive targets set for each indicator per year. To assess the
implementation of the Hospital Scorecard this year, the finalization and review of the 2022
Hospital Scorecard Rating Scale was done by the Technical Working Group (TWG) on Hospital
Matters and representatives from the DOH Central Offices, namely, the Field Implementation and
Coordination Teams (FICT), the Performance Monitoring and Strategy Management Division
(PMSMD)
of the Health Policy Development and Planning Bureau, and the Health Facility
Development Bureau (HFDB).

Attached herewith as Annex A is the approved 2022 Hospital Scorecard Rating Scale for
your reference. The hospital scorecard indicators serve as the core functions of the hospital’s
Office Performance Commitment Review report. Kindly note that the analysis of indicators will
be disaggregated according to hospital levels. Efficiency, quality and timeliness dimensions have
been incorporated into each Scorecard indicator. Thus, the core function indicators will be rated
as one domain.

For your information and guidance.

By Authority of the Seeretary of Health:

LA
LILIBETH C. DAVID, MD, MPH, MPM, CESO I
Undersecretary of Health
Health Policy and Infrastructure Development Team

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila @ Trunk Line 651-7800 local 1108, 1111, £112, 1113
Direct Line: 8711-9502; 8711-9503 Fax: 8743-1829 @ URL: https://www.doh,gov.ph; email: dohosec@).doh.zov.ph
Annex’A:,

2022 Hospital Scorecard Rating Scale

Target Rating Scale

Indicator Formula/ Operational Definition Range of. the Actual
2022 Score
Accomplishment

100% 0,
5
Numerator: Number of patients in basic
accommodation with zero co-payment
Indicator 1. Denominator: Total number of patients in 95.00% - 99.99% 4

IPC
basic accommodation

_for
% patients in basic
100%
accommodation with
: .

zero co-payment . .
90.00% - 94.99% 3
*Basic accommodation refers to ward
accommodation. This indicator measures how
many patients in basic/ward accommodation are
with zero co-payment or No-Balance Billing. 89.99% and below 2

5
Numerator: Number of PhilHealth claims

personne]
returned to hospital
Level 1 Will not be 4
and 2: included in the
Denominator: Total number of PhilHealth
. 2022 Hospital
claims processed and returned to hospital +
:

3
<6% Scorecard
2.
;
claims processed and paid by PhilHealth
: :

Indicator
2
% of Returned-to *% of RTH claims isthe percentage of PhilHealth
claims which were returned to the hospital due to
Hospital of the
some deficiency with certain requirements, 5
PhilHealth claims
among all
the PhilHealth claims processed.
Will not be
3: 4
in
Level .
EXCLUSION: included the
1. Auto-rejected claims (which the hospital °
2022 Hospital
will identify and provide documentation) <2% 3
Scorecard
2. All COVID-19 laboratory procedures
claims 2

Numerator: Number of ER Patients with <4 100% 5

hours Turnaround Time
Denominator: Total number of patients who
were received in the ER
Indicator 3. 95.00% - 99.99% 4

4%
of ER Patients with <
, .
*ER TAT
is defined as the time interval from the
time the patient is received in the ER up to the
100%
4 hours Turnaround time the patient is released (admitted
Time /discharged), minus the time spent by the medical 90.00% - 94.99% 3

_donning/doffing/other
rocedures when to the
attending patient.
The decision to admit/discharge may not reflect
the actual transfer of the patients from the ER to
wards/rooms. DOA is excluded
but ER deaths are included.
in
this indicator, 89.99% and below 2
as
95.00% - 100%

Numerator: Number of patients with <4

hours Discharge Process Turnaround Time
Indicator 4. Denominator: Total number of patients 90.25% - 94.99%
% of patients with<4 ‘discharged
:
°
95%
hours Discharge Process
*Disch
ischarge P Process TAT is defined as the titime
is

defined
Turnaround Time
the

interval between discharge order of the doctor 85.50% - 90.24%

and the actual discharge of the patient. Deaths are
not included in this indicator

85.49% and below

Numerator: Total number of inpatients who

had infection after 48 hours upon admission
Denominator: . Total number of discharges
. : 0% - 0.99%
Indicator 5. and deaths occurring after 48 hours upon
.
admission during the same year
<1%
/

Hospital Acquired
Infection Rate (%)
*Based on General Appropriations Act 2021
DOH Commitment with a target of <I% for
Hospital Acquired Infection Rate. Including all 1.00% and above
types of HAI (Device- VAP, CLABSI, CAUTI;
and Non-device-SSI)

Numerator: No. of inpatient laboratory test 95.00% - 100%

results with < 5 hours Turnaround Time
Denominator: Total number of
inpatient
laboratory tests
.
Indicator 6. 90.25% - 94.99%
j : *Laboratory test results TAT is defined as the
%
%
inpatient
of of
time interval between the doctor’s order request
laboratory test result in the chart and the release of results.
°
95%
with < 5 hours Inclusion: Scope of lab tests- routine clinical and
85.50% - 90.24%
Turnaround Time hematologic lab tests only (CBC, Platelet Count,
aPTT, FBS, Na, K, Creatinine, UA, BUN, Total
Cholesterol, HDL, LDL, Triglyceride, SGOT,
SGPT, Urinalysis)
Exclusion: Histopathologic and microbiological
85.49% and below
°,

test requests, other lab tests which require fasting

ISO 2015
accreditation
+ PGS (Stage 2 or
.
Indicator 7. PGs
any stages above)
seas aoa: and/or other
Accreditation to ISO, Accreditation of the hospital to ISO, PGS, or :
:

Complian international
PGS or international
ses
any international accreditation body ce Stage «att
accreditation
accrediting body (Stage 2)

ISO 2015
accreditation + PGS
Stage 1
 ISO 2015
accreditation +
Attended the PGS
module/bootcamp
but not yet initiated

ISO 2015
accreditation only
(No PGS accreditation)

Or

PGS accreditation
(Stage 1 or any
stage) only
(No ISO 2015
accreditation)

Attended the PGS

module/bootcamp
but not yet
initiated only
(No ISO 2015
accreditation)

No ISO 2015
accreditation + No
PGS accreditation

The overall score in the Report Card Survey

which reflects results in terms of two core Will not be
Indicator 8. areas: included in the
95%°
Report Card Survey : vos 2022 Hospital
(1) Compliance with ARTA Provisions and
:

(RCS) Scores Scorecay d

(2) Overall Client Satisfaction.

4 or more
researches

3 researches
Total number of clinical or operational
improvement research output which are: Level 1
and 2: .

1. Funded by the
hospital, or; 2 researches
2. Presented to a _local/international 4
Indicator 9.
Research output
consortium and conference (including
hospital and intradepartmental consortia) I research

*Must satisfy at least 1 of the given criteria for No research

the research to be counted.
**Published case study/series (unique or rare
case) are counted as researches. 9 or more
Level 3: researches

9
7-8 researches
 5-6 researches 3

3-4 researches 2

0-2 researches 1

Submitted by:

MA. THERESA
Director IV
&. YERA, MD, MSc, MHA, CESO
III
Health Facility Development Bureau

Concurred by:

ENRIQUE

North Luzon
pf
Undersecretary of Heal
PHSAE, FPSMID, CESO

Field Implementation and Coordination Team (FICT)-

III NESTOR
F. SANTIAGO, JR., MD, MPHC, MHSA, CESO II
Undersecretary of Health
Field Implementation and Coordination Team (FICT)-
NCR
and South Luzon

CAMILO
Undersecretary ofHealth
SCOLAN, MPM, CESE ABDULLAH B. D
Undersecretary of Healt
, JR., MD, MPA, CESO I

Field Implementation and Coordination Team (FICT)- Field Implementation an¥ Yoordination Team (FICT)-
Visayas Mindanao

Approved by:

UA J
LILIBETH C. DAVID, MD, MPH, MPM, CESO I
Undersecretary of Health
Health Policy and Infrastructure Devetopment Team