QUALITY MANUAL

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HISTORY AND Effectivity Date: January 1, 2021

HOSPITAL BACKGROUND
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The NATIONAL CHILDREN’S HOSPITAL started as an Indigent Children’s Clinic on

February 11, 1945 by the Emergency Civilian Administration (ECA) which primarily took
care of war refugees particularly the sick and the undernourished children. The clinic was
located in the defunct Bureau of Public Welfare at San Rafael Street, Manila.

By virtue of Commonwealth Act No. 705 dated October 1945, the Indigent Children’s Clinic
attained its hospital status as the Indigent Children’s Hospital and was transferred to a two-
storey house at 715 Gastambide Street, Sampaloc, Manila in 1947. In the same year,
President Elpidio Quirino issued Presidential Proclamation No.439 assigning the Mori
Bicycle Compound at España Extension in Quezon City to be the future site of the Indigent
Children’s Hospital.

In 1952, Republic Act No. 731 changed the name of Indigent Children’s Hospital to National
Indigent Children’s Hospital. Subsequently, Republic Act No. 1340, dated June 16, 1955
amended Republic Act No. 731 changing the name of National Indigent Children’s Hospital
to its present name – the NATIONAL CHILDREN’S HOSPITAL.

July 28, 1955 shined out as a memorable day for the National Children’s Hospital for it was
on that day that the cornerstone of the new building was laid. The new 2 story hospital
building was inaugurated on April 26, 1958. In 1977, as an expansion of the facilities, a 3rd
floor was added to the building. Also on this year, subspecialty care units were established
including the Intensive Care Unit, Neonatology Unit and a Surgical Unit. The Pediatric
Residency Training Program was started and accredited by the Philippine Pediatric Society
as Phase I and II in 1981.

In 2005, Total Quality Management (TQM) Program was organized and launched. This
became a priority program for the hospital. Quality Circle Teams were created in all services
and departments. Weekly TQM meetings were conducted to review, write and standardize
hospital processes. This empowered all hospital workers to evaluate and improve on their
own work processes to attain the National Children’s Hospital Vision of becoming a Center
of Excellence.

On July 10, 2010 this was affirmed when the National Children’s Hospital became the first
government hospital to achieve the highest accreditation given by PHILHEALTH which was
a “CENTER OF EXCELLENCE”. The hospital accreditation as Center of Excellence was
valid up to April 30, 2013.
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HOSPITAL BACKGROUND

Hospital programs were created, institutionalized and strengthened such as the 5S Program,
the Patient Safety Program, 100% Smoke Free Environment Program, Disaster Risk
Management Program, Kangaroo Mother Care, Newborn Screening Program, Breast Feeding
Program, Tuberculosis Control Program (TB-DOTS), Animal Bite Center and the Violence
Against Women and Children Program.

As a testimony to the efficient implementation of various hospital programs, the 100%

Smoke Free Environment Program received several awards from the Department of Health
such as the PINK ORCHID AWARD (2011), the RED ORCHID AWARD for 2012 and
2013 and the highest award, the RED ORCHID HALL OF FAME AWARD in 2014 for
sustaining the highest award (RED ORCHID) for 3 successive years.

The 5S implementation garnered for the hospital recognition as a GOLD AWARDEE for
OSPITAL NG BAYAN: Malinis, Mabango in 2011 by the Department of Health.

The Disaster Risk Management Program received the GAWAD KALASAG, 2nd Place for
Best Medical Institution advocating disaster risk management (National Government
Hospital Category) given by the Office of Civil Defense on December 12, 2012.The same
award was again given to NCH for the year 2013 and 2014. In 2015 and 2016, the hospital
was given the 1st place as Best Specialty Hospital in the Search for Excellence in Disaster
Risk Reduction Management and Humanitarian Assistance.

The hospital Patient Safety Program was created to ensure safety of patients in the
environment of care. The Patient Safety Manual was approved on January 11, 2012 and a
hospital wide orientation was conducted in the succeeding month. Full implementation of the
Patient Safety Program was started in May, 2012. To measure effectiveness of the program a
2nd Safety Climate Survey was conducted on August 13-17, 2012. The second survey showed
a safety climate measure of 74% (+21.8% increase compared to the baseline of 52.5% in
2010). The Safety Climate Measure for 2015 is at 76.77% (increase of 2.5%). The Hospital
Safety Climate for 2019 is at 3.57 (61-80%).
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HISTORY
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Since the institution was formally inaugurated on April 26, 1958 during the incumbency of
Dr. Peregrino H. Paulino , the Department of Pediatrics started accepting resident physicians.
As mandated by the Department of Health, teaching and training activities were included in
its functions in addition to provision of health care services to pediatric patients. Through the
years, affiliations were forged with universities and institutions with students in health
sciences, pediatric residents and fellows in training who need pediatric clinical exposures.
These institutions include FEU (Far Eastern University), UERMMMC (University of the
East Ramon Magsaysay Memorial Medical Center), OLFU (Our Lady of Fatima University),
UST ( University of Santo Tomas), SLMC (St. Luke’s Medical Center), Fe Del Mundo
Medical Center, Mary Chiles General Hospital, Las Pinas Doctor’s Hospital and Perpetual
Help Rizal Medical Center .

As early as 1960, prominent paediatricians and pillars of the Philippine Pediatric Society,
(PPS) like Dr. Simona Alikpala, a General Pediatrician-Neonatologist, Dr. Eustacia Rigor, a
Pediatric Hematologist and Dr. Luis Mabilangan, Pediatric Cardiologist, became members of
the hospital medical staff, initially as volunteers and then as regular part-time medical
specialists. These three well-known past presidents of the PPS worked together to develop
standardized instructions for the resident staff of the institution and eventually established
affiliation with the PPS.

On January 27, 1977 Dr. Crisanta de Joya Agregado, designated Dr.Susana Elena Baltazar
as Chairman of the Department of Pediatrics. She was succeded by Dr. Aurora Meneses, a
pediatric cardiologist and fellow of the PPS in 1979. During this time an intensive effort to
restructure and upgrade the department particularly its residency training program was
made. Since the department head was a cardiologist, competency for Cardiology rotators
was formulated and implemented. In subsequent years, more and more teaching and
training activities were introduced as more consultants joined the department.
Dr. Agregado applied for PPS accreditation of the Residency Training Program in 1981
which was approved for Phase 1and II Category effective September 1, 1981 to
September 30, 1983.

In 1988 in-house consultants who were already certified as Medical Specialists by the
Department of Health were also required to take the PPS Specialty Board Examination so
that in 1995, almost all full-time consultants were already diplomates of the PPS.
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The Department of Pediatrics’ accreditation status was maintained at Phase 1 and II until
January 1993 when it was upgraded to Phase 1 and II A during the chairmanship of Dr.
Myrna Rosel. Dr. Rosel, a pediatric nephrologist, included research activities in the
Residency Program and facilitated resident’s rotation at the National Kidney and Transplant
Institute (NKTI) as well as in other tertiary hospitals where residents needed special clinical
exposures. During her tenure, NCH held its first Post Graduate Course in October 2-4,
1991. This was held annually for (6) consecutive years until PPS released a
recommendation for Phase II-b training hospitals to conduct post graduate courses every 3
years.

From the time NCH was accredited by PPS, there was continuous upgrading of the training
program. Aside from in-house case exposures, outside rotation of residents with other
institutions was undertaken for clinical exposures not available in the institution. This
included Dr. Jose Fabella Memorial Hospital (DJFMH) and Quirino Memorial Medical
Center (QMMC) for Newborn Care; Philippine General Hospital for Toxicology, Research
Institute for Tropical Medicine and Infectious Diseases for Infectious Diseases.

The research program gradually improved through the participation of in-house consultants
with expertise in this field. Seminars and workshops on research (Good Clinical Practice,
Data Analysis and others) are now part of research workshops for residents as well as
consultants.

At present, NCH continues to be one of the leading government hospitals in training

paediatricians from all over the country. The Department’s Vision is by the year 2020, the
National Children’s Hospital Department of Pediatrics is the forefront in pediatric training
and research, providing excellent and holistic quality health care, responsive to the needs of
the country and neighbouring regions. Our mission is to provide excellent and
compassionate patient care to all children. We produce leaders in pediatric health care
services anchored on evidence-based practice, community involvement, competent health
care management and continuing medical education and research with our Core Values
(DOCS 4 KIDS) which stands for Dedication, Optimism, Competence, Service Excellence
4 Kindness, Innovativeness, Diligence and Spirit of teamwork.
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The Department of Laboratory and Pathology Services started its Medical Technology
Internship Training Program in 1978 up to the present time. In the span of 38 years of
providing quality training to Medical Technology Interns, 14 universities have affiliated with
the hospital with a total of 3,108 medical technology interns trained. The passing rate in the
Medical Technology Board Examination is almost 100% for those trained at the National
Children’s Hospital.

The DOH Nurse Certification Program (NCP) for Pediatric Nursing is a competency-based
program crafted to ensure exceptional nursing performance in particular specialty areas such
as Pediatric Nursing, trauma, infections and others. The Chief Nurse and Assistant Chief
Nurse for Training contributed much in the development of the assessment tool and
implementation of this DOH-NCP. The NCH Nursing Service became an assessment center
for Pediatric Nursing not only for in-house nurses but also for other DOH hospitals. More so,
through the Nursing Development and Training Office, learning and development
interventions were provided both for internal and external participants. Furthermore, to
support the continuous quality improvement endeavors of the institution, the Nursing Service
institutionalized the Quality Improvement Studies (QIS). A total of 13 QIS have been done
by the Nursing Service for the years 2011 and 2012.For 2016 alone, there were 12 QIS
presented and standardized. To date, the Nursing Service has thrice won a Silver Award from
the Philippine Society for Quality in Healthcare –QIS Competition.

National Children’s Hospital continues its journey on improving its facilities and services to
delight its customers. The Customer Care Unit (CCU) has been created to engage patients in
all the hospital surveys and obtain valuable feedback for quality improvement. National
Children’s Hospital is the first government hospital to be accredited to the Philippine
Tripartite Accreditation for Health Facilities, Inc. (PTAHF) in November of 2020.
In 2019, the hospital has also adopted the Performance Governance System (PGS) platform
for formulating, executing, monitoring and sustaining its strategy and long term directions.

National Children’s Hospital has continually grown, evolved and expanded with the
changing times. The hospital has been the frontrunner in the care of pediatric patients, in
different stages of life and different types of diseases. The delivery of services for indigent
patients is done through innovation, sourcing out of funds and sponsorship, collaboration
with government and non-government organizations and individuals.

Through the years, this edifice has been and will always be a living testament of loving
quality patient care and concern for all Filipino children.