QUALITY MANUAL Doc. No.

NCH-QM-2021
Section 11
Document Name Revision No.: 0
Effectivity Date: January 1, 2021
LEADERSHIP AND
COMMITMENT Page 1 of 5

Performance Governance System (PGS) Strategy Map

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Doc. No. NCH-QM-2021
Section 11
Document Name Revision No.: 0

LEADERSHIP AND Effectivity Date: January 1, 2021

COMMITMENT
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Management ensures that the needs and expectations of its relevant interested parties
are identified and met taking into consideration the existing service capabilities and
financial resources of the hospital.

Management ensures that appropriate resources, training and opportunities are

provided to ensure success in the implementation of the quality management system.

Management ensures that full QMS internal audits and management reviews are
conducted at least twice (2x) a year as part of its continuing improvement
endeavours.

Management ensures to provide a work environment that is based on trust,

transparency and fairness. Top management engages and supports its people to
contribute to the effectiveness of the QMS. It supports other relevant management
roles in order for them to demonstrate leadership, work with responsibility and
accountability.
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Doc. No. NCH-QM-2021
Section 11
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LEADERSHIP AND COMMITMENT Effectivity Date: January 1, 2021

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11.2 Customer Focus

National Children’s Hospital values its customer, the patient. It determines the
customer requirements and expectations by providing a wide range of medical,
diagnostic and support services as stated in its service capabilities.

Management ensures that the quality objectives of the hospital are linked to the
patient’s needs and expectations. The patient’s needs and expectations are
communicated regularly and effectively throughout the organization.

Management ensures a balance between satisfying both the patient and the internal
customers (employees) and other stakeholders (suppliers, donors, financiers, local
communities, NGO’s and the society). The needs and expectations of other relevant
interested parties are identified and likewise met within the capability of the
hospital.

Customer and applicable statutory and regulatory requirements are determined,

understood and consistently met by the hospital.

The risks and opportunities that can affect the conformity of the delivery of services
and products are identified and addressed appropriately.

Management regularly measures and analyses customer satisfaction. Patient

Satisfaction Surveys are conducted daily in all areas of the hospital. The results of
surveys are analysed quarterly and is communicated throughout the organization.
Results of patient satisfaction surveys are discussed in the management review and
acted upon as part of continuing improvement.
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Section 11
Document Name Revision No.: 0
Effectivity Date: January 1, 2021
LEADERSHIP AND COMMITMENT
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11.3 Quality Policy

National Children’s Hospital has established a quality policy which serves as a framework
on the set quality objectives. The quality policy is reviewed once a year to check its
suitability in the organization and communicated to all levels and functions for proper
understanding and application in the hospital. The quality policy is posted in all areas of
the hospital, uploaded in the hospital website and is available in flyers for the relevant
interested parties’ information.

Refer to Section 5 of this manual: Quality Policy Statement

11.4 Mission, Vision, Core Values Review

National Children’s Hospital has established its mission, vision and core values as an
integral part of its Strategy Map of the Performance Governance System. These are
reviewed at least every 2 years to determine its suitability to the mandate and the strategic
positioning of the hospital.

Refer to Section 5 of this manual: Vision, Mission and Core Values

and to Section 11, Page 2 of this manual: PGS Strategy Map
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Doc. No. NCH-QM-2021
Section 11
Document Name Revision No.: 0

LEADERSHIP AND COMMITMENT Effectivity Date: Janaury 1, 2021

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11.4 ORGANIZATIONAL ROLES, RESPONSIBILITIES AND AUTHORITIES

National Children’s Hospital organizational chart is shown in section on the

organizational structure of this quality manual. The responsibilities and authorities
as defined below and are communicated within the organization and being
acknowledged by the employees.

Medical Center Chief

Reports directly to the Secretary of Health.
Provides overall leadership of the clinical, financial, administrative
and human resource functions and services of the hospital.

Chief Administrative Officer

Reports directly to the Medical Center Chief.
Oversees hospital operations and various patient support service
delivery within the hospital, provides guidance in programs, gives
advice and technical assistance.

Financial Management Officer

Reports directly to the Medical Center Chief .
Supervises the operation of the Finance Service to ensure proper
implementation of financial policies especially the control of funds,
collection of revenues and recommends the approval of the Work
and Financial Plan/Operational Plan and Budget Proposal of the
hospital.

Chief, Medical Professional Staff

Reports directly to the Medical Center Chief.
Oversees the operations of the six (6) big departments under the
Medical Service to ensure the delivery of efficient, timely and
quality medical care to patients.

Chief Nurse
Reports directly to the Medical Center Chief.
Oversees the operations of the entire Nursing Service to ensure the
delivery of quality nursing care at all times, professional growth and
training of the entire service.