6.

Quality Assurance and Compliance

6.1 Quality improvement initiatives

We are committed to delivering exceptional care and continuously improving our services to
better meet the needs of our patients. We aim to foster a culture of excellence, innovation,
and continuous learning at Asian Orthopedics, ensuring that our patients receive the highest
quality of care possible.

Our commitment to quality improvement is guided by the following principles:

1. Data-Driven Decision Making: We utilize data and metrics to identify areas for
improvement and measure the effectiveness of our interventions, allowing us to
make informed decisions and prioritize initiatives that have the greatest impact on
patient care and outcomes.

2. Continuous Monitoring and Evaluation: We conduct regular monitoring and

evaluation of clinical processes and outcomes, including patient outcomes, safety
indicators, and patient satisfaction surveys, to identify opportunities for improvement
and track progress over time.

3. Root Cause Analysis: We employ root cause analysis techniques to investigate

adverse events, near misses, and other quality issues, identifying underlying causes
and implementing corrective actions to prevent recurrence and improve patient
safety.

4. Patient Feedback and Engagement: We actively seek input from patients and
families through surveys, focus groups, and patient advisory councils, incorporating
their perspectives and preferences into our quality improvement efforts and ensuring
patient-centered care.

5. Staff Engagement and Empowerment: We engage and empower our staff

members to participate in quality improvement initiatives, providing opportunities for
education, training, and collaboration to enhance their skills and knowledge in quality
improvement methods and tools.

6. Benchmarking and Best Practices: We benchmark our performance against

national and industry standards and identify best practices from peer organizations to
inform our quality improvement efforts and drive innovation in patient care delivery.
6.2 Compliance with regulatory standards

We are dedicated to upholding the highest standards of regulatory compliance to ensure the
safety, quality, and integrity of our healthcare services in accordance with Philippine
regulations. Hence, we aim to maintain the trust and confidence of our patients, staff, and
stakeholders, and to ensure the ongoing success and sustainability of Asian Orthopedics.

Our commitment to compliance with regulatory standards is guided by the following

principles:

1. Adherence to Regulations: We closely monitor and adhere to regulations

established by Philippine regulatory agencies such as the DOH, PhilHealth, and
OSHC, ensuring that our practices, policies, and procedures align with local
regulatory requirements.

2. Continuous Education: We provide ongoing education and training to our staff

members on regulatory standards, ensuring that they understand their roles and
responsibilities in maintaining compliance and are equipped with the knowledge and
skills necessary to adhere to local regulatory requirements.

3. Documentation and Recordkeeping: We maintain accurate and up-to-date

documentation and records to demonstrate compliance with regulatory standards,
including policies and procedures, training records, incident reports, and audits,
ensuring transparency and accountability in our compliance efforts.

4. Regular Audits and Assessments: We conduct regular audits and assessments of

our practices, processes, and facilities to identify areas of non-compliance with
regulations and implement corrective actions promptly, minimizing risks and ensuring
continuous improvement in our compliance efforts.

5. Collaboration with Regulatory Agencies: We maintain open communication and

collaboration with regulatory agencies, responding promptly to inquiries, inspections,
and requests for information, and implementing any recommendations or
requirements issued by local regulatory authorities.

6. Commitment to Excellence: We view compliance with regulatory standards as

integral to our mission of providing high-quality, safe, and effective healthcare
 services to our patients, and we are committed to upholding the highest standards of
regulatory compliance in all aspects of our operations.

6.3 Credentialing and privileging process for staff

We are dedicated to ensuring that our staff members are highly qualified, competent, and
capable of delivering safe and effective care to our patients. This process is designed to
verify the qualifications and credentials of our healthcare professionals and grant appropriate
clinical privileges.

Our commitment to excellence in credentialing and privileging is guided by the following

principles:

1. Credential Verification: We conduct thorough verification of the credentials,

education, training, licensure, certifications, and professional experience of each staff
member applying for clinical privileges, ensuring that they meet the necessary
qualifications and standards for their respective roles.

2. Peer Review: We engage in peer review processes to assess the clinical

competence and professional conduct of staff members, soliciting feedback from
peers, supervisors, and other stakeholders to evaluate their clinical skills, judgment,
and interactions with patients and colleagues.

3. Performance Evaluation: We conduct performance evaluations of staff members on

an ongoing basis to assess their adherence to clinical protocols, quality of care
delivery, patient outcomes, and compliance with organizational policies and
procedures, identifying areas for improvement and providing constructive feedback
and support as needed.

4. Continuing Education and Professional Development: We support the ongoing

education and professional development of our staff members, providing
opportunities for training, certification, and skill enhancement to ensure that they
remain current with best practices and advancements in their respective fields.

5. Ethical and Legal Compliance: We ensure that all staff members adhere to ethical
principles and legal requirements governing their practice, including patient
confidentiality, informed consent, documentation standards, and compliance with
regulatory standards and professional codes of conduct.
 6. Transparency and Accountability: We maintain transparent and accountable
processes for credentialing and privileging, documenting all decisions, evaluations,
and recommendations in a clear and standardized manner, and providing
opportunities for staff members to appeal decisions or address concerns through
established channels.

6.4 Risk management strategies

We recognize the importance of proactive risk management to ensure the safety of our
patients, staff, and visitors, as well as to protect the reputation and integrity of our clinic.
Hence, we aim to minimize the likelihood and impact of adverse events, enhance patient
safety and satisfaction, and protect the interests and reputation of Asian Orthopedics.

Our commitment to excellence in risk management is guided by the following principles:

1. Risk Identification: We systematically identify and assess potential risks associated

with our clinic's operations, including clinical processes, facility management,
information technology systems, human resources, and external factors such as
regulatory changes and market trends.

2. Risk Assessment: We conduct thorough risk assessments to evaluate the likelihood

and potential impact of identified risks, considering factors such as severity,
frequency, and vulnerability, and prioritizing risks based on their potential
consequences and significance to patient safety and organizational objectives.

3. Risk Mitigation: We implement proactive measures to mitigate identified risks,

including process improvements, policy and procedure enhancements, staff training
and education, facility upgrades, and the implementation of safeguards and controls
to prevent or minimize adverse events.

4. Incident Reporting and Management: We establish clear protocols for incident

reporting and management, encouraging staff members to report any adverse
events, near misses, or safety concerns promptly and confidentially, and ensuring
that incidents are thoroughly investigated, documented, and addressed in a timely
manner.
 5. Continuous Monitoring and Improvement: We continuously monitor and evaluate
the effectiveness of our risk management strategies, analyzing trends, reviewing
incident data, and soliciting feedback from stakeholders to identify opportunities for
improvement and enhance our risk management practices over time.

6. Communication and Transparency: We maintain open communication and

transparency with stakeholders regarding identified risks, mitigation efforts, and
outcomes, fostering a culture of accountability, trust, and collaboration across our
clinic.

6.5 Incident reporting and resolution procedures

We prioritize the safety and well-being of our patients, staff, and visitors. We aim to promote
a culture of safety, transparency, and accountability at Asian Orthopedics, ensuring that all
incidents are promptly addressed, lessons are learned, and improvements are made to
prevent recurrence and enhance the quality of care provided to our patients.

6.5.1 Incident Reporting:

a. Prompt Reporting: All staff members are required to promptly report any incidents,
near misses, or safety concerns they observe or experience during the course of
their duties.

b. Multiple Reporting Channels: We provide multiple reporting channels, including

electronic reporting systems, paper forms, and direct communication with supervisors
or designated incident response personnel, to ensure accessibility and confidentiality.

c. Encouraging Reporting Culture: We foster a culture of openness and

accountability, encouraging staff members to report incidents without fear of reprisal
and emphasizing the importance of learning from mistakes to prevent future
occurrences.

6.5.2 Incident Investigation:

a. Thorough Investigation: Upon receipt of an incident report, an investigation team is

convened to conduct a thorough and impartial investigation of the incident, involving
relevant stakeholders as needed.
 b. Root Cause Analysis: The investigation team utilizes root cause analysis
techniques to identify the underlying causes of the incident and determine
contributing factors, such as system failures, human errors, or environmental factors.

c. Documentation: All findings from the incident investigation are documented in detail,
including findings from interviews, observations, and analysis, to ensure
transparency and accountability.

6.5.3 Incident Resolution:

a. Corrective Actions: Based on the findings of the investigation, appropriate

corrective actions are identified and implemented to address root causes and prevent
recurrence of similar incidents in the future.

b. Timely Resolution: Priority is given to implementing corrective actions in a timely

manner to minimize the risk of further harm and ensure the safety of patients and
staff.

c. Follow-Up and Monitoring: The incident resolution process includes follow-up and
monitoring to ensure the effectiveness of corrective actions and verify that they have
been successfully implemented.

6.5.4 Communication and Feedback:

a. Communication with Stakeholders: Throughout the incident reporting and

resolution process, clear and timely communication is maintained with all relevant
stakeholders, including patients, staff, families, and regulatory agencies as required.

b. Feedback Mechanisms: We provide opportunities for staff members and other

stakeholders to provide feedback on the incident reporting and resolution process,
soliciting suggestions for improvement and addressing any concerns or questions.

6.5.5 Continuous Improvement:

a. Learning Culture: We foster a culture of continuous learning and improvement,

using insights gained from incident reports to identify opportunities for enhancing
patient safety, improving clinical processes, and strengthening our overall
performance.
b. Quality Improvement Initiatives: Incident reports are analyzed to identify trends
and patterns, which inform quality improvement initiatives aimed at reducing risks,
enhancing patient care, and promoting a culture of safety within the clinic.