Form 3 Proposed Priority Strategies and Actvities / Annual Operational Plan (AOP)

Hospital: Buluan District Hospital

Department / Section: LABORATORY

Key Performance Indicator Resources Needed with Budget

Priority Problem Strategies Major Final Output Specific Activities Success Indicator / Target Resources Needed with Budget Allocation Responsible Person Time Frame Target Area
(KPI) Allocation
Q1 Q2 Q3 Q4 Annual Particulars Annual Q1 Q2 Q3 Q4
Strategic Function 17,132,000.00 528,000.00 15,538,000.00 538,000.00 528,000.00
Provision of Level 2 Organize tertiary lab Microbiology Lab Hire RMT's no. of hired RMT's 2 Salary and 2,112,000.00 528,000.00 528,000.00 528,000.00 528,000.00 HRMO - Alma Jan-Feb
hospital services sections benefits
Send RMT's to Bacteriology no. of trained RMT's 1 1 TEV 20,000.00 10,000.00 10,000.00 Section Supervisor - April, July
training in CRMC NPM
Prepare Purchase Requests for Approved Purchase 1 List of 15,000,000.00 15,000,000.00 Section Supervisor - April
equipment with technical Request equipment NPM
specifications

Core Function 160,000.00 160,000.00 160,000.00 160,000.00

Access to Blood Recruit healthy blood Blood units Conduct mobile blood donation No. of MBD's conducted 20 20 20 20 80 Van rental 100,000.00 100,000.00 100,000.00 100,000.00 Blood Center Supervisor Jan-Dec
Services donors collected (MBD) - Norhan Mangansakan

No. of blood units collected 1,000 1,000 1,000 1,000 4,000 snack for 60,000.00 60,000.00 60,000.00 60,000.00 MBD Team Leaders - Jan-Dec
donors Kiko, Rara, Lorraine

Support Function 10,004,000.00 5,001,000.00 1,000.00 5,001,000.00 1000

Access to Blood ensure availability of Laboratory Prepare Purchase Requests with Approved Purchase 1 1 2 Reagents and 10,000,000.00 5,000,000.00 5,000,000.00 Section supervisor - NPM Jan and
Services lab tests reagents and technical specifications Request supplies June
supplies
rational blood use HBTC meeting Organize quarterly HBTC no. of meetings organized 1 1 1 1 4 AV equipment 0 0 0 0 0 HBTC Secretariat - NPM Feb, May,
meeting July, Nov
no. of participants attended 10 10 10 10 40 Meals 4000 1000 1000 1000 1000 HBTC Chair - Dr. Kalim Feb, May,
July, Nov
Form 3 Proposed Priority Strategies and Actvities / Annual Operational Plan (AOP)

Hospital: Buluan District Hospital

Department / Section:

Resources Needed with

Priority Problem Strategies Major Final Output Specific Activities Key Performance Indicator (KPI) Success Indicator / Target Resources Needed with Budget Allocation Responsible Person Time Frame
Budget Allocation

Q1 Q2 Q3 Q4 Annual Particulars Annual Q1 Q2 Q3 Q4

CORE FUNCTIONS
HOSPITAL SERVICES
Monitor and Implement a 95% of patients have a 1. Develop and implement a 100% of PACU services
analyze patient standardized process trans-out process from standardized process for achieved 95% of patients have a
flow and discharge for patient assessment Doctor's Orders within patient assessment and trans-out process from Doctor's
times to identify and transout planning 4 hours and attain an discharge planning, Orders within 4 hours and Attain
areas for average Aldrete score including the use of the an average Aldrete score of at
improvement and of at least 9 for patients Aldrete score. least 9 for patients before
implement before transout. transout.
necessary
changes.

Establish a strong Improved patient safety 1. Collaborate with other

interdisciplinary team to and quality of care in departments, such as
ensure patient safety the PACU, as surgery and anesthesia, to
and quality of care evidenced by positive ensure smooth patient
patient feedback. transfers and timely patient
transout.

Monitor and evaluate Efficient patient flow 3. Monitor and analyze

patient flow and and timely patient patient flow and transout
discharge times to transout, resulting in times to identify areas for
identify areas for improved operational improvement and implement
improvement. efficiency and patient necessary changes.
satisfaction.

PATIENT SAFETY
Preventing adverse 1. Establish a culture of Patient Safety 1. Implement a system for 0% Adverse events such as BT
events such as BT open communication anonymous error reporting error, sentinel and Medication
errors, sentinel and and reporting to identify and encourage staff to error, and 100 % staff adherence
medication errors, and address potential report near-misses. to patient safety protocols
and ensuring 100% errors.
staff adherence to
patient safety
protocols. 2. Regularly review and 2. Coordinated with the
update patient safety patient safety committee to
protocols based on review and update protocols
best practices and based on incident reports
incident reports. and best practices.

CUSTOMER SATISFACTION
Ensuring that 90% Implement a PACU Patient 1. Regularly review and 90% of PACU patients have
of PACU patients comprehensive patient- Satisfaction Survey. analyze patient satisfaction rated very satisfactory in PACU
rate their centric approach, data, identify trends, and Patient Satisfaction Survey
experience as very focusing on effective implement continuous
satisfactory in the communication, improvement initiatives to
PACU Patient personalized care, and maintain and enhance the
Satisfaction continuous overall satisfaction of PACU
Survey. improvement initiatives patients.

2. Implement regular and

clear communication
channels between
healthcare providers and
patients, ensuring that
information about
treatments, medications,
and care plans is easily
understood.

Incomplete Implement a robust E-Cart Inventory 1. Develop a checklist for Verified that no incidence of
inventory of drugs system for real-time regular audits and incomplete inventory of drugs
and supplies in the tracking and monitoring reconciliations and assign and supplies in E-cart
E-cart, leading to of E-cart inventory. responsibilities for
potential conducting audits and
disruptions in reconciliation activities.
patient care,
delays, and Conduct routine audits
compromised and reconciliations to
safety. promptly identify and
rectify discrepancies.

Inconsistent 1. Establish a Calibration of PACU 1. Develop a detailed 100% of listed equipment in

calibration of comprehensive Equipment equipment calibration PACU calibrated submitted to
equipment in the equipment calibration schedule with clear the Assistant Chief Nurse within
PACU leading to schedule to ensure deadlines for each listed the prescribed deadline.
potential timely compliance. item.
operational
disruptions,
compromised 2. Conduct regular 2. Perform regular audits to
audits to verify the verify the accuracy and
accuracy and completeness of the
completeness of the equipment calibration list.
equipment calibration
list.

STAFFING
Ensuring that 1. Clearly define and Staffing 1. Regularly conduct a
100% of the PACU document the optimal thorough analysis of patient
Nursing Service staffing requirements census and acuity to
has adequate for each shift, determine the optimal
staffing during considering patient staffing levels for each shift.
each tour of duty. acuity, workload, and
industry standards.
 2. Develop and 2. Ensure that the staff-to- 100% of PACU Nurse will have
communicate clear patient ratio meets or adequate staffing during on tour
policies and procedures exceeds established of duty
for staffing, ensuring standards and guidelines.
transparency and
consistency.

5. Infection 1. Foster strong Creation of a 1. Establish a system of 100% compliance to IPC

Prevention Control collaboration with the healthcare accountability for employees standard protocols
infection control team, environment where IPC regarding IPC compliance.
ensuring a unified standard protocols are
approach to IPC ingrained in the culture,
initiatives. resulting in a high level
of safety, reduced
infection rates, and
improved overall
quality of care for
patients.

2. Emphasize individual 2. Regularly review and

accountability for IPC update standard operating
compliance, ensuring procedures (SOPs) related
that each staff member to IPC in collaboration with
understands their role the infection control
in maintaining a safe committee.
environment.

3. Empower charge nurses

and unit leaders to take
leadership roles in ensuring
IPC compliance on the unit.

6. Reports 1. Define Clear Consistent and 1. Clearly outline the Timely submission of required
reporting process punctual delivery of reporting processes, reports to Assistant Chief Nurse
accurate reports within including the types of
the established reports required, submission
deadlines deadlines, and formatting
guidelines.
2. Regularly Monitor 2. Regularly check in with
Progress your nursing staff to monitor
the progress of report
completion.
 3. Periodic Audits 3. Conduct periodic audits
of submitted reports to
ensure accuracy and
completeness.

4. Continous 4. Solicit feedback from staff

Improvement and make necessary
adjustments to improve the
overall submission
workflow.
7. Documents 1. Develop Consistent and 1. Create standardized 100% of discharged patient
Standardized thorough validation of checklists outlining the health records are reviewed for
Checklists every patient's health essential components that completeness prior to
record to ensure that it should be present in each submission to medical records
meets the established patient's health record.
criteria for
completeness

2. Assign Record 2. Clearly designate

Review Responsibilities individuals or teams
responsible for reviewing
the health records before
submission to medical
records.
3. Implement Double- 3. Incorporate a double-
Check Processes check process where two
individuals independently
review each health record to
enhance accuracy.

Strategic Function

Support Function
Target Area
NURSING SERVICE
Priority problems Strategy Major Final Output

1. Personnel Workforce Development Fully staffed IN General ward

1. Assess current staffing levels unit with improved efficiency
Identify gaps and determine
the need for additonal personnel

2. Adequate Area/ Expansion and Renovation Expanded and renovated General Ward
Spacing/Building 1. Collaborate with hospital unit with updated facilities and increased
administration to assess current capacity.
space and identify expansion
opportunities.
2. Develop a proposal for necessary
renovations and expansion, considering
patient capacity, privacy, and
comfort.

3. Medical Equipments 1. Conduct an inventory of existing Up-to-date and functional medical

equipment equipment In the General ward unit
2. Identify Deficiencies
3. Procure necessary medical eqipment

4. Trainings Implement a training program to enhance Well-trained and knowledgeable

 the skills and knowledge of General ward staff providing high-quality patient
unit staff care

5. Infection Control Develop and Implement strict Infection Improved Infection control measures
control protocols to minimize the risk of and reduced infection rates
infection within General ward unit.

6. Patient Safety Implement measures to enhance patient Enhanced patient safety practices
safety within the General ward unit and reduced adverse events
 Success Indicator / Target
Activity KPI
2024 2025

1. Assess current staffing levels Staffing levels completion rates Hire 20% of needed staff 50%
and identiy gaps
2. Develop a recruitment plan to fill
vacant positions

1. Conduct a comprehensive space Completion of renovation or expansion Achieve 25 % completion 50%

utilization analysis projects for General ward unit
2. Collaborate with Hospital Engineer
for ward redesign
3. Secure funding and resources for
the expansion project.

1. Inventory existing equipment and Equipment inventory, procurement Complete equipment Procure 50% of needed
assess their condition. completion rate inventory Equipment
2. Develop a procurment plan for
necessary medical equipment
3. Collaborate with the hospital's
procurement department to acquire
neede equipment

1. Identify training needs through Training completion rates, staff Complete 25% of 50% completion
staff assessment performance improvement scheduled training
2. Develop a training curriculum and
schedule
3. Implement training session and
evaluate their effectiveness

1. Review and update existing Infection Infection rates, compliance with Infection Achieve 20% reduction 50% reduction in infection
control protocols control protocols in infection rates rates
2. Implement regular training on Infection
control practices
3. Conduct routine audits to ensure
compliance with protocols

1. Review and update patient safety Adverse events rates, staff adherence Achieve 15% reduction in 40% reduction
protocols to patioent safety prtotocols adverse events
2. Conduct training on patient safety for
all staff
3. Establish a reporting system for
adverse events and near missess
dicator / Target Budget Allocation
2026 2027 Tier 1 (40%) Tier 2 (30%) Tier 3 (30%) Total

75% 100%

75% 100%

75% procurement 100%

75% completion 100% completion

75% reduction in 100% reduction in
infection rates infection rates

70% reduction 100% reduction