QualityAssuranceProgram Benchbook

Benchbook
On Performance Improvement of Health Services
Philippine Health Insurance Corporation

Quality Assurance Research and Policy Development Group
2004
Benchbook
on performance improvement of health services
Published by the Philippine Health Insurance Corporation (PhilHealth)
Copyright © 2004 PhilHealth
All rights reserved. No part of this book may be reproduced or used in any form or by any
means, electronic or mechanical, including photocopying, recording, scanning or by any
information storage or retrieval system, without permission in writing from the publisher.
Editor: Wystan de la Peña

Book and cover design: Arnulfo Aquino
Technical Consultant: Mary Ann Evangelista, M.D.
Table of Contents
From the President and CEO ................................................................................ i

From the Quality Assurance Research
and Policy Development Group (QARPDG) ..................................................... iii
PhilHealth Quality Standards for Health Provider Organizations .................... 1

1. Patient Rights and Organizational Ethics .............................................. 5
2. Patient Care Standards .......................................................................... 9
2.1 Access.............................................................................................. 9
2.2 Entry............................................................................................... 10
2.3 Assessment ...................................................................................... 12
2.4 Care Planning ................................................................................. 15
2.5 Implementation of Care .................................................................. 16
2.6 Evaluation of Care........................................................................... 19
2.7 Discharge ........................................................................................ 20
3. Leadership and Management................................................................. 23
3.1 e Management Team ................................................................... 23
3.2 External Services ............................................................................. 24
4. Human Resource Management ............................................................. 26
4.1 Human Resources Planning ............................................................ 26
4.2 Staff Recruitment, Selection, Appointment
and Responsibilities .........................................................................27
4.3 Staff Training and Development ......................................................28
5. Information Management ..................................................................... 31
5.1 Data Collection, Aggregation and Use............................................. 31
5.2 Records Management...................................................................... 32
6. Safe Practice and Environment.............................................................. 34
6.1 Patient and Staff Safety.................................................................... 34
6.2 Maintenance of the Environment of Care ....................................... 35
6.3 Infection Control ............................................................................36
6.4 Equipment and Supplies .................................................................3 7
6.5 Energy and Waste Management ...................................................... 38
7. Improving Performance.........................................................................40
Glossary............................................................................................................... 43
Preface
From the President and CEO

This Benchbook aims to show how PhilHealth providers can serve
Filipinos with high quality health care. It is a systematic overview of
the accreditation process, policies and standards, and how they relate
to PhilHealth’s mission as an insurance company and as an agent for
reforming the Philippine health system.
The Benchbook is not an all-encompassing and exhaustive textbook

on quality of care. Nor is it meant to be a permanent code of conduct.
Readers should refer to many excellent resources on quality of care,
attend training seminars or formal courses, and network with as many
experts as possible.
Envisioned to serve as a yardstick for measuring and assessing the

quality of health care rendered by PhilHealth and its accredited health
providers and professionals, the Benchbook lays out basic concepts on
the value of quality assurance in health care and how the accreditation
process supports continuous quality improvement.
Also included is an updated list of standards and criteria which

health care provider organizations and professionals can use for
self-assessment prior to applying for accreditation and even after
obtaining it. Both accredited providers and professionals and
accreditation applicants should refer to the Benchbook during and
after the accreditation process in order to have a common ground for
discussion and partnership. The Benchbook should also be consulted
in cases when accreditation has been denied, appealed or reinstated.
Production of this Benchbook has been made possible through a

grant from the AusAID, through the Philippines–Australia Governance
Facility, and the Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ), or the German Development Cooperation.
Finally, I commend Dr. Madeleine R. Valera, PhilHealth Vice President

for Quality Assurance Research and Policy Development, for her vision
of quality assurance in health care in the Philippines, her determined
efforts in realizing it despite Herculean obstacles, and her endless
patience and dedication in managing the team of in-house Quality
Assurance specialists in the writing of this Benchbook.
Francisco T. Duque, M.D., MSc

President and CEO
BENCHBOOK
ii
From the Quality Assurance Research

and Policy Development Group (QARPDG)
The provision of quality health care has always been in the agenda of
the Philippine Health Insurance Corporation.
Realizing that deficiencies in processes would not be corrected by

focusing only on improving the quality of inputs, we decided to move
beyond the traditional accountability framework and work towards
helping our providers aim for continuing improvement.
In the past couple of years since PhilHealth assumed the role

of national health insurance administrator, we have made only
incremental improvements in elevating the quality standards of our
providers. Even as we wanted to focus more on improving processes,
particularly outcomes, we have continued to emphasize mostly
structure standards.
Avedis Donabedian, a pioneer in quality assurance in health care,

states we should focus on all three components–structure, process and
outcome—if we want to improve quality. We at PhilHealth have also
recognized that the presence of quality inputs alone will not guarantee
good process and consequently good outcomes.
The Benchbook features a concise list of best possible conditions that

should exist in the organization. It goes beyond the usual emphasis
on structures—such as facilities and equipment—by providing
process standards as well, such as waiting time and turnaround time
for procedures and treatments. We hope this guidebook will serve as
a useful reference for providers, and for PhilHealth as well, in carrying
out data collection regarding performance and in making appropriate
decisions and actions based on the data.
As writing the Benchbook involved different kinds of input from

different people, we feel we should give credit where it is due,
especially to those individuals who bore the brunt of the Benchbook
production. Those who participated in the Stakeholders’ Meeting for
Standards Development in 2001 and in the Focused Group Discussion
in copytesting the Benchbook in 2004, are named in a list which
appears in the appendix.
Acknowledgement
iii
For starters, the writing of this Benchbook needed financial allies: the
AusAID, through the Philippines-Australia Governance Facility, and the
Deutsche Gesellschaft für Technische Zusammernarbeit (GTZ) GmbH.
These two foreign agencies provided the financial lifeline for the
initial writing of the draft and its final editing to make the Benchbook
publication ready. For their administrative support at the start of
the project, Ms. Christine McMahon and Mr. Carlos Mendoza, of the
Philippines-Australia Governance facility deserve our thanks. So do Dr.
Claude Bodart, health program manager; Dr. Matthew Jowett, advisor;
and Mr. Manolito Novales, senior technical coordinator, of the GTZ for
similar assistance in the completion of the Benchbook.
Mr. Karl Karol and Ms. Brenda Ballantyne of the Australian Health
Insurance Commission facilitated the participation of two of their
consultants, Dr. Denis Smith and Dr. Jose Acuin. These two doctors,
joined by Prof. Don Hindle, a PhilHealth consultant, assisted in the
creation of the PhilHealth Quality Standards, the conceptualization
of quality improvement in the context of the Philippine health
system. They also led the brainstorming for a new quality assurance
framework for PhilHealth. Dr. Acuin concretized everything in black
and white by producing the original manuscript. Dr. Hindle wrote
the PhilHealth drafts for the clinical pathways for Outpatient Cataract
Surgery and Low Risk Maternity Care featured in Part III of the
Benchbook.
Reviewing and rewriting Part II (PhilHealth Quality Standards for

Health Provider Organizations) fell on the shoulders of the division
chiefs of the Quality Assurance Research and Policy Development
Group: Dr. Francisco Soria (Utilization Review Division), Dr. Clementine
Almario-Bautista (Health Technology Assessment Division), Dr.
Mary Ann Evangelista (Medical Informatics Division). Dr. Ma.
Theresa Bonoan and Dr. Errol Ciano, quality assurance officers, also
participated in the review and rewriting sessions.
In the final production phase of the Benchbook, Dr. Evangelista acted

as technical consultant from PhilHealth, and working closely with the
editor, did additional research to expand the text and bibliography
where needed, adding information from selected 2000-2003
published titles to ensure that the Benchbook carries state-of-the-art
Quality Assurance ideas. She also executed the various figures and
illustrations.
BENCHBOOK
iv
As editor, Prof. Wystan de la Peña of the University of the Philippines

Diliman designed the methodology for the Focused Group
Discussions/Copytesting sessions, and drafted the accompanying
survey instrument. In the end, he crafted a cohesive yet engaging
and easy-to-read final version, and even enriched the concept of
the Benchbook by fashioning it for a three-fold purpose: as a handy
Quality Assurance reference manual for health care professionals, a
document for PhilHealth’s institutional memory, and literature for local
discourse on quality care.
Arnold Aquino executed the cover design and most of the layouting.
His wife, Bituin Acebron-Aquino, assisted in the layout work and
proofreading.
Thanks are also in order for the entire QARPDG staff, for their assistance
in all forms.
May this Benchbook serve its purpose of improving the way health
care is delivered to every Filipino.
Madeleine R. Valera, M.D., MScCHHM

Vice-President for Quality Assurance Research and Policy Development
Quality Standards
PhilHealth Quality Standards

for Health Provider Organizations
➠ Patient Rights and Organizational Ethics
➠ Patient Care Standards
➠ Leadership and Management
➠ Human Resource Management
➠ Information Management
➠ Safe Practice and Environment
➠ Improving Performance
BENCHBOOK
2
Quality Standards
PhilHealth Quality Standards

for Health Provider Organizations 1
Sometime in 2000, PhilHealth’s Quality Assurance Research

and Policy Development Group (QARPDG), in the wake of its
monitoring of delivery of care practices and facilities of accredited
hospitals and other providers, felt the need to create a document
which laid out basic criteria for quality standards. As PhilHealth
was then using for accreditation purposes standards similar to the
Department of Health’s (DOH) structure-based requirements for
hospital licensing, PhilHealth thought it should instead require a
different set of standards that would be more in keeping with its
corporate mission.
us, while DOH standards focus on structure (physical plant,

equipment, manpower, etc.), PhilHealth thought it appropriate
to orient its standards thinking in terms of process and outcomes.
is Quality Standards portion is divided into the following

seven standards groups:
1. Patient Rights and Organizational Ethics
2. Patient Care
3. Leadership and Management
4. Human Resource Management
5. Information Management
6. Safe Practice and Environment
7. Performance Improvement
Each group has specific goals which serve as targets for
improvement. All but two—the Patient Rights and
Organizational Ethics and Performance Improvement groups—
are further subdivided into subgroups which in turn have
separately-listed goals.
While goals picture the desired-for situation targeted by a

performance improvement program, standards delineate the best
possible condition that should exist in the organization for it to
1
Organization from hereon refers to health care organization.
BENCHBOOK
attain quality performance. Standards set maximum achievable

performance expectations for activities that affect the quality of
care (like compliance with patient pathways) which emphasize
the interface between management units. Since standards aim
to improve outcomes, there is no prescribed manner on how
to achieve improvement. e focus is on what the organization
actually does, not its capability. Hence, the standards listed herein
are made as general as possible to make them equally applicable
to all health care organizations regardless of whether they are a
hospital, day surgery unit, community service, or some other type
of health care organization.
One or more criteria flesh out the standard. ese criteria lay
down specific actions that need to be done to meet the standard.
ese actions, determined by the organizations themselves, should
reflect contemporary best practice principles, be achievable, easily
understood and measurable.
Assessment of a health care organization’s performance in

service provision as reflected in compliance with standards is
measured through indicators. Indicators are measurable variables
or characteristics that can be used to determine the degree of
adherence to a standard or achievement of quality goals. To
illustrate:
Standard 4.2.4
• All services are provided by staff members with
appropriate qualifications, experience or training.
Criteria
• All doctors, nurses and midwives providing clinical
care have current licenses and documented evidence of
appropriate training and experience.
• All administrative, business and technical services staff
have current licenses and documented evidence of
appropriate training and experience.
Indicator
• Percentage of staff with current licenses.
A complete listing of indicators will be published separately as an

accompanying reference to this Benchbook.
Quality Standards
5
55
Performance Patient Rights

Improvement & Organizational
Ethics
Safe Practice &

Patient Care
Environment
Information Leadership &

Management Management
Human Resource
Management
Figure 7. PhilHealth Quality Standards for Health Care
1. Patient Rights2 and Organizational Ethics
GOAL To improve patient outcomes by respecting patients’ rights and

ethically relating with patients and other organizations.
STANDARDS 1.1 Organizational policies and procedures respect and

support patients’ right to quality care and their
responsibilities in that care.
Criteria
• Informed consent3 is obtained from patients prior to
initiation of care.
2
A copy of the “World Medical Association Declaration on the Rights of the Patient” adopted by
the 34th World Medical Assembly in Lisbon in 1981 and amended during the same organization’s
47th General Assembly in Bali in 1995 can be found in Part IV (Appendix).
3
Informed consent is defined in the glossary. Johns Hopkins University professors Debra Roter
and Judith Hall’s work (1993) on the patient-doctor communication process, links it with issues
regarding informed consent. Also see the University of Washington School of Medicine’s website
discussion on bioethics.
BENCHBOOK
• Policies and procedures which identify and address

patients’ rights and responsibilities are documented
and monitored.
• Patients receive written statements of their rights
and responsibilities.
• e hospital protects patients and respects their
rights during research involving human subjects.
1.2 e organization encourages and promotes

opportunities to involve patients and their families in
their care.
Criteria
• Policies and programs to educate patients and
families on how to take a more pro-active role
in health care decision making are documented,
monitored and evaluated for their effectiveness.
• Patients and their families are involved in making
care decisions with ethical issues4, such as
withholding resuscitation, foregoing life-sustaining
treatment, end of life care, etc.
1.3 e organization documents and follows policies

and procedures for addressing patients’ needs for
confidentiality, privacy, security, religious counseling
and communication.
Criteria
• Hospital staff is aware of and follows policies
and procedures in addressing patients’ needs for
confidentiality, privacy, security, counseling and
communication.
• e hospital systematically determines, monitors
and improves the extent to which patients’ needs
for confidentiality, privacy, security, counseling and
communication are addressed.
4
Examples of ethical issues may include, but are not limited to, insisting on giving blood transfusion to
a Jehovah’s witness patient who refuses transfusion but will most likely save his life in a critical case.
Quality Standards
1.4 e organization systematically elicits, monitors and

acts upon feedback from patients, their families, visitors
and communities.
Criteria
• Policies and procedures for routinely determining
and improving the level of patient satisfaction with
all relevant aspects of care are documented and
monitored.
• Policies and procedures for addressing and resolving
patients’ complaints are documented and monitored.
1.5 e organization’s personnel discharge their functions

according to codes of ethical behavior and other relevant
professional and statutory standards.
Criteria
• e organization identifies relevant codes of
professional conduct and other statutory standards
and informs its personnel about these codes and
standards.
• e organization identifies and monitors personnel
compliance with the code of ethics relevant to their
respective disciplines.
• Procedures for resolving ethical issues related to
professional practice or to conflicts of interest are
based on the relevant code of ethics and other
professional and legal standards.
1.6 e organization documents and follows procedures for

resolving ethical issues as they arise from patient care.
Criteria
• Procedures for resolving ethical issues that arise in
the course of providing care are monitored for their
effectiveness.
BENCHBOOK
1 Patient Rights and

Organizational Ethics
STANDARDS
• respect and support for patients’

rights and responsibilities
GOAL:
To improve patients’ outcomes
• opportunities for patients’ by respecting patients’ rights and
involvement in care provision ethically relating with patients
and other organizations.
• confidentiality and security
of patients’ information and
communication
• feedback to patients
• staff code of ethics
• resolution of ethical issues

Quality Standards
2. Patient Care Standards
2.1 Access
GOAL e organization is accessible to the community that it aims to serve.
STANDARDS 2.1.1 e organization informs the community about the

services it provides and the hours of their availability.
Criteria
• Information detailing the clinical services offered
and hours of their availability is strategically5
distributed and prominently posted.
• Clinical services are appropriate to patients’ needs
and the former’s availability is consistent with the
organization’s service capability and role in the
community.
• e community is aware of clinical services offered
and times of availability.
2.1.2 Physical access to the organization and its services is

facilitated and is appropriate to patients’ needs.
Criteria
• Entrances and exits are clearly and prominently
marked, free of any obstruction and readily
accessible.
• Directional signs are prominently posted to help
locate service areas within the organization.
• Alternative passageways for patients with special
needs (e.g., ramps) are available, clearly and
prominently marked and free of any obstruction.
• Major service areas have nearby waiting facilities
that are clean, well-lit, adequately ventilated and
equipped with appropriate fixtures and furniture.
5
The following example distinguishes prominent from strategic: if a clinic is located far from the
main street, then the signage should be located at the street corner nearest the clinic. Otherwise
it would not be seen. That is strategic. Making the signage big enough to be seen from a block
away is prominent.
BENCHBOOK
10
• e organization documents, follows policies and

procedures, and provides resources for the safe and
efficient direction of patients, their families and visitors,
and staff traffic.
• Patients, their visitors and staff can efficiently and safely
move within the confines of the organization.
2.2 Entry
GOAL e entry processes meet patient needs and are supported by

effective systems and a suitable environment.
STANDARDS 2.2.1 Patients receive prompt and timely attention by

qualified professionals upon entry.
Criteria
• Patient waiting times are routinely monitored,
evaluated and improved based on standards and
procedures developed by the organization. Depending
on their needs, patients are seen within the planned
waiting period.
• Patients are informed of the cause of any delay in the
delivery of services.
• Patients are satisfied with the actual waiting time.
2.2.2 e organization documents and follows policies and

procedures, and provides resources to ensure proper
patient triaging.
Criteria
• e staff follows policies and procedures in
determining and prioritizing patients’ clinical needs
and in identifying clinical services that will best
address them.
• e staff follows policies and procedures in
determining admissibility of patients or the need for
referral to other organizations.
• Patients are correctly and efficiently assigned to the
clinical services appropriate to their needs.
Quality Standards
11
2.2.3 e organization uniquely6 identifies all patients

including newborn infants, and creates a specific
patient chart for each patient that is readily accessible
to authorized personnel7.
Criteria
• All patients are correctly identified by their patient
charts.
• e patient charts contain identifiers unique to each
patient.
• Patient charts are appropriately and systematically
indexed to facilitate retrieval and storage and to
avoid duplication or loss.
2.2.4 e health professional8 responsible for the care of the

patient obtains informed consent for treatment.
Criteria
• Prior to admission, patients and/or their families
are appropriately informed by authorized qualified
personnel of their disease, condition or disability,
its severity, likely prognosis, benefits, and possible
adverse effects of various treatment options, and the
likely costs of treatment.
• Patients and/or their families demonstrate
knowledge of their disease, condition or disability,
its severity, likely prognosis, benefits, and possible
adverse effects of various treatment options, and the
likely costs of treatment.
2.2.5 Planning for discharge begins upon entry into the

organization and ensures a coordinated approach to
discharge and continuing management.
Criteria
• Patients and/or their families are informed of the
expected (barring any complications) approximate
6
To uniquely identify a patient may mean making the patient number a lifetime number.
7
The organization itself determines the limits of who are authorized personnel in any given situation.
8
Doctors are not the only providers of care within the organization; hence health professional is
preferred to encompass a wider spectrum of health care providers.
BENCHBOOK
12
duration of treatment, the extent or frequency of re-

assessment, the likely outcomes and their need for
follow-up care after discharge
• Patients and/or their families are informed of the
need for and availability of resources to continue care
after discharge.
2.3 Assessment
GOAL Comprehensive assessment of every patient enables the planning

and delivery of patient care.
STANDARDS 2.3.1 Each patient’s physical, psychological and social status is

assessed.
Criteria
• An appropriately comprehensive history and physical
examination is performed on every patient within 24
hours from admission. e history includes present
illness, past medical, family, social and personal
history.
• Whenever appropriate, mental status examinations,
psychological evaluations and nutritional and
functional assessments are performed on the patient.
2.3.2 Appropriate professionals9 perform coordinated and

sequenced patient assessment to reduce waste and
unnecessary repetition.
Criteria
• Based on collaboratively developed policies and
procedures, qualified personnel conduct initial
assessments in an efficient and systematic manner to
avoid repetition.
• e order of assessment is determined by the patient’s
prioritized needs.10
9
This is not about determining who is qualified because this should have been done already at
the credentialing process. Rather it is about determining who are appropriate for the roles in
patient care. For example, a qualified radiologist is not appropriate to make a pre-operative
assessment.
10
The optimal order of assessment could be pre-determined through clinical pathways based on
clinical practice guidelines, or other forms of evidence.
Quality Standards
13
• Previously obtained information obtained is

reviewed at every stage of the assessment to guide
future assessments.
2.3.3 Assessments are performed regularly and are

determined by patients’ evolving response to care.
Criteria
• During the course of management, qualified
personnel re-assess the patients’ physical and
psychological conditions according to the patient’s
needs.
• Re-assessment is done whenever the patients’
condition take an unexpected turn.
• Re-assessment results in a review of the patients’
management.
• Qualified personnel give patients for surgery pre-
operative physical and pre-anesthetic assessment.
• e status of post-operative patients is assessed
upon admission into, during confinement and upon
discharge from the recovery area.
2.3.4 Assessments are documented and used by the health

care team to ensure effective communication and
continuity of care.
Criteria
• Legible written records of the initial and ongoing
assessments are accomplished for each patient and
kept in the patient chart.11
• Medical records are stored in an area that is safe and
accessible to all members of the health care team,
and whenever appropriate, to external providers.12
11
Results of re-assessment may be documented as problem-oriented progress notes in SOAP
(subjective complaints/objective findings / assessment / plan) form for each patient and
kept in the medical record.
12
The term external providers includes, but is not limited to, other health care providers to
whom the patient is referred for continuity of care.
BENCHBOOK
14
2.3.5 Diagnostic examinations appropriate to the provider

organization’s service capability and usual case mix are
available and are performed by qualified personnel.
Criteria
• Policies and procedures for the standard
performance, monitoring and quality control of
diagnostic examinations are documented and
monitored.
• Policies and procedures for accessing and referring
patients to approved external providers when
diagnostic services are not available within the
provider organization are documented and
monitored.
2.3.6 Assessments of patients with special needs are

determined by policies and procedures that are
consistent with legal and ethical requirements.
Criteria
• Policies and procedures identify patients with
special needs and the specific types of assessment
appropriate to their needs.13
13
Patients with special needs include infants, school-age children, adolescents, the elderly and the
disabled, victims of alleged or suspected sexual abuse or violence, patients with emotional or
behavioral disorders, patients with drug dependencies or alcoholism.
Quality Standards
15
2.4 Care Planning
GOAL e health care team develops in partnership with the patients a

coordinated plan of care with goals.
STANDARDS 2.4.1 e care plan addresses patients’ relevant clinical,

social, emotional and religious needs.
Criteria
• e plan, aside from delineating responsibilities,
includes goals to be achieved, services to be
provided, patient education strategies to be
implemented, time frames to be met, resources to be
used.14
2.4.2 e care plan is consistent with scientific evidence,

professional standards, cultural values, medico-legal
and statutory requirements.
Criteria
• e care plan is developed by a multidisciplinary
team of health professionals within the organization.
• e care plan is developed following search and
appraisal of published scientific literature.
• Expert judgment, practice standards and patients’
values are considered in developing care plans.
2.4.3 e organization ensures that information about the

patient’s proposed care is clear and readily accessible to
designated multidisciplinary health care providers and
other relevant persons.
Criteria
• Care planning is documented in the patient chart.
• Clinical pathways, algorithms and problem-oriented
notes15 in SOAP format are incorporated in the
medical record.
14
Clinical pathways derived from clinical practice guidelines and other types of clinical evidence
should be developed or implemented for the top 10 cases of admissions and / or consultations.
For more information, refer to Part III.
15
Problem oriented notes may take other forms aside from SOAP, such as SOAPIE, etc.
BENCHBOOK
16
2.5 Implementation of Care
GOAL Care is delivered to ensure the best possible outcomes for the
patient.
STANDARDS 2.5.1 Care is delivered in a timely, safe, appropriate and

coordinated manner, according to care plans.
Criteria
• In the management of clinical pathway-covered
conditions, the order and timing of treatments follow
the pathway.
• Orders for treatments are implemented within time
intervals established by the organization.
• Referrals to other specialties are made according to
established pathways or guidelines.
• Results of referrals are communicated to relevant
members of the health care team and are considered
in the management.
2.5.2 Rights and needs of patients are considered and

respected by all the staff.
Criteria
• Patients receive explanations on the nature of a test or
treatment, the need for it prior to administration, its
likely effects and side effects, and what patients can
do to cope with them.
• Patients’ wish to decline tests or treatments is respected.
2.5.3 Care is coordinated to ensure continuity and to avoid

duplication.
Criteria
• Policies and procedures that determine the extent of
duplicate assessments and treatments performed by
trainees respect patients’ rights, and are documented
and monitored.
Quality Standards
17
2.5.4 Appropriate personnel educate patients and/or their

families to help them understand patients’ diagnosis,
prognosis, treatment options, health promotion and
illness prevention strategies.
Criteria
• .e organization documents and implements
policies and procedures, and provides resources
to promote interactive, appropriate and relevant
educational programs for patients.
• Patients are aware of their roles and responsibilities
in their health care.
2.5.5 Drugs are administered in a standardized and

systematic manner in the provider organization.
Criteria
• Drugs are administered in a timely, safe, appropriate
and controlled manner.16
• e provider organization documents and follows
policies and procedures and allocates resources
for the training, supervision and evaluation of
professionals who administer drugs.17
• Only qualified personnel order, prescribe, prepare,
dispense and administer drugs.
• Regular review of prescription orders is undertaken
by appropriately trained staff to ensure safe and
appropriate use of drugs.18
• Prescriptions or orders are verified and patients are
identified before medications are administered.
• Telephone orders are countersigned by the ordering
physicians not later than standards set by the
organization and based on statutory requirements.
• Discontinued or recalled drugs are retrieved and
safely disposed of according to established policies
and procedures.
16
The processes of administering drugs should be documented in flowcharts. See Part III (Flow
Chart) for more information.
17
The Generics Act, National Drug Policy and the PhilHealth “Positive” List of Reimbursable
Drugs are examples of these government policies.
18
This is to ensure that prescriptions are written correctly (e.g., in generic form), and that
precautions for drug-drug and drug-food interactions have been adequately addressed.
BENCHBOOK
18
• Drugs are selected and procured based on the

organization’s usual case mix and according to policies
and procedures that are consistent with scientific
evidence and government policies.
• Drug administration is properly documented in the
patient chart.
• Policies and procedures for detecting, reporting
and monitoring adverse effects are documented and
monitored.
2.5.6 Treatment procedures are performed in a standardized

and systematic manner in the provider organization.
Criteria
• Treatment procedures are performed in a timely, safe,
appropriate and controlled manner.19
• e provider organization documents and reviews
policies and procedures and allocates resources for the
training, supervision and evaluation of professionals
who perform procedures.
• Only qualified personnel order, plan, perform and
assist in performing procedures.
• Orders are verified, and patients are identified before
treatment procedures are performed.20
• Treatment procedures are legibly and accurately
documented in the patient chart by qualified
personnel.21
• Medical devices and equipment are used, maintained,
stored and disposed based on technical specifications.
• Medical devices and equipment are selected and
procured based on the organization’s case mix, staff
expertise, service capability and according to policies
and procedures that are consistent with scientific
evidence and government policies.
19
The processes of performing the most common treatment procedures should be documented
in flowcharts. See Part III (Flow Chart) for more information.
20
Armbanding may be one method for identifying patients for surgery. The actual operative site
may be marked indelibly beforehand.
21
Treatment records should document who did what to whom, when and for what indication.
An appropriately adequate description of the procedure and operative findings should be
included in the records.
Quality Standards
19
2.5.7 e care of patients with special needs is governed by

policies and procedures that are consistent with legal
and ethical requirements.
2.6 Evaluation of Care
GOAL e health care team routinely and systematically evaluates and

improves the effectiveness and efficiency of care delivered to
patients.
STANDARDS 2.6.1 Data relating to processes and outcomes of patient

care are analyzed to provide information for care
improvement.
Criteria
• e organization routinely collects process and
outcomes data from its provision of patient care.
• e organization provides resources for the formal
and collaborative evaluation of care using analysis of
process and outcomes data.
• Results of evaluation of care are fed back to the
health care providers concerned.
• Results of evaluation of care are routinely presented
and discussed in meetings of top management.22
2.6.2 e health care team takes action to address any

improvements required.
Criteria
• Evaluation of care leads to formal and collaborative
performance improvement activities that harness the
resources of appropriate services.
22
There are many clinical tools that can be used to evaluate care, including medical audit,
utilization review, sentinel event monitoring and incident reporting. For more information on
how to conduct these routine assessments of care, refer to Part III.
BENCHBOOK
20
2.6.3 Quality improvement activities are documented, enable

continuous quality improvement and incorporate the
following elements:
➠ Monitoring, assessment, analysis and evaluation of

activities
➠ Appropriate and timely action
➠ Evaluation of the effectiveness of any action taken
➠ Feedback of evaluation results
2.7 Discharge
GOAL Care is coordinated between the organization and other health care
providers in the community to ensure that the needs of the patient
are continuously met.
STANDARDS 2.7.1 e discharge plan is part of the patient’s care plan and
is documented in the patient chart.
2.7.2 e organization provides information about the

continuing management plan to the patient and
relevant health care providers in a manner that
maintains patient confidentiality and privacy.
2.7.3 e organization arranges access to other relevant

community health services23 in a timely manner, and
ensures that patients are aware of appropriate services
before discharge.
2.7.4 Patients understand the discharge plans and their

responsibilities for continuing management.
23
Examples of other relevant community health services include, but are not limited to, rural health
units (RHU), Botika sa Barangay, etc.
Introduction
21
2 Patient Care
ACCESS STANDARDS GOAL:

• information about services The organization is accessible to the
• access to services community that it aims to serve.
ENTRY STANDARDS
• prompt and timely attention

• efficient triaging GOAL:
• unique patient identification The entry processes meet patient
• informed consent needs and are supported by
• planning for discharge and effective systems and a suitable
continuing care environment.
ASSESSMENT STANDARDS
• physical, psychological, social

assessment
GOAL:
• coordinated assessment by
professionals Comprehensive assessment of
every patient enables the planning
• regular assessments
and delivery of patient care.
• proper documentation of
assessments
• appropriate diagnostics
• special needs assessments
GOAL:
CARE PLANNING STANDARDS
The health care team develops in
• relevant to patients’ needs partnership with the patients a
• evidence-based care plan coordinated plan of care with goals.
• clear and accessible information
on care
BENCHBOOK
22
IMPLEMENTATION OF CARE
STANDARDS
• timely, safe, appropriate and

coordinated care delivery
• respect for patients’ needs and

GOAL:
rights
Care is delivered to ensure the best
• coordinated care delivery possible outcomes for the patient.
among professional
• patient education
• standardized drug
administration
• standardized treatment
procedures
• appropriate care for patients

with special needs
GOAL:
The health care team routinely
EVALUATION OF CARE STANDARDS and systematically evaluates and
improves the effectiveness and
• analysis of process and efficiency of care delivered to
outcomes data patients.
• actions for improvement
activities
CARE PLANNING STANDARDS
• discharge plan
GOAL:
• continuing management plan Care is coordinated between the
• patient access to community
organization and other health care
health services providers in the community to ensure
that the needs of the patient are
• patient understanding of continuously met.
discharge plan
Introduction
23
3. Leadership and Management
3.1 e Management Team
GOAL e organization is effectively and efficiently governed and

managed according to its values and goals to ensure that care
produces the desired health outcomes, and is responsive to
patients’ and community needs.
STANDARDS 3.1.1 e provider organization’s management team provides

leadership, acts according to the organization’s policies
and has overall responsibility for the organization’s
operation, and the quality of its services and its
resources.24
3.1.2 e organization’s management team ensures the

presence of effective working relationships within the
organization, with the community, and with other
relevant organizations and individuals.
3.1.3 Terms of reference, membership and procedures are

defined for the meetings of all committees within the
organization. Minutes of meetings are recorded and
approved.
3.1.4 e organization’s management team regularly assesses

its own performance and the performance of the
organization.
3.1.5 e organization develops and implements policies and

procedures which cover the major services and aspects of
operations.
24
The organization’s management team may consist of the hospital director or chief of
hospital or chief health officer together with the administrative officer and / or service
heads.
BENCHBOOK
24
Criteria
• e organization develops its mission, vision and
corporate goals based on agreed-upon values.
• e organization’s by-laws, policies and procedures
support care delivery and are consistent with its
goals, statutory requirements, accepted standards
and its community and regional responsibilities.
• Policies and procedures, aside from being complied
with, are reviewed and revised as necessary.
• e organization communicates its policies and
procedures to all levels of the workforce.25
3.2 External Services
GOAL e organization ensures that services provided by external

contractors meet appropriate standards.
STANDARDS 3.2.1 Documented agreements and contracts cover external

service providers and specify that the quality of
services provided must be consistent with appropriate
set standards.
25
Total quality management begins with commitment and tangible support from the
organization’s top leadership. Refer to the ”What is Quality of Care” section in Part 1 for a
discussion on its importance to the organization’s survival and on how it can be assessed and
improved. Also refer to Part III for step-by-step instructions on how to establish a total quality
management program.
Quality Standards
25
3 Leadership and
Management
GOAL:
The organization is effectively and
THE MANAGEMENT TEAM STANDARDS
efficiently governed and managed
according to its values and goals
• leadership to ensure that care produces
the desire health outcomes, and
• effective working relationships is responsive to patients’ and
community needs.
• committee meetings
• management performance
assessment
• policies and procedures for GOAL:

operations
The organization ensures that
EXTERNAL SERVICES STANDARDS services provided by external
contractors meet appropriate
• contracts standards.59
BENCHBOOK
26
4. Human Resource Management
4.1 Human Resources Planning
GOAL e organization provides the right number and mix of competent

staff to meet the needs of its internal and external customers and to
achieve its goals.
STANDARDS 4.1.1 Planning ensures that appropriately trained and

qualified (and where relevant, credentialed) staff are
available to undertake the type and level of activity
performed by the organization. is includes those who
are consulted26 when suitable expertise is not available
within the organization.
Criteria
• e organization defines the qualifications and
competencies of its staff.
• e organization documents and follows policies and
procedures for hiring, credentialing and privileging of
its staff.
4.1.2 Workload is monitored and appropriate guidelines

consulted to ensure that appropriate staff numbers and
skill mix are available to achieve desired patient and
organizational outcomes.
Criteria
• Staff numbers and skill mix are based on actual
clinical needs.27
• Appropriate policies and procedures are monitored

to temporarily compensate for, and to definitively,
address inadequacies in staff numbers or expertise.
26
Those who are consulted include technical as well as medical consultants, such as engineers,
waste disposal experts, accountants, etc.
27
The hospital may document and analyze information, like daily patient loads, utilization rates of
services, turnaround times, to determine staff size and mix.
Quality Standards
27
4.2 Staff Recruitment, Selection, Appointment and Responsibilities
GOAL Recruitment, selection and appointment of staff comply with

statutory requirements and are consistent with the organization’s
human resource policies.28
STANDARDS 4.2.1 Recruitment, selection, appointment and reappointment

procedures ensure appropriate competence, training,
experience, licensing and credentialing of all appointees.
Criteria
• e organization defines, disseminates and ensures
compliance with policies and procedures governing
personnel recruitment, selection and appointments.
• e recruitment and selection process is open and
transparent, is consistent with legal and ethical
requirements, and allows a fair and unbiased
evaluation of the qualifications and competencies of
all applicants.
• Relevant staff members participate in the
development and implementation of personnel
recruitment, selection and appointment.
• Selection and appointment and evidence of staff
compliance with selection or appointment standards
are documented
• Relevant licenses are routinely monitored for renewal.
• Evidence of continuing staff education and training is
routinely monitored and assessed.
4.2.2 Upon appointment, staff members receive a written

statement of their accountabilities and responsibilities
that specifies their role and how it contributes to the
attainment of the goals and maintaining quality of care.
e statements are reviewed when necessary.
28
Staff in this context refers to employees, contractors and other service providers.
BENCHBOOK
28
Criteria
• Written job descriptions are given to and discussed
with all newly-appointed staff members.
4.2.3 Staff members are accountable for the care and services
they give and for the discharge of their delineated
responsibilities.29
Criteria
• e organization ensures that staff accountabilities
and responsibilities are consistent with their
qualifications, training, experience, registration and
licensure.
4.2.4 All services are provided by staff members with

appropriate qualifications, experience or training.
Criteria
• All doctors, nurses and midwives providing clinical
care have current licenses and documented evidence
of appropriate training and experience.
• All administrative, business and technical services
staff have current licenses and documented evidence
of appropriate training and experience.
4.3 Staff Training and Development
GOAL A comprehensive program of staff training and development

meets individual and organizational needs.
STANDARDS 4.3.1 ere are relevant orientation, training and

development programs to meet the educational needs
of management and staff.
29
Logbooks of procedures document the identities of the staff member who did the procedures. All
entries in the patient chart are legibly signed by the originators—those who wrote the entry in the
patient chart—and dated.
Quality Standards
29
Criteria
• e organization assesses the educational needs of
management and staff and identifies and/or provides
resources to meet those needs.
• Policies and procedures for orientation of new
management and staff are documented and
monitored.
• e organization evaluates the effectiveness of
training and development programs to ensure that
they meet organizational, community and individual
needs.
4.3.2 e organization clearly defines and ensures compliance

with the lines of authority and supervision.
Criteria
• New personnel—including trainees, volunteers, new
graduates and external contractors—are adequately
supervised by qualified staff.
• e staff are provided with a documented
job description outlining accountabilities and
responsibilities.
BENCHBOOK
30
4 Human Resource
Management GOAL:
The organization provides
the right number and mix of
HUMAN RESOURCES PLANNING competent staff to meet the
STANDARDS needs of its internal and external
customers and to achieve its goals.
• HR needs assessment
• workload monitoring
STAFF RECRUITMENT,
SELECTION, APPOINTMENT AND GOAL:
RESPONSIBILITIES STANDARDS Recruitment, selection and
appointment of staff comply with
• procedures
statutory requirements and are
• job descriptions consistent with the organization’s
human resource policies.
• staff accountabilities
• service provision by appropriate

staff
GOAL:
STAFF TRAINING & DEVELOPMENT A comprehensive program of

STANDARDS staff training and development
meets individual and
• orientation, training and organizational needs.
development programs
• supervision
Introduction
31
5. Information Management
5.1 Data Collection, Aggregation and Use
GOAL Collection and aggregation of data are done for patient care,
management of services, education and research.
STANDARDS 5.1.1 Relevant, accurate, quantitative and qualitative data are

collected and used in a timely and efficient manner for
delivery of patient care and management of services.
Criteria
• e organization defines the relevant aspects of its
operations from which data will be collected.
• e organization defines data sets, data generation,
collection and aggregation methods and the qualified
staff who are involved in each stage.
• e organization defines policies and procedures to
monitor and improve the accuracy, completeness and
reliability of relevant qualitative and quantitative data
relating to its operations.
• e organization provides resources and opportunities
to enable management and staff to use data in their
decision and policymaking activities.
• Policies and procedures on record storage, retention
and disposal are documented and monitored.
5.1.2 e collection of data and reporting of information

comply with professional standards, statutory and
PhilHealth requirements.
Criteria
• e organization collects and submits reports required
by the Department of Health and PhilHealth.
BENCHBOOK
32
5.1.3 Every patient has a sufficiently detailed patient chart

to facilitate continuity of care, and meet education,
research, evaluation and medico-legal and statutory
requirements.
Criteria
• Care providers document management details in the
patient chart. All entries are promptly accomplished,
accurate, legible, dated and duly signed by the care
providers whose designations are clearly indicated.30
• Patient charts are routinely checked for

completeness and accuracy, and action is taken to
improve their quality.
5.1.4 Data in the patient charts are coded and indexed to

ensure the timely production of quality patient care
information and reports to PhilHealth.31
Criteria
• Data from the patient charts are routinely
collected, aggregated and reported for use in quality
improvement activities, for administrative purposes
and for mandatory reporting to the Department of
Health and PhilHealth.
5.2 Records Management
GOAL Integrity, safety, access and security of records are maintained and
statutory requirements are met.
30
Documentation in patient charts should be sufficiently detailed to enable any member of the
health care team to understand care plans and care provision. Clinical pathways are excellent
means to achieve this.
31
Data from patient charts are used in peer review, medical audits, variance analysis, quality
circle meetings, etc.
Introduction
33
STANDARDS
5.2.1 Clinical records are readily accessible to facilitate patient

care, are kept confidential and safe, and comply with all
relevant statutory requirements and codes of practice.
Criteria
• When patients are admitted or are seen for ambulatory
or emergency care, patient charts documenting any
previous care can be quickly retrieved for review,
updating and concurrent use.
• e organization has policies and procedures, and
devotes resources, including infrastructure, to protect
records and patient charts against loss, destruction,
tampering and unauthorized access or use. Only
authorized individuals make entries in the patient chart.
5 Information Management
GOAL:
Collection and aggregation
DATA COLLECTION, AGGREGATION AND
USE STANDARDS
of data are done for patient
care, management of services,
• timely and efficient data education and research.
collection
• standardized information
• detailed medical charts
• coding and indexing of data GOAL:

Integrity, safety, access
RECORDS MANAGEMENT STANDARD and security of records are
maintained and statutory
• accessible records requirements are met.
BENCHBOOK
34
6. Safe Practice and Environment
6.1 Patient and Staff Safety
GOAL Patients, staff and other individuals within the organization are
provided a safe, functional and effective environment of care.
STANDARDS 6.1.1 e organization plans a safe and effective

environment of care consistent with its mission,
services, and with laws and regulations.
Criteria
• e organizational environment complies with
structural standards and safety codes as prescribed
by law.32
• ere are management plans which address safety,
security, disposal and control of hazardous materials
and biological wastes, emergency and disaster
preparedness, fire safety, radiation safety and utility
systems.
• ere are management plans for the safe and
efficient use of medical equipment according to
specifications.
6.1.2 e organization provides a safe and effective

environment of care consistent with its mission and
services, and with laws and regulations.
Criteria
• Policies and procedures that address safety, security,
control of hazardous materials and biological wastes,
emergency and disaster preparedness, fire safety,
radiation safety and utility systems are documented
and implemented.
32
The organization maintains current licenses and permits that ensure safe and effective
operations. Such permits include, but are not limited to, occupancy, electrical, plumbing,
radiation safety, fire safety, occupational safety, food storage and handling and waste disposal.
Introduction
35
• Policies and procedures for the safe and efficient use

of medical equipment according to specifications are
documented and implemented.
• e design of patient areas provides sufficient space
for safety, comfort and privacy of the patient and for
emergency care.
• All personnel understand and fulfill their role in safe
practice.
• Risks are identified, assessed and appropriately
controlled. Where elimination or substitution is not
possible, adequate warning and protection devices are
used.
• A coordinated security arrangement in the
organization assures protection of patients, staff, and
visitors.
6.1.3 e organization routinely collects and evaluates

information to improve the safety and adequacy of the
environment of care.
Criteria
• e effectiveness of safety procedures and devices are
routinely tested, monitored and improved.33
• An incident reporting system identifies potential
harms, evaluates causal and contributing factors for
the necessary corrective and preventive action.
6.2 Maintenance of the Environment of Care
GOAL A comprehensive maintenance program ensures a clean and safe

environment.
33
Staff compliance with safety procedures, performance in emergency and fire drills, handling
and operation of medical devices are regularly assessed and monitored. Findings of routine
checks of equipment and facilities are documented and appropriately reported.
BENCHBOOK
36
STANDARDS 6.2.1 Emergency light and / or power supply, water and

ventilation systems are provided for, in keeping with
relevant statutory requirements and codes of practice.
6.2.2 Regular maintenance of grounds, facilities and

equipment in keeping with relevant statutory
requirements, codes of practice, or manufacturers’
specifications are done to ensure a clean and safe
environment.
6.2.3 Equipment is serviced only by people trained in the

maintenance of that equipment. Registers and records
of equipment and related maintenance are kept.
6.2.4 Current information and scientific data from

manufacturers concerning their products are available
for reference and guidance in the operation and
maintenance of plant and equipment.
6.3 Infection Control
GOAL Risks of acquisition and transmission of infections among

patients, employees, physicians and other personnel, visitors and
trainees are identified and reduced.
STANDARDS 6.3.1 An interdisciplinary infection control program ensures

the prevention and control of infection in all services.
6.3.2 e organization uses a coordinated system-wide34

approach to reduce the risks of nosocomial infections.
34
System wide refers to the different processes making up the entire system.
Introduction
37
Criteria
• e organization undertakes case finding and
identification of nosocomial infections.
• e organization takes steps to prevent and control
outbreaks of nosocomial infections.
6.3.3 e organization uses a coordinated system-wide

approach to reduce the risks of infection the staff are
exposed to in the performance of their duties.
Criteria
• ere are programs for prevention and treatment of
needlestick injuries, and policies and procedures for
the safe disposal of used needles are documented and
monitored.
• ere are programs for the prevention of transmission
of airborne infections, and risks from patients with
signs and symptoms suggestive of tuberculosis or
other communicable diseases are managed according
to established protocols.
6.3.4 Cleaning, disinfecting, drying, packaging and

sterilizing of equipment, and maintenance of
associated environment, conform to relevant statutory
requirements and codes of practice.
6.3.5 When needed, the organization reports information

about infections to personnel and public health
agencies.
6.4 Equipment and Supplies
GOAL e provision of equipment and supplies supports the

organization’s role.
BENCHBOOK
38
STANDARDS 6.4.1 Planning of facilities and selection and acquisition of

equipment and supplies involve input from relevant
staff and are undertaken by appropriately-qualified
personnel.
Criteria
• Appropriate equipment and supplies that support
the organization’s role and level of service are
provided. Consideration is given to at least:
➠ the intended use
➠ cost benefits
➠ infection control
➠ safety
➠ waste creation and disposal
➠ storage
6.4.2 Specialized equipment is operated according to

specifications and only by appropriately-trained staff.
6.4.3 Items designated by the manufacturer for single use

are not reused unless the organization has specific
policies and guidelines for safe reuse which take into
consideration relevant statutory requirements and
codes of practice.
6.5 Energy and Waste Management
GOAL e organization demonstrates its commitment to environmental

issues by considering and implementing strategies to achieve
environmental sustainability.
STANDARDS 6.5.1 e handling, collection, and disposal of waste

conform to relevant statutory requirements and codes
of practice.
6.5.2 e organization implements a waste disposal program

which involves reuse, reduction and recycling.
Quality Standards
39
6 Safe Practice and

Environment
GOAL:
PATIENT AND STAFF SAFETY STANDARDS Patients, staff and other individuals
• plan of safe and effective within the organization are
environment of care provided a safe, functional and
• provision of safe and effective effective environment of care.
environment of care
• routine evaluation of
environment of care
MAINTENANCE OF THE ENVIRONMENT GOAL:

OF CARE STANDARDS
A comprehensive maintenance
• emergency light, power supply,
water and ventilation program ensures a clean and safe
environment.
• regular maintenance of facilities
and equipment
• maintenance of equipment by
qualified personnel
• current information on products
are available GOAL:
INFECTION CONTROL STANDARDS Risks of acquisition and transmission

of infections among patients,
• infection control program
employees, physicians and other
• risk reduction of nosocomial personnel, visitors and trainees are
infection
identified and reduced.
• standardized cleaning and
sterilization procedures
• internal and external reporting
GOAL:
EQUIPMENT & SUPPLIES STANDARDS
The provision of equipment
• planning and acquisition of and supplies supports the
equipment and supplies
organization’s role.
• specialized equipment operated
by qualified staff
• safe reuse guidelines
GOAL:
ENERGY & WASTE MANAGEMENT
STANDARDS The organization demonstrates its
• standardized waste handling and commitment to environmental issues
disposal program by considering and implementing
• implementation of a waste disposal strategies to achieve environmental
program sustainability.
BENCHBOOK
40
7. Improving Performance
GOAL e organization continuously and systematically improves its

performance by invariably doing the right thing the right way the
first time and meeting the needs of its internal and external clients.
STANDARDS 7.1 e organization has a planned systematic organization-

wide approach to process design and performance
measurement, assessment and improvement.
7.2 New processes of care are designed collaboratively based

on scientific evidence, clinical standards, cultural values
and patient preferences.35
Criteria
• ere are resources available for developing or
adopting clinical practice guidelines.
• Clinical practice guidelines for the top 10 causes of
admissions and / or consultations and PhilHealth-
adopted guidelines are disseminated and monitored.
7.3 Management is primarily responsible for developing,

communicating, and implementing a comprehensive
quality improvement program throughout the
organization and delegating responsibilities
to appropriate personnel for its day-to-day
implementation.
7.4 All service units and staff are responsible for, and
demonstrate involvement in, performance improvement
that results in better services for internal and external
clients.
35
Important processes of care include invasive and non-invasive surgical procedures, medication use, and
hospital admissions. Important outcomes include patient and staff satisfaction, lengths of stay, staff
views, and autopsy results.
Quality Standards
41
7.5 Managers and staff evaluate the effectiveness of the

quality improvement program and take action to
address any improvements required.
7.6 e organization provides better care and service as a

result of continuous quality improvement activities.
7.7 Quality improvement activities respect the

confidentiality of data regarding patients, staff and
other care providers.
7
GOAL:
Improving Performance
The organization continuously
and systematically improves its
STANDARDS
performance by invariably doing
the right thing the right way the
• organization-wide approach
first time and by meeting the
• collaboration in new processes needs of its internal and external
of care clients.
• management responsibility
• service unit and staff

responsibility
• evaluation of quality
improvement program
• better service and care
• confidentiality of data
BENCHBOOK
42
Glossary
43
Glossary

BENCHBOOK
44
Glossary
45
Glossary
Accreditation verification process of the qualification and capabilities of

health care providers prior to granting of privilege of
participation in the National Health Insurance Program (NHIP),
to ensure that health care services they are to render have the
desired and expected quality.
• Accreditation, initial
accreditation given to a health care provider applying for
the first time.
• Accreditation, renewal
accreditation given to a health care provider after the
expiration of a previous accreditation.
• Accreditation, provisional
accreditation granted to a health care provider applying
for renewal while compliance to standards/ requirements
set by the Corporation are being completed for a period
determined by the same.
• Accreditation, reinstatement
restoration of accreditation following a suspension of an
accreditation after compliance with the requirements,
conditions and corrections imposed by the Corporation.
• Re-accreditation
accreditation given to a health care provider following the
expiration or denial of a previous accreditation or
following a change of ownership or upgrading of
capability of institutional health care providers or
acquisition of specialty capabilities and skills by
professional health care providers.
Adverse events injury caused by medical management (and not necessarily the
disease process) that either caused death, prolonged
hospitalization or produced a disability at the time of discharge.
BENCHBOOK
46
Affinity diagram used to creatively generate a large number of ideas/issues and then
organize and summarize natural groupings among them to
understand the essence of a problem and its breakthrough solutions.
Ambulatory surgical clinic an institution or entity accredited by the Department of Health to

provide out-patient surgical services.
Audit a process used to identify opportunities for improvement by

reviewing the procedures used in the diagnosis, treatment and care
of specific patients, as well as the associated use of resources and
the resulting outcomes.
Bar graph summarizes continuous data by showing the frequency of

occurrence of different kinds of events.
Benchmarking process of measuring an organization’s performance on certain

processes or procedures in comparison with identified centers or
practices of excellence in order to improve performance.
• Comparative method
standards are derived from comparison with other
performance rates of compliance to common performance
measures.
• Prescriptive method
standards are derived from medical literature and expert
opinions on what should be achieved.
Brainstorming an activity used to creatively and efficiently generate a high volume

of ideas on any topic by a process.
Case mix the type and number of patient groups an organization serves.
Case payment payment based on the condition itself, and not on the specific
medical or surgical intervention used.
Cause-effect analysis used to identify, explore and graphically display, in increasing

detail, all possible causes related to a problem or condition to
discover its root cause(s).
Glossary
47
Check sheet used to systematically record and compile data from historical
sources, or observations as they happen, so that patterns and
trends can be clearly detected and shown.
Clinical audit see Medical audit.
Clinical pathway an interdisciplinary plan of care that outlines the optimal

sequencing and timing of interventions and expected outcomes
for patients with a particular diagnosis, procedure or symptom.
Clinical practice guidelines systematically developed statements, built on synthesis of

evidence, which provide formal recommendations about
appropriate and necessary care, intended to assist practitioner
and patient to make decisions about appropriate health care for
specific clinical circumstances.
Competence required expertise necessary for the performance of a medical

intervention or the delivery of health services.
Complaints analysis process wherein expressions of dissatisfaction of patients and staff

are analyzed to identify areas for improvement.
Compliance utilization of performance data to identify problems and

opportunities for improvement, and pave the way for concrete
action to improve performance.
Complications circumstances that make an event difficult to manage.
Control chart line graph used to monitor, control and improve performance
over time by studying process variations and their causes.
Credentialing and privileging a process that matches the work that a practitioner wishes to
perform in a hospital with his or her demonstrated competence
and professional skill.
Criteria statements that lay down specific actions that need to be done to
meet a standard.
Deming cycle see Plan-Do-Check-Act cycle.

BENCHBOOK
48
Diagnostic procedure any procedure employing analysis and examination to identify a

disease or condition.
Document review inspection or assessment of a document intended to identify

opportunities for improvement.
Emergency unforeseen combination of circumstances which calls for immediate

life-preserving or quality-of-life preserving actions (to preserve sight
in one or both eyes, hearing in one or both ears, extremities at or
above the ankle or wrist).
Environment of care surroundings or conditions under which the process of health care
provision occurs.
Equitable access fair and impartial opportunity to enter a place or to obtain a

particular service.
Evaluation of care assessment of the process of care provision.
Evidence-based medicine the use of current best evidence in making medical decisions.
Expanded incident monitoring routine process of identification, processing, analysis and reporting of
deviations from expected or standard practice to prevent recurrence.
Fee-for-service reasonable and equitable health care payment system in which

physicians and other health care providers receive payment not
exceeding their billed charge for each unit of service provided.
Fishbone diagram see Cause-effect analysis.
Flowchart diagram used to show the actual flow or sequence of events in a

process.
Force field analysis analysis tool used to identify the forces and factors in place that
support or work against the solution of an issue or problem so that
the positives can be reinforced and/or the negatives eliminated.
Goal statement describing the desired-for situation targeted by a

performance improvement program.
Glossary
49
Gross negligence the want of care and diligence expected of a reasonable

individual, which may point to a presumption of indifference to
potential or actual danger of injury to another person or of
damage to property of others.
Guideline flexible technical references describing what health care providers

should or should not do for a given clinical condition.
Health care provider any of the following:

• Health care institution
duly licensed and/or accredited, devoted primarily to the
maintenance and operation of facilities for health
promotion, prevention, diagnosis, treatment and care of
individuals suffering from illness, disease, injury,
disability or deformity, or in need of obstetrical or other
medical and nursing care. It shall also be construed as
any institution, building, or place where there are
installed beds, cribs, or bassinets for twenty-four hour use
or longer by patients in the treatment of disease, injuries,
deformities, or abnormal physical and mental states,
maternity cases; or infirmaries, nurseries, dispensaries,
and such other similar names by which they may be
designated.
• Health care professional

any doctor of medicine, nurse, midwife, dentist or other
health care professional or practitioner duly licensed to
practice in the Philippines and accredited by PhilHealth.
• Health maintenance organization

an entity that provides, offers or arranges for coverage of
designated health services needed by plan members for a
fixed pre-paid premium.
• Preferred provider organization

a network of providers whose services are available to
enrollees at lower cost than the services of non-network
providers.
BENCHBOOK
50
• Community-based health care organization

an association of residents in a community organized for the
improvement of the health status of that community through
preventive, promotive and curative health services.
Health education any and all information that help patients make informed choices
about personal health, available health services, healthy lifestyles,
disease prevention and early detection of illness.
Health provider organizations see Health care provider.
High-volume services frequently-performed services or those which affect a large number

of people.
Histogram see Bar graph.
Hospital an institution, building or place, government or private, duly

licensed by the Department of Health and accredited by PhilHealth,
where there are installed beds, cribs or bassinets for 24-hour use or
longer by patients in the treatment of diseases, injuries, deformities,
abnormal physical and mental states, and/or maternity cases.
Indicator a measurable variable or characteristic that can be used to determine

the degree of adherence to a standard or achievement of quality
goals.
Information meaningful, interpreted and processed data used to make judgment

on a hypothesis or answer a research question.
Informed consent Generally understood as the implied or explicit (read: written

permission) given by the patient prior to initiation of care following
provision of sufficient information to make an informed judgement
on medical treatment choices. It, however, refers more to the process
by which patients are made to participate in the decisions involved in
their health care. Informed consent is founded on patients’ legal and
ethical right to direct what happens to their bodies and from the
doctor’s ethical duty to involve patients in the treatment process. It
includes a patient-doctor discussion of the following issues: the
nature of the decision or procedure; reasonable alternatives to the
proposed intervention; the relevant risks, benefits, and uncertainties
Glossary
51
related to each alternative; assessment of patient understanding;

and patient’s acceptance or refusal of the intervention.
Initial accreditation see Accreditation.
Length of stay the number of days a patient remains in the hospital.
Line graph graph showing the number of events through time.
LOS see Length of stay.
Matrix diagram diagram used to systematically identify, analyze and rate the
presence and strength of relationships between two sets of
information.
Medical audit process of identifying opportunities to improve diagnosis

treatment and care of specific patients.
• Clinical audit
patient-focused audit process involving doctors, nurses and
other clinicians who comprise the clinical care team.
• Nursing audit
patient-focused audit process of nursing care.
Medical intervention any action of a health care professional aimed at providing life
saving action, relief of pain, prevention or mitigation of disability
using pharmacological, surgical or diagnostic modalities.
Medical review criteria Medical review criteria are statements used to assess specific
health care decisions, services and outcomes.
Meta-analysis the statistical synthesis of the results of several studies testing the
same relationship into a single outcome measure, thus increasing
the strength of the conclusion.
National Health Insurance the compulsory health insurance program of the government as
Program (NHIP) established in the National Health Insurance Act of 1995 (RA
7875) which shall provide universal health insurance coverage
and ensure affordable, acceptable, available and accessible health
care services for all citizens of the Philippines.
BENCHBOOK
52
Nominal group technique team brainstorming method used to quickly come to a consensus
on the relative importance of issues, problems or solutions by
combining individual rankings.
Nosocomial infection infection acquired from the hospital
Nursing audit see Medical audit.
Organizational ethics code of moral values that should be present in an organization
Outcome the effect of care on the health status of patients and populations
seen in less impairment of functions, less pain and suffering,
and/or less illness.
Outcomes assessment process of monitoring and review of end results of the health
service rendered by providers both from the standpoint of effects
on health and/or member satisfaction.
Outcome-based standard measure of the quality of care rendered based on the end-result of
health care provision, including the presence or absence of death,
disability, pain, dissatisfaction, or cure.
Pareto chart data analysis tool which combines analysis of the frequency of a
problem and analysis of its causes by identifying the most
influential cause or causes, also called the “vital few,” thereby
separating them from the “trivial many.”
Pathway review assessment or evaluation of the flow of care provision for a specific
condition.
Patient pathways see Clinical Pathway.
Patient rights the moral and legal entitlement of a patient to care.
PDCA see Plan-Do-Check-Act cycle.
PDPC see Process Decision Program Chart.
Peer review process by which the treatment of a patient or the performance of a

health care professional is reviewed by his/her professional
colleagues either within his/her professional organization or
Glossary
53
hospital, when commissioned by the Corporation to undertake

the same, or within the Corporation itself. e result of said
review can be utilized as basis for payment or non-payment of
claims.
Performance measure a standard used to assess the level of function of a task, activity or
program.
Performance monitoring ongoing measurement of a variety of indicators of health care

quality to identify opportunities for improvement in health care
delivery.
Philippine Health Insurance the corporation mandated by law to administer the National
Corporation (PHIC) Health Insurance Program
Philippine National Drug Formulary the essential drugs list for the Philippines prepared by the
National Drug Committee of the Department of Health in
consultation with experts and specialists from organized
professional medical societies, academe and the pharmaceutical
industry and which is updated every year.
Pie chart pictorial diagram which illustrates proportion of specific items to

the entire unit.
Plan-Do-Check-Act cycle a systematic method for identifying areas for improvement, pilot
testing solutions, evaluating results, and institutionalizing long-
term solutions
Practice guidelines the usual standard operating procedure followed by a certain

group.
Prescription drug a drug approved by the Bureau of Food and Drug and which can
only be dispensed through a prescription order from a duly
licensed physician.
Primary care the basic or general medical care sought by the patient for
treatment of the simpler and more common illnesses.
Problem-oriented progress notes records regarding the developments in a patient’s condition based
on the most recent assessment of difficulties encountered.
BENCHBOOK
54
Process denotes what is actually done to and for the patient in giving and
receiving care. It includes the patient’s activities in seeking care and
carrying it out, as well as the physician’s activities in making a
diagnosis and recommending or implementing treatment.
Process Decision Program Chart used for contingency planning after the identification of a possible
solution to a certain problem, wherein possible problems are
identified for each step of the proposed solution and reasonable
steps are listed as countermeasures.
Provider organization see Health care provider
Quality assurance a formal set of activities to review and ensure the quality of services
provided. It includes quality assessment and corrective actions to
remedy any deficiency identified in the quality of direct patient,
administrative and support services.
Quality circle a group of 5 to 10 workers from one work area of an organization

who meet regularly to identify and solve problems in their work
area using their own resources.
Quality control inspection of finished products to detect deviations from

predetermined design.
Quality health care optimum attainable outcome as a result of health care provision.
Quality improvement upgrading from previously accepted minimal performance

standards.
Quality management the organization-wide pursuit of quality.
Quality team see Quality circle.
Radar chart data analysis tool which illustrates in one graph the size of the gaps
between a number of current organizational performance levels and
ideal performance levels.
Randomized control trial (RCT) an experimental study in which participants have equal
opportunity to be assigned to a treatment or control group.
Reinstatement see Accreditation.

Glossary
55
Renewal accreditation see Accreditation.
Risk management an organized effort to identify, assess, and reduce, where

appropriate, risks to patients, visitors, staff and organizational
assets.
Scatterplot diagram data analysis tool which shows whether or not two sets of
observations or data are related in a linear fashion.
Sentinel event an unexpected occurrence involving death or serious physical or

psychological injury, and includes any process variation for which
recurrence would carry a significant chance of a serious adverse
outcome.
Skill mix the type and number of skills/expertise available in the

organization.
SOAP subjective-objective-assessment-plan sequence of evaluating the

care needed for any particular patient.
Stakeholder person or group of persons with an interest in or concern with

something.
Standards statements of expectations for the inputs, processes, behaviors

and outcomes of health systems.
Structure concrete, countable, measurable and often visible attributes of

the setting in which the provision of health care occurs. Major
categories include: physical inputs, staffing, money and
organizational management.
“Swiss cheese” model a theory proposed by human factors engineering pioneer James
Reason, which states that errors happen in any organization
because there are “holes” in the system and when they “align”—
happening at a certain sequence or combination—they form a
trajectory which opens up opportunities for errors to happen.
System problem a difficulty attributed to the organization or its processes, in

contrast to individual attribution of cause.
BENCHBOOK
56
Terms of reference an enumeration of expected input and output, methodology and

whatever limitations that would bind involved parties.
Timeline timeframe showing chronological sequence
Triage the act of assigning degrees of urgency to wounds or illnesses to

decide the order of treatment of a large number of patients.
Total quality management see Quality Management.

(TQM)
Treatment procedure any method used to remove the symptoms and cause of a disease.
Tree diagram graphic tool used to organize tasks into increasing levels of detailed
actions that must or could be done to achieve stated goals.
Utilization review a formal evaluation of the necessity, appropriateness and efficiency

of the use of medical services, procedures and/or facilities on a
prospective, concurrent or retrospective basis, including but not
limited to examination of the clinical application of medical
knowledge as revealed by medical records.
Variance analysis data interpretation tool used to document and identify the most
common causes of deviation from routine care.
Warranties the guarantee that a health care provider applying for accreditation
agrees to abide by the provisions of the National Health Insurance
Law (RA 7875), its Implementing Rules and Regulations and all
PhilHealth Administrative Orders during its participation in the
National Health Insurance Program.

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Benchbook

On Performance Improvement of Health Services

Philippine Health Insurance Corporation

Published by the Philippine Health Insurance Corporation (PhilHealth)

Copyright © 2004 PhilHealth

Editor: Wystan de la Peña

From the President and CEO ................................................................................ i

PhilHealth Quality Standards for Health Provider Organizations .................... 1

From the President and CEO

The Benchbook is not an all-encompassing and exhaustive textbook

Envisioned to serve as a yardstick for measuring and assessing the

Also included is an updated list of standards and criteria which

Production of this Benchbook has been made possible through a

Finally, I commend Dr. Madeleine R. Valera, PhilHealth Vice President

Francisco T. Duque, M.D., MSc

Philippine Health Insurance Corporation

From the Quality Assurance Research

Realizing that deficiencies in processes would not be corrected by

In the past couple of years since PhilHealth assumed the role

Avedis Donabedian, a pioneer in quality assurance in health care,

The Benchbook features a concise list of best possible conditions that

As writing the Benchbook involved different kinds of input from

Reviewing and rewriting Part II (PhilHealth Quality Standards for

In the final production phase of the Benchbook, Dr. Evangelista acted

Philippine Health Insurance Corporation

As editor, Prof. Wystan de la Peña of the University of the Philippines

Madeleine R. Valera, M.D., MScCHHM

PhilHealth Quality Standards

➠ Patient Rights and Organizational Ethics

➠ Patient Care Standards

➠ Leadership and Management

➠ Human Resource Management

➠ Safe Practice and Environment

Philippine Health Insurance Corporation

PhilHealth Quality Standards

Sometime in 2000, PhilHealth’s Quality Assurance Research

us, while DOH standards focus on structure (physical plant,

is Quality Standards portion is divided into the following

While goals picture the desired-for situation targeted by a

Philippine Health Insurance Corporation

attain quality performance. Standards set maximum achievable

Assessment of a health care organization’s performance in

A complete listing of indicators will be published separately as an

Performance Patient Rights

Safe Practice &

Information Leadership &

Figure 7. PhilHealth Quality Standards for Health Care

1. Patient Rights2 and Organizational Ethics

GOAL To improve patient outcomes by respecting patients’ rights and

STANDARDS 1.1 Organizational policies and procedures respect and

Philippine Health Insurance Corporation

• Policies and procedures which identify and address

1.2 e organization encourages and promotes

1.3 e organization documents and follows policies

1.4 e organization systematically elicits, monitors and

1.5 e organization’s personnel discharge their functions

1.6 e organization documents and follows procedures for

Philippine Health Insurance Corporation

1 Patient Rights and

• respect and support for patients’

• staff code of ethics

• resolution of ethical issues

2. Patient Care Standards