Cotabato Regional and Medical Center

PGS Module

July 16 – 18, 2018

DAPA Hall, Philippine Heart Center
Vision

Cotabato Regional and Medical Center shall be a Multi-specialty Center for Health and Research by
2022

Mission

To deliver quality, affordable, equitable and sustainable specialized health services and research in
partnership with all stakeholders towards customers' satisfaction

Core Values

Commitment, Competence, Compassion, Loyalty,

Integrity, Teamwork, Gender Sensitivity
 STRATEGIC POSITION

TO
FROM AREA
2022 2028
Multi-specialty Centers Multi-specialty Centers

Trauma Neurology
Cancer Kidney and Transplant
Level III Teaching and Training
Cardiology Toxicology and Poisoning
Hospital with General and
Services Reproductive Health Tropical Medicine
Specialty Services
Neonatology Burn
Physical and Rehabilitation Medicine Lung
Mental Health Orthopedic
Stroke Geriatric
Diabetes

Region XII and ARMM Region XII and ARMM

Constituents
400-bed capacity 600-bed capacity
 STRATEGIC GOALS

Goal Measure BL 2022 2028

Trauma
Neurology
Cancer
Kidney and Transplant
Cardiology
Position CRMC as a Toxicology and Poisoning
Reproductive Health
Multi-specialty DOH Recognition Tropical Medicine
Neonatology
Center in Region XII of center Burn
Physical and Rehabilitation Medicine
and ARMM by 2022 Lung
Mental Health
Orthopedic
Stroke
Geriatric
Diabetes
 IMPACT
BL
Impact Indicator 2022
2018
Decrease Mortality Rate 2.73% < 2.5%
Increase Number of patient's discharged
86.5% 90%
Better Health Outcomes improved/recovered
Decrease referral to higher centers for Level III cases TBD TBD
Increase referral from other hospitals for Level III cases TBD TBD
Increase Customer Satisfaction Rating 98% 100%

Responsive Health Research translated into guideline for better case

0 10
management
System
Research translated into policies for better public health
0 -
management
Increase in Number of Patients Enrolled in POC/POS 80.3% 85%
Financial Risk Protection
Increase Number of No Balanced Billing patients 53.9% 80%
 VISION STRATEGY MAP 2022
Cotabato Regional and Medical Center shall be a COTABATO REGIONAL AND
Multi-specialty Center for Health and Research by 2022 MEDICAL CENTER
Impact

Better Health Outcomes Responsive Health Services Financial Risk Protection

Strategic
Position

Position CRMC as a Multi-specialty Center in Region XII and ARMM by 2022

Produce institutional research Strengthen and establish

Process

Deliver quality and specialized Develop proficient, competent aligned with community needs linkages
Core

patient care and certified personnel towards improvement of to provide multi-specialty

patient services services

Build a network of human

resources trained in different
specialties to facilitate and run
the different multi-specialty
Process
Support
Institutionalize a culture of Complete infrastructure Use technology to improve
patient safety, holistic care and projects on time and accepted efficiency of health delivery and
satisfaction by end-users processes

centers

Generate and utilize funds to meet the financial

and operational requirements of multi-specialty service centers

MISSION CORE VALUES

To deliver quality, affordable, equitable and sustainable Commitment, Competence,
specialized health services and relevant research in partnership Compassion, Loyalty, Integrity,
with all stakeholders towards customers' satisfaction Teamwork, Gender Sensitivity
 Patient Care PERFORMANCE COMMITMENTS
Provide quality and
Number of patients served by the specialty centers
specialized patient care
DELIVERABLES
OPR 2017 BL
2018 - 2019 2020 2021 2022

Operational Centers: Operational Centers: Operational Center: • Family Medicine

• Cancer Center • Minimally Invasive • Neonatology Center practitioner
General and Specialty services • Heart Center Surgery Unit • Department of
in Medicine, Surgery (including • Physical and • Women’s Health Center Neurology
Ophthalmology, Rehabilitation Medicine • Department of • Department of
Otorhinolaryngology and Center Orthopedics Ophthalmology
Orthopedics), Obstetric and • Mental Health Center • Department of ENT -
Gynecology, Pediatrics • Stroke Center HNS
• Diabetes Center • Emergency Medical
• Trauma Center Physician
At least one (1) clinical At least one clinical pathway At least one clinical At least one clinical pathway
Medical pathway for top two (2) for top two cases or pathway for top two for top two cases for each
Nursing cases or procedures for procedures for each center: cases or procedures for center (all)
each center: • Women’s Health each center
• Cancer • Minimally Invasive • Neonatology
• Heart Surgery Unit
No clinical pathways • Physical and
Rehabilitation Medicine
• Mental Health
• Stroke
• Diabetes
• Trauma
 Patient Care PERFORMANCE COMMITMENTS
Provide quality and
Number of patients served by the specialty centers
specialized patient care
DELIVERABLES
OPR 2017 BL
2018 - 2019 2020 2021 2022

DOH-accredited Centers
• Cancer Center
• Heart Center
• Physical and
Medical No accredited DOH-accredited DOH-accredited Women’s DOH-accredited
Rehabilitation Medicine
Nursing specialty center Trauma Center Health Center Neonatology Center
Center
• Mental Health Center
• Stroke Center
• Diabetes Center
 Training
Provide proficient, competent
and certified personnel
OPR 2017 BL
Medical Oncologist,
Interventional Cardiologist,
Rehab Med, Interventional
and Stroke Neurologist,
Psychiatrist, Endocrinologist
and Diabetologist, Trauma
Surgeon
Medical
Accredited Residency
Training Programs in
• Internal Medicine
• Pediatrics
• Surgery,
• OB-GYN
PERFORMANCE COMMITMENTS
Number of trained and certified personnel
DELIVERABLES
2018 - 2019 2020 2021 2022
Graduates sent for fellowship training:
Graduates sent for
• Neurology (1) Board-certified
fellowship training:
• Pediatric Cardiology (1) specialists
• Reproductive Graduates sent for
• Pediatric Gastroenterology (1)
Endocrinology and fellowship training):
• Pediatric Surgeon (1) Graduates sent for
Infertility (1) Perinatology (1)
• Pediatric Hematology and fellowship training:in:
• Pediatric Neurology (1)
Oncology (1) Toxicology (1)
• Neurosurgery (1)
• Neonatology (1)
Accredited Residency Training Program
in Anesthesiology (2018-2019) Accredited Residency
Training Program in
Re-accreditation of Residency Training Radiology and
Program in Pathology
Monitoring compliance of Monitoring compliance
• Internal Medicine (2018)
residents to hospital policy of residents to hospital
• Obstetrics and Gynecology (2019) Re-accreditation of
manual policy manual
• Pediatrics (2019) RTP in
• Surgery (2019) • Anesthesiology
• Internal Medicine
Monitoring compliance of residents to • Pediatrics
hospital policy manual
 Training PERFORMANCE COMMITMENTS
Provide proficient, competent
Number of trained and certified personnel
and certified personnel
DELIVERABLES
OPR 2017 BL
2018 - 2019 2020 2021 2022

Heart station nurses (2)

Cardio nurses (5)
Trained nurses:
Cardiac OR nurses (2)
• Trauma nurses (1)
Cathlab nurses (3)
• Medical oncology (2)
Ortho nurses (2)
• Radiation oncology (2) Attendance to CME activities by nurses
Infection control nurse (4)
• Cerebral angiography (2)
Endoscopy nurse (2)
• Neurophysiology (2)
Stroke nurse (3)
• Orthopedics (2)
NICU nurse (4)

Nursing

All specialty
Not all specialty trained nurses are Completion of certification of specialty
trained nurses
certified trained nurses
are certified.
 Research PERFORMANCE COMMITMENTS
Produce institutional research aligned with Formulation of health policies based on completed institutional
community needs and improvement of patient researches
services Institutional research published or presented in a forum
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

CRMC Research Ethics

Committee is not accredited by
Level II PHREB
PHREB. Level III PHREB accreditation
accreditation
PETRU
Level I PHREB accreditation
CREC Three CREC members are All CREC members are trained in basic
All CREC members are
trained and certified in basic ethics, policy and GCP.
trained in basic ethics.
ethics. No member is certified
in GCP.

Technical writing skills for

case reports and research
PETRU Only technical assistance Technical writing skills for papers
Technical review services offered to
Research through Technical Review case reports and research
other institutions
Comm Committee is provided. proposals Technical review
committee members
trained in technical review
 Research PERFORMANCE COMMITMENTS
Formulation of health policies based on completed institutional
Produce institutional research aligned with
researches
community needs and improvement of patient
services
Institutional research published or presented in a forum
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Completed research outputs in line with CRMC Research

Agenda.
CRMC Research
Hospital policy
PETRU Agenda • Level I residents should have at least one case report
based on
Research No research agenda each.
institutional
Comm Creation of registry of • Level II residents should have a CREC-approved research
research outputs
cases proposal.
• Level III or senior residents should have a completed
research paper.

CRMC Annual
Research Week
Completed
CRMC Annual Research Participation in PCHRD CRMC Annual Research Month
Research proposals researches
Forum consists only of Annual Research
PETRU presented during presented during
interesting case Forum CRMC is the host of Regional
CRMC Research Forum CRMC Research
reports. Health Research Contest.
Forum
Collaborative
research with other
institutions
 Linkages PERFORMANCE COMMITMENTS
Strengthen and establish linkages
Decreased number of level I and level II referrals
to provide multi-specialty services
Increased number of level III referrals
in Central Mindanao
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Permanent member of Collaborating agency for Level II studies

PETRU Regional Ethics Committee
of HRDC 12 Research Ethics Reviewer for members of the consortium

MOA with LGU to All 37 Barangays Program Reevaluation

Standard First Aid Training
HEMS train Barangay of Cotabato City
for Emergency Responders
Officials and BHW trained Possible MOA with another LGUs

Physical MOA with one (1) Senator to

At least one (1) MOA with other senators or funding agencies to assess PWD needs of at least one (1)
Medicine and assess PWD needs in one
community
Rehab (1) community
 Linkages PERFORMANCE COMMITMENTS
Strengthen and establish linkages
Decreased number of level I and level II referrals
to provide multi-specialty services
Increased number of level III referrals
in Central Mindanao
DELIVERABLES
OPR 2017 BL
2018 - 2019 2020 2021 2022

MOA with RHU Alamada, Aleosan, Libungan, Midsayap,

MOA with Cotabato City
Pigcawayan,
Health Office, RHU
Dept of OB GYN
Kalamansig and RHU Lebak Yearly renewal of MOA with RHUs
Radiology MOA with RHU Sultan Kudarat, Datu Odin Sinsuat, Upi
for training of government-
employed midwives
MOA with Camp Siongco Awang, Maguindanao

Program
Reevaluation
MOA with LGU to train All 37 Barangays of
Standard First Aid Training
HEMS Barangay Officials and Cotabato City will have
for Emergency Responders Possible MOA
BHW undergone the training
with another
LGUs
 Human Capital PERFORMANCE COMMITMENTS
Increase number of trained personnel with specific training for a particular
To be able to build a network of employees trained in
subspecialty
different specialty to facilitate and run the different
Increase number of health worker ratio
multispecialty center
Increase in costumer satisfaction rating
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Hire additional personnel

75% plantilla for Cardiology, Stroke
90% filled plantilla
position Center, Cancer center,
position for 600 bed --- --- ---
1258 personnel for Reproductive health,
capacity
400 bed capacity Physical and Rehabilitation
center

MCC
Dept.
Heads
HR
Manpower
capacity based
on:
197 227 129 129 128
400 bc – 1,122
500 bc -1349
600 bc – 1735
 Org Culture PERFORMANCE COMMITMENTS
Decrease in sentinel events
Institutionalize a culture of patient safety and holistic care
Increase in customer satisfaction rating
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Protocols for all units and

Hospital departments
Patient Orientation of newly hired personnel on hospital protocols
Safety Incident reports for sentinel Orientation of all employees on hospital
Comm. events and protocols Re-orientation of existing employees who consistently
And Nursing monthly audit of different deviated from hospital protocols
service units and departments
 Infrastructure PERFORMANCE COMMITMENTS

Objective Measure

DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Phase 1
Phase II
Dormitory
Mental Health
Cancer Center Phase II:
• Multi-
4th/5th Floor Phase 1 • Cancer Center
specilaty
Auditorium Phase 1: • Storage
center
Storage Bldg. • MHU 1 • Warehouse
• Watchers’
Warehouse • Dormitory • Renov. Of MB and
Pavillion
Sewage Treatment Plant • 4th/5th Fr/Phase 1 conversion to OPD
• Parking Area
Renovation of main bldg and • Auditorium Pedia OB-Gyne
• Dialysis
conversion to OPD Pedia, OB Gyne Surgery Wards
Center
and Surgery Wards • Blood Center
Parking Area
Dialysis Center
Watchers’ Pavillon
Blood Center
 Infrastructure PERFORMANCE COMMITMENTS

Objective Measure

DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

Linear Accelerator
• Linear Accelerator
Brachytherapy
• Brachytherapy
Nuclear Medicine Equipment
• Nuclear Medicine Equipment
Digital Mamography with 3D
• Digital Mamography with 3D
Tomosynthesis
Tomosynthesis
Generator Set
• Generator Set
OR Tables with OR Led lights and
• OR Tables with OR Led lights and Camera
Camera Sysem (1)
Sysem (1)
For 1 Hybrid OR and 6 General ORs
• For 1 Hybrid OR and 6 General ORs
 IT PERFORMANCE COMMITMENTS
Use of technology to improve efficiency of health delivery and
Measure
processes
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022

HOMIS as external provider 100% digital patient

general database 100% digital billing
Laboratory and Radiology and patient charging 100% digital human 100% complete
---
information System 100% digital access for all services resource record digital patient record
for laboratory and rendered
Paperless technology radiology results

10% Telemedicine for

Online access for
rural health access
medical journal
Hospital wide internet
--- --- ---
connection 10% teleconference
Online access for
for different training
PHIC members
programs
 Finance PERFORMANCE COMMITMENTS
Generate and utilize funds to meet the financial
and operational requirements of our multi-specialty service centers
DELIVERABLES
OPR 2017 BL
2018 2019 2020 2021 2022
Budget (2018: 900M) 350% increase 380% increase 300% increase 267% increase
GAA

Utilization Rate (98%) 99% 99% 99% 99% 99%

Reimbursement of Claims
65% 70% 75% 80% 85%
(59.47% = Php 297M)
Denied Hospital Claims
0.7% 0.5% 0.3% 0.1% 0.05%
PhilHealth

(1.7% = Php 5.2M)

Return to Hospital
3% 2.5% 2% 1.5% < 1%
(3.9% = Php 11.5M)
Accounts Receivables
30% 25% 20% 15% 10%
Finance (34.85%)
Services
stall rentals in food court,
dormitory rental fees,
MAB, additional rooms
auditorium and function
for private patients
Other funding sources

Other business income Drug consignment room rental fees, raw

materials for herbal
Multi-level parking
medicine manufacturing
plants
Completion of Phase II
Completion of multi-
HFEP support for CAPEX requirements Cancer center, Blood
center building
Center
PCHRD support for research At least 1 PCHRD supported research
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 IMPACT

Impact Indicator # Measure BL 18 19 20 21 22

 STRATEGIC GOAL

Goal # Measure BL 18 19 20 21 22
 CORE PROCESSES

Objective # Measure BL 18 19 20 21 22 Initiative

 SUPPORT PROCESSES

Objective # Measure BL 18 19 20 21 22 Initiative

 STRATEGIC CHANGE AGENDA

FROM KEY RESULT AREAS TO

Patient Care

Training

Research

Linkages

HR

Infrastructure

Organizational Culture

IT

Finance
 READINESS RATING

COMPETENCE TO DELIVER SCORE

0 0.5 1.0

Teams lack the adequate skills and Teams are skilled but lack training to Teams are highly skilled and trained to deliver
training to deliver tasks deliver tasks tasks

RESOURCE AVAILABILITY

0 0.5 1.0

Sufficient resources but not available;

Insufficient; external resources difficult to OR
Sufficient and available staff and budget
source Insufficient but external resources can
be tapped

CONFIDENCE TO DELIVER

0 0.5 1.0

Low confidence because of high degree of High confidence despite organizational change
Moderate confidence
organizational change required required

TOTAL SCORE
 PATIENT SAFETY & PATIENT EXPERIENCE PROTOCOL

UNIT TOUCH POINT A TOUCH POINT B TOUCH POINT C TOUCH POINT D

Duration

Patient Safety
Deliverable

“Wow Moment”
Deliverable

Script

Actor/s
 CFR MECHANISMS

UNIT PLATFORM FREQUENCY IPR

Offline
CONVERSATION
for Performance
Monitoring
Online

Offline

FEEDBACK
for Accountability

Online

Compensatory
RECOGNITION
via Rewards and
Incentives
Non-Compensatory