8th MEETING

MINUTES OF THE MEDICAL EXECUTIVE COMMITTEE MEETING

SEPTEMBER 09, 2019 – Monday

RIZAL MED BOARD ROOM

I. Invocation: The Invocation was led by Dr. Lumague

II. Call to Order: The Meeting was Called to order at 09:30 am
III. Roll Call and Declaration of Quorum

Presiding Officer: Dr. Maria Rica M. Lumague

CMPS

Attendees:
Present:
1. Dr. Primo B. Valenzuela 9. Dr. Michael Alexius A. Sarte
2. Dr. Carmencita S. Solidum 10. Dr. Heriberto P. Guballa
3. Dr. Noel C. Santos 11. Dr. Francisco C. Rivera IV
4. Dr. Rodante A. Roldan 12. Dr. Roel Tito A. Marcial
5. Dr. Mariano B. Lopez 13. Dr. Vincent G. Moderes
6. Dr. Ray I. Sarmiento 14. Dr. Karen O. Bongas
7. Dr. Marie Karen C. Jiz 15. Dr. Nancy M. Aquino
8. Dr. Nelinda Catherine P. Pangilinan 16. Dr. Jesus Nazareno J. Velasco

Absent:
1. Dr. Ruth G. Valeriano
2. Dr. Teresa Tricia G. Bautista
3. Dr. Edilinda G. Patac

IV. Approval of the Agenda

1. First OR cases TAT presentation by Dr. Franklin Kleiner for the month of August 2019 (to include cases by
GI endoscopists)
2. Prescription policy discussion (will send the draft and forms as prepared by the Pharmacists in another email)
3. PF of doctors
4. CF4 issues & concerns
5. Outcome of the ISO re-certification (by Dr. Carmen Solidum) & action plans
6. Rizal Med Christmas Party on Dec 10, 2019 at SMX SM Aura BGC (to be discussed by Dr. Carmen Solidum)
7. Department Concerns
8. Other Matters

V. Reading and Approval of the Minutes

Upon the motion of Dr. Moderes and duly seconded by Dr. , the body approved the minutes of the
meeting held on August 19, 2019 with some corrections:
1. Invocation on previous meeting was led by Dr. Roldan.

Matters Discussed:
1. Agenda:
1.1. First OR cases TAT presentation by Dr. Franklin Kleiner for the month of August 2019 (to include
cases by GI endoscopists)
1.1.1. Noticeable improvement on timeliness of Turn-around-time of first OR case timeliness for the
second half of August.
1.1.2. Major causes of delay has gown down from 82% to 64%.
1.1.3. Increased in On-time cases from 9 to 18 cases
1.1.4. Delays caused by Doctors decreased from 20 to 14 cases, other causes of delays also decreased from
23-13 cases.
1.1.5. Five hours delay from previous report was reduced to less than an hour.
1.1.6. Dr. Lumague did a random check and one of her observation is the incomplete information on
accomplished Turn-Around-Time forms.

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 1.1.7. Proper time adjustment should be done for cases wherein anticipated patient preparation will take
more than an hour, Dr. Jiz suggested to adjust cutting time to 8 am for patient with longer preparation
period. Dr. Lumague didn’t agree with the suggestion.
1.1.8. ORMAT Chairman recommended that Surgeons and Anesthesiologist must come early to give
allowance for patient preparation, difficult intubation, preparation for supplies needed for surgery
and other causes of delay.
1.1.9. ORMAT will submit monthly report of late and early doctors of first cases, to inform respective
departments regarding habitual tardiness of each departments’ doctors, to penalize doctors with
habitual tardiness. Doctors who performed their OR on time will be given an award.
1.1.10. Dr. Lumague informed Dr. Kleiner that penalizing/rewarding of Doctors is for discussion.

1.2. Prescription policy discussion (will send the draft and forms as prepared by the Pharmacists in another
email)
1.2.1. A soft copy of Prescription Policy draft was sent to all Chairpersons.
1.2.2. Dr. Lumague urged all the Chairpersons to be actively involved in finalizing the policy if there will
be no comments or revision is raised on the Prescription Policy draft two days after it was sent out,
the policy will be posted.
1.2.3. Dr. Roldan agreed with the list of inappropriate abbreviations but suggested a thorough review of
the medication policy and forms.
1.2.4. Finalized and approved policy and forms will be submitted to and issued by the Patient Safety
Committee.
1.2.5. The departments can invite Pharmacists to discuss medication errors and possible ways of correction.
1.2.6. Dr. Solidum suggested to involve Nurses in the discussion of medication management, Internal
Medicine offered to invite Nurses during the discussion of Pharmacists in their department.

1.3. PF of doctors
1.3.1. Dr. Lumague informed all the Chairpersons that a suggestion was raised during the Management
Review to avoid delays in discharging patients.
1.3.2. One of the suggestion is to give two hours to doctors to provide their professional fees if the doctors
failed to give the amount, a professional fee will be prescribed as agreed upon by all the Chairpersons.
1.3.3. Dr. Sarmiento suggested to establish an official communication line between Billing Department and
Doctors specifically for PF inquiry.
1.3.4. One of the suggestion made was to use Philhealth PF case rate matrix for cases with procedures; a
copy of the RVS code will be provided to Billing for their reference.
1.3.5. The Board agreed to one-hundred fifty pesos (₱150) as daily multiplier for non-surgical patients.
1.3.6. Dr. Lumague volunteered to make the draft for the Professional Fee matrix as discussed with the
Chairpersons.

1.4. CF4 issues & concerns

1.4.1. A memo regarding reiteration of the standard procedure in submitting required claim forms was sent
by Billing and Claims to CMPS Office, a copy of the memo will be sent to the departments.
1.4.2. Obstetrics and Gynecology discussed some of the problems they encountered while complying the
CF4/CF3 RTH.

1.5. Outcome of the ISO re-certification & action plans (by Dr. Carmen Solidum)
1.5.1. Dr. Solidum informed all the Chairpersons regarding the outcome of the management review.
1.5.2. Dr. Solidum read the Positive findings, Opportunities for improvements involving medical, the
hospital does not need to take any actions on the opportunities for improvements.
1.5.3. Corrective action report (CAR) will be issued to departments where AJA auditors noted some
observations. A root cause analysis should be presented in CAR.
1.5.4. Recruitment of new batch of Auditors was suggested, requesting two auditors from each
departments.
1.5.5. Submitted names of new auditors should not have other hospital administrative task.
1.5.6. Submitted names of new auditors will be sent for two days IQA training, target dates are on
November 21-22, 2019.
1.5.7. IQA committee will identify “audit season”, all audits must be done during the identified season.

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 1.5.8. During the “audit season”, all auditors will be excused from all hospital duties for three days, 1 day
for audit preparation, 1 day for actual audit, and 1 day for preparation of audit reports.
1.5.9. IQA committee will recommend to PMT to include Internal Quality Audit as part of strategic
function in auditor’s IPCR. Dr. Lumague agreed with the recommendation.
1.5.10. Will recommend to PMT to include in IPCR of Chairman the response to CAR and submission of
Risk assessment
1.5.11. Dr. Lumague asked the Chairperson to identify two consultants who were recently promoted to
Medical Specialist III (MS III) with no or minimal administrative tasks to be part of new batch of
auditors. Identified consultants must clear their schedule on November 21-22, 2019 for the IQA
training.

1.6. Rizal Med Christmas Party on Dec 10, 2019 at SMX SM Aura BGC (to be discussed by Dr. Carmen
Solidum)
1.6.1. Dr. Solidum informed all the Chairpersons that the Christmas/Anniversary party is on December 10,
2019 at SMX Aura
1.6.2. Christmas party committee will survey on who will attend the party, deadline of submission of list
of attendees is on October 15, only replacements will be accepted after the set deadline.
1.6.3. Dr. Solidum announced to the Board that the theme of the party is Gatsby.

1.7. Department Concerns

1.7.1. Chief Training Office – Dr. Valenzuela
a. Reminded Chairpersons to have their new Residents sign the contract for deployment.
b. Recommended to have all incoming residents from all departments sign the contract for deployment.
c. Suggested to set residency rule, particularly in the length of stay of residents after completion of
training.

1.7.2. Quality Management System – Dr. Solidum

a. Asked for the opinion of Dr. Lopez and Dr. Santos regarding sending of all ECGs to Heart Station
for reading
b. Dr. Santos informed Dr. Solidum that the Heart Station made a process flow chart of the ECG
reading. Dr. Santos will approve the flow chart when it is edited in ISO format.

1.7.3. Ancillary Services / BAC – Dr. Santos

a. PMRU will temporarily stop services during transfer to new area.
b. SPECT machine was installed in Nuclear Medicine, still testing the software but is expected to be
operational by the end of September.
c. BAC – Cath lab was awarded to Shimadzu, laboratory will be temporarily managed by Dr. Orillaza

1.7.4. Allied Health Services – Dr. Roldan

a. Malasakit fund for implant of MSWD can only be utilized if the supplier is named under Rizal Med
b. PCSO is complained about the clinical abstract having admission date but no consultation date for
OPD.
c. HIMD earned ₱ 27, 604 from disposing 2003 records.

1.7.5. Internal Medicine – Dr. Lopez

a. Requested to utilize 4th floor of the new building as Neuroscience Center for IM, Surgery and
Pediatrics. Dr. Saquilayan agreed to the request.
b. Dr. Lumague explained the risk and losses of the request of Dr. Lopez.

1.7.6. Surgery – Dr. Sarmiento

a. Starting interview Pre-residents; planning to hire 4 Residents for 2020
b. Will change duty patterns of Residents in preparation of opening of SICU, Resident on duty in SICU
will be on perpetual duty for three months
c. Planning to open Surgical Oncology Fellowship, with a condition that takers must finish MBA while
taking the Fellowship.
d. Listed Dr. Irene Abisinia and Dr. Willie Hao as member of new batch of Auditors

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 e. Suggested to have an event where all the consultants from all the departments meet. Dr. Lumague
agreed to the suggestion and proposed to have the postponed Consultant’s party last year as platform
of introduction.
f. Reported that St. Luke’s Global is planning to donate CT-Scan machine to Rizal Med.

1.7.7. Anesthesiology – Dr. Jiz

a. Resident in service exam will be on September 29, 2019.
b. Reported the time schedule of residents in the department is 6am-4pm.
c. Started to recruit trainees for 2020 fellowship training, recruitment and pre-fellow is from September
15 – November 15, 2019
d. Explained the need for MO III items.
e. Dr. Lumague inquired if the residency of Dr. Luckie Diane De Leon will be extended due to her
maternity leave, Dr. De Leon’s Residency will not be extended as long as she’s able to complete the
number of requirements to take the exam
f. Gave names of Dr. May Hermoso, Dr. Louis Gonzaga and Dr. Erlinda Oracion as member of new
batch of auditors.

1.7.8. Obstetrics and Gynecology – Dr. Pangilinan

a. Lack of stock in sutures, macroset, methyldopa, nifedipine, ceftriaxone, the department required the
patients to buy the needed supplies, drugs and medicines outside the hospital and advised them to
keep the receipts.
b. Informed Dr. Lumague that ER patients for ultrasound are tagged as In-patients. ER and In-patients
for ultrasound are charged differently, the hospital is losing income due to this situation.
c. Explained the need for more MO III items.
d. Can give one person for new batch of auditors because all of the consultants of the department is
members of different committees.
e. Suggested to have patient referral monitoring, Dr. Lumague and Dr. Valenzuela agreed and
suggested that each department can do the monitoring on their own.

1.7.9. Pediatrics – Dr. Valenzuela (reported by Dr. Velasco)

a. Residents will have their In-service exam on October 10, 2019.
b. Submitted a proposal of process flow to Dr. Saquilayan for activation of contingency plan in case a
surge in dengue admission happen, trigger for contingency activation is when the department is
admitting 13 dengue patients per day, dengue admission is being monitored at the moment.

1.7.10. Otorhinolaryngology-Head and Neck Surgery – Dr. Sarte (reported by Dr. Roldan)
a. 4th year Residents are taking their practical on September 17, 2019.
b. Started screening the second batch of Pre-residents.

1.7.11. Ophthalmology – Dr. Guballa

a. Resident applicants will be interviewed by Dept Consultants.
b. Inquired regarding signatory of acquisition receipt, Dr. Lumague asked Dr. Guballa to come-up with
a solution regarding this matter.

1.7.12. Dermatology – Dr. Rivera

a. Reported the successful transfer of the departments to their permanent office
b. Currently processing 39 applicants for 2020 Residency program, and will be giving exam on
September 20, target date of submission of list for final interview is on October 9, 2019.
c. Presently involved in creation of research agenda of the Skin Center with participants from different
departments, representatives from institutions with Dermatology and stakeholders from different
pharmacy companies. One of the agenda is to create benefit package.
d. Looking forward to develop own Service Delivery Network.

1.7.13. Emergency Department – Dr. Marcial

a. Reminded all the chairperson about the four hours turn-around-time (TAT) in the Emergency Room,
wherein TAT will be counted per department to easily identify which departments is causing the
delay.
b. Informed Dr. Aquino that Radiology Residents should inform the departments of the X-ray results.
c. Requested an additional resident at the Triage (1 clinical and 1 non clinical) for times when PGIs are
not available, CTO will think of a solution for this request.

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 d. Communicated with CFO about extension of billing hours, Dr. Sarmiento suggested to utilize the 24
hours Cashier in ER to act as biller.
e. Reported lack of supplies in medicines at the Emergency Room.

1.7.14. Emergency Medicine – Dr. Moderes

a. Follow-up on request for five cardiac monitors, 2 ECG machine and laryngoscope.
b. Dr. Lumague and Dr. Santos suggested to talk with Dr. Francisco regarding the request for ECG
machine.

1.7.15. Out Patient Department – Dr. Patac (reported by Dr. Roldan)

a. Reminded all the Chairpersons regarding the leaving of office keys to Admitting and Information
Unit.
b. Dental services is limited due to water line problem.
c. Reported that the comfort room in third floor is not in operation and the main door of Family
Medicine is hard to lock and that the office is secured with chain and padlock.

1.7.16. Laboratory Medicine – Dr. Bongas

a. Department is back in their permanent office, half of the laboratory, histopath and bacteriology is
now operational.
b. Found out that ER complaint regarding delayed turn-around-time of diagnostics was caused by delay
in encoding of nurses.
c. Proposed two solutions to avoid delay, 1) let the department do the encoding, 2) give request directly
to the department and have the extraction before encoding.

1.7.17. Radiology – Dr. Aquino

a. Department is undergoing renovation.
b. Renovation in ultrasound section is done.
c. Inquired regarding availability of MO IV items because the department is planning to accept
Ultrasound and CT-MRI fellowship training applicants.

1.8. Other Matters

1.8.1. Dr. Lumague discussed the plantilla items and distribution for Residents to the departments.
1.8.2. Will prioritize departments with no graduates for plantilla items distribution.
1.8.3. Borrowing items from National Center for Mental Health is no longer possible.
1.8.4. Dr. Lopez inquired if splitting of Resident plantilla item is possible, Dr. Lumague will discuss the
inquiry with Dr. Saquilayan.
1.8.5. Seven MO IV items were reserved for fellowship training (Anesthesiology, Radiology, and Surgery)
and the rest of the available items were given to Emergency Medicine.

No other matters taken up.

Next meeting will be on October 7, 2019.
Meeting was adjourned at 12:05 pm.

Prepared by:

NINA GLADYS R. BILLONES

CMPS, Secretary

Approved by:

MARIA RICA M. LUMAGUE, MD, FPCS, MHA

Chief of Medical Professional Staff II

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