2

CONTENTS
INTRODUCTION 2
MESSAGES
Medical Center Chief ……………………………………………………………………………… 3
Chief of Medical Professional Staff …………………………………………………………. 4
Chief Nurse …………………………………………………………………………………………… 5
Chief Administrative Officer ………………………………………………………………….. 6
HISTORY OF NATIONAL CHILDREN’S HOSPITAL 7
PAST AND PRESENT DIRECTORS OF NATIONAL CHILDREN’S HOSPITAL 12
VISION AND MISSION STATEMENTS 13
CITIZEN’S CHARTER – SERVICE PLEDGE 14
SERVICES OFFERED 15
ARTA COMMITTEE 20
POLICIES - COMPLIANCE TO ARTA PROVISIONS 21
Identification Card of Hospital Employees on Duty …………………………………. 22
Public Assistance Complaints Desk (PACD) …………………………………………….. 23
Procedure on Filing of Complaints ………………………………………………………….. 24
Procedure on Handling Patients Complaints …………………………………………… 25
Provision on Priority Service …………………………………………………………………. 27
FRONTLINE TRANSACTIONS 29
Out- Patient Department ……………………………………………………………………….. 30
Dental Service ………………………………………………………………………………………. 31
Department of Laboratory and Pathology Services …………………………………. 32
Radiology Section ………………………………………………………………………………….. 33
Pharmacy Section ………………………………………………………………………………….. 34
Medical Records ……………………………………………………………………………………. 36
Medical Social Service ……………………………………………………………………………. 38
Billing/ Philhealth Section ……………………………………………………………………… 40
Cashier ………………………………………………………………………………………………….. 42
ANNEXES 43
PACD Patient Feedback/ Complaint Form (ARTA FORM No.01) ………………. 44
PARU Form (NCH-F-MED-MSS-014) 45
OPD- Front-liners Patients Survey Form (NCH-F-GEN-003) …………………….. 47
In- Patient Satisfaction Survey Form (NCH-GEN-005) ……………………………... 49
Emergency Room Patients Satisfaction Survey Form (NCH-F-GEN-004) ….. 51
Panunumpa sa Watawat ………………………………………………………………………… 53
Panunumpa ng Kawani ng Gobyerno ……………... 54
DOH Hymn………………………………………... 55
Awit ng Serbisyo Sibil …………….. 56
3

INTRODUCTION
Republic Act No. 9485 also known as The “Anti-Red Tape Act of 2007” was enacted by
the Thirteenth Congress of the Philippines on June 2, 2007. It is “An Act to Improve Efficiency in
the Delivery of Government Service to the Public by Reducing Bureaucratic Red Tape,
Preventing Graft and Corruption, and Providing Penalties Thereof”.
Pursuant to Section 16 of the Anti-Red Tape Act of 2007, the Civil Service Commission
has promulgated the Implementing Rules and Guidelines (IRR) which was published in the
Philippine Star on August 21, 2008 and which took effect on September 5, 2008.
Under the law, each office or agency is tasked to perform the following within (1) year
from effectivity of the IRR:
1. Identify its frontline services;
2. Undertake re-engineering of its transactions which includes limiting the number of
signatories to (5) and providing a period within which transactions are action upon
which should not be longer than (5) working days for simple transactions and (10)
working days for complex transactions;
3. Set up service standards to be known as the CITIZEN’S CHARTER, including forming a
task force to prepare said charter, to be presented on a billboard or other prominent
announcement at the office handling the processes and services explained therein.
The National Children’s Hospital has initiated the formulation of its Citizen’s Charter
through Hospital Order No. 2012- 044 creating the Anti-Red Tape Act (ARTA) Committee on
February 16, 2012. The committee was given the responsibility to formulate the respective
service standards to be known as the CITIZEN’S CHARTER which contains the following details:
1. The procedure to obtain a particular service;
2. The person/s responsible for each step;
3. The maximum time to conclude the process;
4. The document/s to be presented by the customer, if necessary;
5. The amount of fees , if necessary; and
6. The procedure for filing of complaints.
Through the CITIZEN’S CHARTER, patients of the National Children’s Hospital are made
aware of the procedures for availing of the various frontline services or offices. Transparency in
all hospital transactions will promote trust, client satisfaction and the delivery of quality
service at all times.
The management and staff of the National Children’s Hospital commit, as reflected in our
service pledge, to deliver quality patient care. We promise to uphold at all times fairness,
honesty and integrity in all our transactions with our fellowmen.

MA. LUISA F. REYES, MD, FPSP

Head, ARTA COMMITTEE
January, 2013
4

Republic of the Philippines

Department of Health
NATIONAL CHILDREN’S HOSPITAL

MESSAGE

The Lord’s greatest commandments are: to love God above all and to love our neighbor
as we love ourselves. As an employee of the government, we serve the public, our neighbors.
Also, in the bible, the Lord said “whatever you did for one of the least brothers of mine, you did
for me.” (Mt. 25:40)

In the preamble of our constitution, there are sixteen (16) Filipino values mentioned:
faith in God, unity, patriotism, work, respect for life, respect for law and government, truth,
justice, freedom, love, equality, peace, promotion of the common good, concern for the family
and future generations, concern for the environment and order. Every Filipino, whether rich or
poor, can do something to help our country.

The National Children’s Hospital manned by competent men and women with faith in
God, love of country and love of neighbor, will continuously serve the public with integrity,
efficiency, effectiveness and compassion.

I congratulate the ARTA Committee headed by Dr. Ma. Luisa F. Reyes for coming up with
this Citizen’s Charter handbook, documenting our pledge of commitment for quality and honest
service to the public.

Mabuhay and God bless us all!

EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief II
5

Republic of the Philippines

Department of Health
NATIONAL CHILDREN’S HOSPITAL

MESSAGE

It is my personal privilege to commend the Anti- Red Tape Act Committee for coming up

with the First National Children’s Hospital Citizen’s Charter Handbook. Congratulations!

The Handbook would not only serve as a guide to the frontliners of our institution. This

would foremost benefit all of us who provide quality efficient and prompt health services to our

clients in accordance with our hospital’s standards, patient satisfaction and commitment from

the organization and the public.

Keep up the good work!

ALICIA T. TALEON, MD, FPPS

Chief of Medical Professional Staff II
6

Republic of the Philippines

Department of Health
NATIONAL CHILDREN’S HOSPITAL

MESSAGE

The stigma of corruption has been deeply embedded both in our history and present
times. It triggers many depressing emotions and scenarios. It destroys the harmony between
the government and the people resulting to partition – leading to stagnation. In a divided
country, penetration of progress and advancement is difficult. As a consequence, people tend to
live continuously in inconvenience.

Along with these is the incessant struggle towards rectification among individuals and
groups. These efforts have been given birth to the Anti Red Tape Act (ARTA). The legislative act
that provides the direction towards good governance thereby, eliminating graft and corruption
practices. It is both evidence and an innovation.

An evidence that as government employee we are serious in our pledge to serve our
countrymen with integrity and accountability in all of our actions. As a product of innovation, it
guides government agencies and employees as well to provide quality service underscoring the
promptness and accuracy in the delivery of the service.

In the health care service like our institution, accessibility and equity are the essential
factors to be taken into consideration in order to ensure that the inherent dignity and worth of
men is preserved.

This ARTA manual serves as an inspiration to continuously pour our best efforts for the
interest of our clients. As we follow the tenets of ARTA, we embrace change. As we change, we

DAISY L. LLARENAS, RN, MPA, MAN

Chief Nurse
7

Republic of the Philippines

Department of Health
NATIONAL CHILDREN’S HOSPITAL

MESSAGE

Apart from the effort of myself, the success of any project depends largely on the

encouragement and guidelines set.

I would like to take this opportunity to express my gratitude to the people who have

instrumental in the successful completion and implementation of this NCH ARTA Manual,

chaired by Dr Ma. Luisa F. Reyes. Thank you is not enough for this tremendous support and

help accorded to the management and employees of the hospital in easing the work flow

processes.

The guidance and support received from all the members of the committee who

contributed and who are contributing to this project were vital for the success of this project.

This ARTA Manual of NCH will assist us all to achieve high quality services through

timely access, efficiency and effectiveness.

Job well done! Congratulations!

REYNALDO C. SALAZAR, M.P.A.

Chief Administrative Officer
8

The History of
On February 11, 1945, the Philippine
Civilian Assistance Unit, a relief agency, later

NATIONAL
placed under the Emergency Civilian
Administration (ECA) established an Indigent
Children’s Clinic in the building of the defunct

CHILDREN’S Bureau of Public Welfare at San Rafael Street,

Manila, under the leadership of Dr. Victoria

HOSPITAL
Kalaw-Linan to take care of the war refugees,
the sick and undernourished children. This
was the humble beginning of what blossomed
to become what people now recognize as the National Children’s Hospital. With the abolition of the
ECA, the Clinic became part of the Social Welfare Commission.
By virtue of Commonwealth Act No. 705 in October 1945, the Indigent Children’s Clinic
attained its hospital status as the Indigent Children’s Hospital and in December of the same year, Dr.
Peregrino H. Paulino was designated Chief of the Hospital. This event can be spoken of as the turning
point. From its temporary quarters at San Rafael Street, the hospital was transferred to a two-storey
house at 715 Gastambide Street, Sampaloc, Manila in 1947. This building, however, proved
inadequate for the fast growing hospital. And being at the commercial hub of Manila, the danger of
fire became an ever increasing threat. The locale itself was far from ideal. The Director, Dr. Peregrino
H. Paulino, in his intense desire and ambition to see a better and modern hospital solicited the help
of former Secretaries of Health as well as the officials of the executive and legislative branches of the
government. This effort saw its reward when the late President Elpidio Quirino issued Presidential
Proclamation No. 439 assigning the Mori Bicycle Compound at Espana Extension in Quezon City to
be the future site of the Indigent Children’s Hospital.
In 1952, Republic Act No. 731 changed the name of Indigent Children’s Hospital to NATIONAL
INDIGENT CHILDREN’S HOSPITAL. Republic Act 948, in 1953, was passed appropriating funds for
the construction of the hospital building. Subsequently, Republic Act No. 1340, dated June 16, 1955
amended Republic Act No. 731 changing the name of National Indigent Children’s Hospital to its
present name –The NATIONAL CHILDREN’S HOSPITAL.
July 28, 1955 shines out as a memorable day for the National Children’s Hospital for it was on
that day that the cornerstone of the new building was laid. The construction of the building started
9

8
in December, 1955. Finally, on April 26, 1958, the first modern hospital building of the National
Children’s Hospital was inaugurated.
On July 1, 1960, Dr. Jose C. Joven was appointed as Chief of the Hospital. He ordered the
landscaping of the grounds and the regular painting of the buildings. Aside from the improvements
in the physical facilities of the hospital, the professional and service areas were given top priority.
During his tenure, the hospital expanded even more. The hospital services offered was proof that the
organization can stand side by side with other leading medical centers during that time.
One aspect of hospital development which also deserves mention is the Nutritional
Rehabilitation Program where the Malnutrition Ward gained much attention. Grants for graduate
studies along this line were obtained allowing some of its doctors to further studies abroad.
In August of 1976, the administration of the hospital changed hands with the appointment of
Dr. Cristina de Joya-Agregado as the incoming Chief. Under her management, the organizational
structure of the hospital was at once reviewed and revised. The objectives of the hospital were
fashioned to jive with the over-all thrust of the “New Society” under the Marcos administration. The
increasing number of patients found the need to increase the hospital’s bed capacity. Thus, in 1977,
an additional 3rd floor of the main building was constructed. Subspecialty care units were
established including the Intensive Care Unit, Neonatology Unit and a Surgical Unit. The hospital
slowly became recognized also as a training hospital, thus, the increased number of student
affiliates. The Pediatric Residency Training Program started and was accredited by the Philippine
Pediatric Society as Phase I and II in 1981.
April 16, 1988 marked a new era in the history of National Children’s Hospital when Dr. Ma.
Isabelita S. Vital-Gozon assumed the position of Medical Center Chief. Armed with enthusiasm and
extraordinary vitality, Dr. Gozon did not waste any time and started propelling the hospital towards
the vision of becoming an excellent “Center of Wellness”. The chief faced the challenges head-on and
for more than a decade, NCH has steadily grown and evolved to become an institution whose noble
mission is to ease the suffering of children from malnutrition, the dreaded respiratory and
gastrointestinal diseases and other chronic diseases like tuberculosis, leukemia and others. NCH
became known for its Hydrocephalus Center hence referrals from all over the country were being
served. Also under Dr. Gozon’s administration, working conditions including a clean, orderly
physical surroundings and supportive employees have become commonplace, giving everyone a
chance to work with an elevated morale. Some of the physical upgrading of the hospital facilities
10

9
were the installation of the communication facilities, renovation of the conference rooms and
improvement of water system of the hospital. A 1000 square meter lot adjacent to the hospital was
acquired to give way for the future expansion of its services. The upgrading of training and
continuing education was also given special attention. Postgraduate Course in Pediatrics started in
1991, then was conducted annually chaired by the department’s competent consultants.
In February 2002, Dr. Marieta R. Siongco was appointed as the new Chief of Hospital. Under
her leadership, Total Quality Management (TQM) Program was organized and launched. This
became a priority program for the hospital. Quality Circle Teams were created in all services and
departments. Weekly TQM meetings were conducted to review, write and standardize various
processes. This empowered the workers to actually evaluate and improve on their own work
processes.
In September 18, 2006, Dr. Robert Enriquez became the new Medical Center Chief. During
this time the hospital was at the forefront thrust of DOH towards ensuring quality assurance and
patient safety in hospitals under the stewardship of the Secretary of Health, Francisco T. Duque III.
With this thrust, the entire hospital under the guidance and direction of TQM, worked together and
achieved the “Center of Excellence” accreditation from PHILHEALTH on July 10, 2010. The National
Children’s Hospital became the first government hospital to achieve the highest accreditation given
by PHILHEALTH which is valid from May 1, 2010 to April 30, 2013.
Under Dr. Enriquez’s headship, construction of a new six-story medical arts building
(Building 4) with an estimated cost of Php 119,000,000.00 was started in the 1000 sq. meter vacant
lot. This new building will provide new space for the following: Outpatient Department, Doctor’s
Clinics, Dental Services, Imaging Services such as X-ray, CT Scan, Pharmacy Complex and additional
patient wards and training rooms. Other areas of the hospital in the older buildings were improved
and renovated to provide a better environment of care for the patients and for the staff as well. The
following were done such as repainting of the interior of all the wards, façade of the hospital and all
exterior, asphalt overlay of the parking lot, renovation of OPD waiting area, re-roofing of the 7th
floor Building 3), improvement of the Multipurpose Conference Hall sound system, upgrading of the
PABX System and improvement of other offices.
Hospital programs and trainings were further strengthened by upgrading quality training of
pediatric residents and other hospital staff. The continued medical education through postgraduate
courses and daily conferences are already institutionalized. The Pediatric Residency Training
11

10
Program accredited by the Philippine Pediatric Society was upgraded to Level III and a Fellowship
Program in Pediatric Surgery was started. New hospital programs/services were started such as the
Touch Therapy Institute (first of its kind in the Philippines), Drug Dependent Treatment and
Rehabilitation for minors and the strengthening of the Tuberculosis Control Program through the
Public-Private Mix Directly Observed Therapy Short Course (PPMD-DOTS). Cardiac Surgeries for
congenital heart defects were also started. Networking and collaboration with donors was
strengthened providing the hospital with expensive medical equipment like the Neuroendoscope
and Heart-Lung Machine.
Due to the untimely demise of Dr. Enriquez, a new Medical Center Chief, who is also the
former Chief of Medical Professional Staff, Dr. Epifania S. Simbul took over the headship of the NCH
on June 1, 2011 up to the present time. Under Dr. Simbul’s leadership, the hospital continued its
pursuit of continuously improving all facets of hospital operations.
Working further on or enhance the previous achievements, the hospital staff continued to
work to sustain and deliver excellent patient care. In the first year of Dr. Simbul’s term, the hospital
received the RED ORCHID AWARD, the highest award given to institutions for the efforts in
maintaining 100 % Tobacco Free Environment, GOLD AWARD for OSPITAL NA MALINIS AT
MABANGO given by the Department of Health, the Philippine Society for Quality Health Care
(PSQUA) PARTNER in QUALITY AWARD and the GAWAD KALASAG , 2nd place , for Best Medical
Institution advocating Disaster Risk Management (National Government Hospital Category) given by
the Office of Civil Defense on December 12, 2012.
Continuous Quality Improvement (CQI) through Quality Improvement Studies (QIS) was
institutionalized in NCH and pioneered by the Nursing Service. A total of 12 Quality Improvement
Studies were done for the period of 2011 and 2012. Other areas such as the Department of
Laboratory and Pathology Services also started to do QIS by making a study on the turn-around-time
(TAT) of laboratory results.
The Hospital Patient Safety Program was created to ensure safety of patients in the
environment of care. The Patient Safety Manual was approved on January 11, 2012 and a hospital
wide orientation was conducted in the month of February. Full implementation of the Patient Safety
Program was started in May, 2012. To measure effectiveness of the program a 2 nd Safety Climate
Survey was conducted on August 13-17, 2012. The second survey showed a safety climate measure
of 74% (+21.8% increase compared to the baseline of 52.5% in 2010). The Clinical Pathway for the
12

11
top ten (10) leading causes of admissions were reviewed and updated including the cost. Continues
monitoring of its implementation and relevance is being done.
The Nursing Service, through the Chief Nurse, Daisy Llarenas , Training Officer Ma. Lenore
Pasol and Ms. Claire Batulan, were the forefront contributors in the development of the NURSE
CERTIFICATION PROGRAM of the Department of Health. The Nurse Certification Program will
accredit competency of nurses in Pediatric Nursing Specialty. There were fourteen (14) NCH nurses
accredited as assessors for this program during its launching in November 23, 2012. Training
modules to prepare all nurses for this nurse certification were crafted and are also available.
FACILITIES renovation and /or improvement continued in the different areas of the hospital
such as the renovation of the 4th floor (Building 2), completion of the new Medical Arts Building
(Building 4) through the assistance of DPWH, completion of the new Operating Room Complex
through the assistance of Hyundai Asia Resources, Inc. Budget from the DOH provided for the
construction of new three story hospital building to replace the old three story building (Building 1)
to start in 2013. The retention and utilization of the hospital income have contributed to the
procurement of more equipment, medical supplies and other needs for the operation of the hospital.
Twenty thirteen (2013) will be an exciting and challenging year for as the hospital prepares
for ISO 9001: 2008 Certification and shortly after for ISO 15189 Medical Laboratory Accreditation.
Fellowship Programs in Pediatric Subspecialties like Hematology, Pulmonology, Infectious Disease,
Neurology and Pediatric Anesthesia will be developed. More Researches will be encouraged and
supported to make NCH a center for pediatric research. Collaboration and networking with partner
organizations locally and internationally will be continued and enhanced for more comprehensive
and continuous improvement of delivery of services to our patients with public-private partnership.
With the dedication and commitment of management and all the hospital staff, this will surely
become a reality for National Children’s Hospital.
National Children’s Hospital has continually grown, evolved and expanded with the changing
times. The hospital has been the frontrunner in the care of pediatric patients, in different stages of
life and different types of diseases. Although almost 90% of patients are indigent, they have never
been deprived of admission despite financial constraints. The delivery of services for indigent
patients is done through innovation, sourcing out of funds and sponsorship, collaboration with
government and non government organizations and individuals. Through the years, this edifice has
been and will always be a living testament of loving quality patient care and concern for all Filipino
children.
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12

The Past and Present Directors of National Children’s Hospital

PEREGRINO H. PAULINO, MD JOSE C. JOVEN, MD CRISANTA DE JOYA-AGREGADO, MD, FPPS, MHA

December 1945 to November 1959 November 3, 1959 to August 3, 1976 August 27, 1976 to October 30. 1987

MA. ISABELITA S. VITAL-GOZON, MD, FPPS MARIETA R. SIONGCO, MD, FPOGS, CESO V ROBERT S. ENRIQUEZ, MD, MHA, CESO IV
April 16, 1988 to November 19, 2001 February 28, 2002 to December 16, 2005 September 18, 2006 to December 29, 2010

EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

June 1, 2011 to present
14

13

VISION
Recognized as an excellent pediatric hospital
in the whole of Asia in the next decade.
Kilalang pinakamahusay na pambatang
pagamutan sa buong Asya sa susunod na
dekada.

MISSION
Provide the best Pediatric healthcare based on
the tradition of excellence in service, research
and training of future leaders in child care.
Magbigay ng pinakamahusay na paggagamot
ayon sa kinamulatang galing sa serbisyo, at
masusing pananaliksik at paghubog sa mga
mamumunong dalubhasa sa larangan ng
paggagamot sa kabataan.

Original mission and vision statements: 2005

1st revision October 2012
TQM/MANCOM approval: January 3, 2013
Implementation date: January 2, 2013
15

14

CITIZEN’S CHARTER

We, the management and staff of the National

Children’s Hospital believe in the inherent dignity
and worth of all men.

We shall work for the best interest of all

patients-in and out, sick and well, and provide at
all times quality health care.

We pledge to commit that we shall give utmost

importance to the well-being of all those we serve.

Approved: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date of Approval: December 20, 2012

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15

CLINICAL SERVICES OFFERED

1. GENERAL PEDIATRICS
Immunizations
Well & Sick Baby, Children & Adolescents
Mon – Fri (8am-4pm)
CECILIA C. DIZON, MD, DPPS
CECILIA C. DIZON, MD, DPPS

Emergency & Ambulatory Pediatrics

MA. LOUISA U. PERALTA, MD, FPPS
ANA LIZA H. DURAN, MD, FPPS
CECILIA C. DIZON, MD, DPPS

2. PEDIATRIC SUBSPECIALTIES
CARDIOLOGY DERMATOLOGY ENDOCRINOLOGY
Mon – Fri (8am-12nn) Tues & Thurs (1pm-4pm) Thurs (8am-10am)
JUAN G. REGANION, MD, DPPS CARLOS E. PAGUIO, MD, FPPS WILSON C. CUA, MD, FPPS

GASTROENTEROLOGY HEMATOLOGY NEONATOLOGY

& NUTRITION Fri (1pm-4pm) Wed (1pm-4pm)
Fri (1pm-4pm) ROSALINA P. ANASTACIO, MD, FPPS JOSE B. SALAZAR, MD, FPPS
GRACE R. BATTAD, MD, FPPS

INFECTIOUS DISEASES INTENSIVE CARE NEPHROLOGY

Daily 24/7 Daily 24/7 Thurs (1pm-4pm)
CYNTHIA A. AGUIRRE, MD, FPPS GENER T. BECINA, MD, FPPS NAOMI P. GROSPE, MD, DPPS
CECILIA C. DIZON, MD, DPPS MA.LOUISA U. PERALTA, MD, FPPS

ONCOLOGY PULMONOLOGY
Fri (1pm-4pm) Mon- Fri (8am-4pm)
AMY GOLETA- DY, MD, FPPS AGNES R. MENDOZA, MD, FPPS

CHILD DEVELOPMENT CENTER

Neurology – Wed (1pm-4pm) Neuro-Dev’t Pediatrics – Tues (8am- 12nn)
MARIETTA M. DIAZ, MD, FPPS JOCELYN A. EUSEBIO, MD, FPPS

Psychiatry – Tues (8am-12nn) Rehabilitation Medicine

PORTIA V. LUSPO, MD, FPPS Thurs (8am- 12nn)
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16

3. SURGERY
CONGENITAL HEART SURGERY
GENERAL PEDIATRIC SURGERY FRANCISCO M. PERALTA, MD, FPATACSI
Daily (8am-4pm)
DELFIN B. CUAJUNCO, MD, FPCS, FPSPS ENT- HEAD and NECK SURGERY
ANTONIO DR. CATANGUI, MD, FPCS, FPSPS Mon (8am- 12nn)
HERMOGENES RD. REGAL, MD, FPCS, FPSPS MA. GRACIA C. MACIAS, MD, FPSO-HNS
LEANDRO L. RESURRECCION, MD, FPCS, FPSPS
JOSE MODESTO B. ABELLERA III, MD, DPCS
OPTHALMOLOGY
Thurs (2pm-4pm)
NEUROSURGERY – Tues (1pm-4pm)
ALFREDO L. TAN, MD, FPCS, FAFN ORTHOPEDICS
CHARLESTON T. YEO, MD, DPBS Thurs (8am-5pm)
LEO O. OLARTE, MD, FPCS, FPOA, FPSA

4. ANESTHESIA
JOSELITO T. MORETE, MD, DPCS
DIVINA P. SERRANO, MD, DPBA
SYLVIA C. ACOSTA, MD, DPBA
JULIET E. CRUZ, MD, DPBA

5. OTHER CLINICAL SERVICES

2-D ECHO – Mon & Wed (8am-11am)
JUAN G. REGANION, MD, DPPS
DENTAL – Mon-Fri (8am-4pm)
ALBERT J. UBAT, DMD
EMILILIA B. BASCO, DMD
PILAR A. LLARENA, DMD
DIABETES EDUCATION CLINIC
Fri (1pm-3pm)
ALICIA T. TALEON, MD, FPPS
DRUG DETOXIFICATION
(By appointment)
WENCESLAO A. KIAT, MD, DPPS
INTERNAL MEDICINE
Mon & Wed (1pm-4pm)
TEODORO B. RAMOS, MD, FPCP, FPCC
PRIVATE-PUBLIC MIX D.O.T.S.
Daily (8am-4pm)
MYRNA T. VALENCIA, MD, FPPS
TOUCH THERAPY
Daily (10am & 3pm)
MA. DOLORES B. CRUZ, MD, FPPS
SMOKING CESSATION CLINIC
For employees
Mon (1pm – 4pm)
TEODORO B. RAMOS, MD, FPCP, FPCC
For Patients / Parents
Fri (1pm – 3p)
AGNES R. MENDOZA, MD, FPPS
JUDITH G. MILAN, MD, FPPS

NEWBORN SCREENING – Daily

MA. DOLORES B. CRUZ, MD, FPPS
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DIAGNOSTIC SERVICES

1. LABORATORY – Daily 24/7 2. RADIOLOGY – Daily 24/7

BLOOD BANKING X-RAY & ULTRASOUND

TERESITA T. ESTABILLO, MD, FPCR
HEMATOLOGY MARIO T. MILO, MD, FPCR
LORNA B. LIOANAG, MD, DPSP
CLINICAL CHEMISTRY & SEROLOGY
3. OTHER DIAGNOSTIC SERVICES
CLINICAL MICROSCOPY & PARASITOLOGY
ELECTROCARDIOGRAM (ECG)
DRUG TESTING
ELECTROCEPHALOGRAM (EEG) Daily
MICROBIOLOGY
MARIETTA M. DIAZ, MD, FPPS
MA. LUISA F. REYES, MD, FPSP
ARTERIAL BLOOD GAS (ABG)
HISTOPATHOLOGY & CYTOLOGY
ICU – Daily
CARMEN S. MANALAYSAY, MD, FPSP
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18

National Children’s Hospital

implements the following provisions of the
Anti-Red Tape Act
20

19
21

20

NCH ARTA COMMITTEE

INITIATIVES and ACCOMPLISHMENTS
 Regular meetings of the ARTA Committee. Conducted (6) meetings for 2012.
 Identified the various frontline services of the hospital.
 Documented the procedure or steps on how to avail of the needed services, the responsible
persons and the actual time required for each of the transactions.
 Recommended to EXECOM a new process flow for the OPD Consultations with the objective of
improving efficiency and reduce waiting time (approved by EXECOM awaiting completion of
needed renovation to be done by engineering).
 Formulated and recommended a new PATIENT IDENTIFICATION CARD (approved and
implemented Jan 2013).
 Formulated the hospital’s SERVICE PLEDGE ( approved and posted in hospital premises)
 Crafted the ARTA Handbook of NCH which will contain our Citizen’s Charter.
 Provision of Priority Services to patients (pediatrics) accompanied by the elderly, disabled and
pregnant.
 Addressed all the recommendations stated in the NCH ARTA Report Card.
 Crafted hospital policies to fully comply with ARTA Provisions.

MA. LUISA F. REYES, MD, FPSP

Members:
CECILIA C. DIZON, MD, FPPS
ESTRELLA L. ALEJO, RSW
ALBERTO J. UBAT, DMD
EVELYN A. GONZALES, RPh
TERESITA LANTIN
GEMMA R. SUAREZ
MYRNA M. DELA ROCA
ARTA Coordinator
Contributors: (OPD Nurses)
- Emergency Room /Out Patient Department
LORETA C. VIDUYA, RN
- Medical Social Service
IMELDA DEVERATURDA, RN
- Dental Section
JULIETA MATEO, RN
- Pharmacy Section
- Cashier
- Medical Records/Admitting Section
- PhilHealth/Billing Section
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21

NATIONAL CHILDREN’S HOSPITAL

POLICIES
(Compliance to ARTA Provisions)

Identification Card of Hospital Employees on Duty

Public Assistance Complaints Desk

Procedure for Filing of Complaints

Procedure for Handling Patient Complaints

Provision of Priority Service for Children

accompanied by Pregnant Individuals, Persons
with Disability and the Elderly
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22

Department of Health
National Children’s Hospital

IDENTIFICATION CARD OF HOSPITAL EMPLOYEES ON DUTY

ARTA PROVISION: All officers or employees transacting with the

public shall be provided with an official identification card which
should be worn during office hours or during their tour of duty.

GUIDELINES:
1. All employees within the premises of the hospital while on duty are required to wear their
official identification card.
2. Frontline employees, especially those administering direct patient care, are required to
introduce themselves to patients prior to any procedure or any form of engagement .
3. Trainees are also required to wear their official identification cards and likewise introduce
themselves to patients prior to any transaction or engagement.

Prepared by:

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Approved by: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date approved: December 10, 2012

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23

DEPARTMENT OF HEALTH
NATIONAL CHILDREN’S HOSPITAL

PUBLIC ASSISTANCE COMPLAINTS DESK

To comply with ANTI-RED TAPE ACT (ARTA) provisions the NATIONAL CHILDREN’S
HOSPITAL shall provide a Public Assistance Complaints Desk in a conspicuous location
preferably in the lobby of the hospital.

GUIDELINES:
1. The Public Assistance Complaints Desk will be manned by hospital staff from the
Administrative Service on a daily rotation basis.
2. A monthly schedule of the officer of the day will be made and approved by the Chief
Administrative Officer and the Medical Center Chief.
3. The officer of the day will physically man the desk from 8am-5pm.
4. The officer of the day is expected to provide assistance to all concerns, inquiries and
complaints of patients.
5. A logbook will be provided where all patient complaints are recorded as they come.
6. The logbook will be submitted to the TQM-CQI office at the end of the day for safekeeping.
7. All complaints will be handled according to set guidelines.

Prepared:

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Recommending Approval: REYNALDO SALAZAR

Chief Administrative Officer

Approved by: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date of Approval: December 10, 2012

Date of Implementation: January 1, 2013
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24

DEPARTMENT OF HEALTH
NATIONAL CHILDREN’S HOSPITAL

PROCEDURE FOR FILING OF COMPLAINTS

A patient may file a complaint through any of the following means:

A. PARU (Patient Assistance Reaction Unit)

A.1 PARU is in the office of the Medical Social Service Section (MSS).
A.2 Responsible person is the head of the MSS or any designated medical social worker.
A.3 Complainant is given a PARU Complaint Form to write his complaint directly or they can be assisted by the
medical social worker in documenting the complaint.
A.4 The complaint is handled by the head of the medical social worker and referred directly to appropriate service/
department or section heads for resolution.

B. PUBLIC ASSISTANCE COMPLAINTS DESK

B.1 Public assistance desk is located in the main lobby of the hospital.
B.2 Person responsible is the officer of the day.
B.3 Complainant is given a form to accomplish directly or can be assisted by the officer of the day.
B.4 Complaints are recorded in a logbook.
B.5 Officer of the day refers complaint report to appropriate hospital officers.

C. TQM –CQI Office

C.1 Complainant can accomplish a patient survey form available in all frontline areas of the hospital.
C.2 The accomplished survey form is dropped in any patient satisfaction survey box (orange boxes) located in (10)
areas of the hospital.
C.3 Admitted patients can also write their complaints in the patient satisfaction survey form given to them prior to
discharge.

Prepared by:

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Approved by : EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date of approval: December 10 , 2012

26

25

DEPARTMENT OF HEALTH
NATIONAL CHILDREN’S HOSPITAL

PROCEDURE FOR HANDLING PATIENT COMPLAINTS

GENERAL GUIDELINES :
1. Attend immediately to patient complaints as soon as they are brought to your attention.
2. Respect complainant’s point of view and adopt a tolerant understanding approach to the
concerns being verbalized.
3. Assure patient that the hospital welcomes complaints as a mechanism to improve on the
delivery of our services.
4. Inform patient that an officer of the hospital will immediately look into his concern and that he
will be given a feedback on the investigation and action/s taken pertaining to his/her
complaint.
5. Refer immediately to designated hospital official the verbalized concern/ complaint.

SPECIFIC GUIDELINES :
1. PARU COMPLAINTS
A. All PARU Complaints will be handled by the head of the Medical Social Service or her
designated representative.
B. All complaints should be properly documented using the official PARU forms.
C. Complainant can write directly his complaint or the medical social worker can assist if
requested.
D. Complaints are processed according to established PARU Policies and Procedures.
E. Resolution of complaint is sought immediately.
F. If resolution cannot be done immediately, assure complainant that a feedback will be given
on his/her complaint (secure a contact tel. number or address to be used for feedback
purposes and make sure you get back to the patient as promised)

2. PUBLIC ASSISTANCE/COMPLAINTS DESK

A. All complaints received by the officer of the day will be recorded in a designated logbook.
B. Complainant will be given a form to accomplish by the person himself or he may seek
assistance of the officer of the day.
C. Officer of the day classifies the complaint as to whether it belongs to the MEDICAL
SERVICE, NURSING SERVICE or ADMINISTRATIVE SERVICE.
27

26

D. The officer of the day will immediately refer the complaint to the appropriate hospital
official as follows:
D.1 Medical Service - CMPS or designated representative
D.2 Nursing Service - Chief Nurse or Assistant Chief Nurse
D.3 Administrative Service - Chief Administrative Officer or designated representative
E. Hospital official immediately attends to the complaint, documents resolution and action
taken and informs the complainant.

3. TQM-CQI OFFICE
A. The TQM-CQI Office officially administers and is responsible for the patient satisfaction
surveys conducted in the entire hospital.
B. There are (3) patient satisfaction forms used in the hospital:
B.1 Out Patient Front-liners Survey Forms
B.2 Emergency Room Survey Form
B.3 In-Patient Survey Form
C. The accomplished survey forms are dropped in designated drop boxes located in many
areas of Hospital (orange boxes). The accomplished survey forms are collected by TQM
office twice a week. A weekly report is prepared by TQM and copies are given to the
different areas of the hospital. Negative feedbacks/comments are addressed through an
ACTION PLAN which will be formulated by the service/department/section/unit
concerned. All action plans should be documented.
D. If patient writes his/her name/contact telephone number/ address on the survey form, a
written feedback on the actions taken pertinent to the complaint will be given.

Prepared by:

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Approved by: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date approved: December 10, 2012

28

27

NATIONAL CHILDREN’S HOSPITAL

Anti- Red Tape Act (ARTA) Committee

DATE: February 8, 2013

TO: ALL HOSPITAL EMPLOYEES RENDERING FRONTLINE SERVICES

TOPIC: PROVISION OF PRIORITY SERVICE

Effective immediately the hospital shall implement the PROVISION OF PRIORITY SERVICE to
patients who are accompanied by senior citizens (matatanda), pregnant (buntis) and the disabled
(maykapansanan).

A signage will be displayed in all frontline service areas for the information of our patients. All
hospital staff are required to implement this priority service consistently to fully comply with the
Anti- Red Tape Act of 2007 (Republic Act No. 9485).

Thank you.

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Approved: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief
29

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FRONTLINE TRANSACTIONS
Out-Patient Department
Daloy ng Konsultasyon sa Out Patient Department

Dental Service
Steps in the Availment of Dental Health Services

Laboratory Department
Procedure in Requesting for Laboratory Examinations and Submission of
Specimens

Radiology Section
Procedure in Requesting for Radiologic Examinations

Pharmacy Section
Procedure in Filling Prescriptions for Sponsored Transactions
Procedure in Filling Prescriptions Cash Basis

Medical Social Service

Procedure for Referral to Medical Social Service for Patient Assistance

Billing/PHILHEALTH Section
Procedure For Discharge of Patient
Procedure for Refund of PCSO, Excess Payment/Deposit

Medical Records Section

Issuance of Medical Certificate
Request for Abstract/Photocopy of Results (discharge patient)

Cashier
Refund of Payment (Consultation Fee, Medical, Laboratory and other
procedures)
31

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Section : OUT –PATIENT DEPARTMENT

DALOY NG KONSULTASYON SA OUT PATIENT DEPARTMENT

Estimate Transaction Time: 30 MINUTES to 4 HOURS

ACTIVITY # FLOWCHART

Start

1 Kumuha ng Triage Form sa guard

Pumunta sa Triage Area para makunan

ng temperatura, pulso at iba pa
2

Pumunta sa Registration Area para

3 magpalista at ipakuha ang chart sa
records section

4 Magbayad sa Cahier

Dalhin ang resibo at pumunta sa Height

5 and Weight area at magpakuha ng taas
at timbang

Pumunta sa waiting area at maghintay

6 sa tawag ng doktor

7 Pumunta sa Consultation Room kung

saan tinawag ng doktor

Sagutin ang Patient’s Satisfaction

8 Survey Form para sa ikakaganda ng
serbisyo ng National Children’s
Hospital at ihulog sa suggestion box

End
32

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Section : DENTAL

STEPS IN THE AVAILMENT OF DENTAL HEALTH SERVICES

Estimate Transaction Time: 1 HOUR & 20 MINUTES

ACTIVITY # FLOWCHART

Start

Proceed to TRIAGE AREA for

1
evaluation

New Proceed to OPD Medical

2 Patient Records Section
(old patients)

Proceed to Dental Section for

3 examination and treatment

Pay at the cashier for services

4 rendered

End
33

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Section : LABORATORY

Subject : PROCEDURE IN REQUESTING FOR LABORATORY

EXAMINATIONS AND SUBMISSION OF SPECIMENS
Estimate Transaction Time: 32 MINUTES

ACTIVITY # FLOWCHART

Start

1 Present laboratory request to the

Pay at the cashier

2  Cashier near OPD Reception 8am –
3pm
 Cashier in front of ER or at the
Pharmacy section, 3 pm - onwards

3 Return O.R. & Laboratory request to

4 Submit specimen and or wait for

End
34

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Section: RADIOLOGY

Subject: PROCEDURE IN REQUESTING FOR RADIOLOGY

EXAMINATIONS
Estimate Transaction Time: 30 MINUTES

ACTIVITY # FLOWCHART

Start

1 Present x-ray request to Radiology office

Pay at the cashier.

2 1. Cashier near OPD Reception 8am–
3pm.
2. Cashier in Pharmacy section located

3 Return O.R. & x-ray request to Radiology office

4
Proceed to x-ray room for the procedure
examination

5 Come back for release of official result as

instructed

End
35

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Section: PHARMACY

Subject: PROCEDURE IN FILLING PRESCRIPTIONS

SPONSORED TRANSACTIONS
Estimate Transaction Time: 25 MINUTES

ACTIVITY # FLOWCHART

Start

1 Present prescription
signed by the
physician to the

2 Inquire on the
maximum amount that
can be availed

3
Receive medicines

End
36

35

Section: PHARMACY
Subject: PROCEDURE IN FILLING PRESCRIPTIONS CASH
BASIS
Estimate Transaction Time: 7 MINUTES

ACTIVITY # FLOWCHART

Start

Present OR and
1 prescription to the
pharmacist

2
Pay to the Cashier

Present the
prescription to the
4 pharmacist

Receive medicines

End
37

36

Section: MEDICAL RECORDS

Subject: REQUEST FOR ABSTRACT / PHOTOCOPY OF

RESULTS (for discharged patients)
Estimate Transaction Time: 40 MINUTES

ACTIVITY # FLOWCHART

Start

Request for Abstract/

1 photocopy of results

Give information
2
needed

3 Fill out request for

Access to Medical
Record Form

4 Receive requested
abstract/photocopy of
result

End
38

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Section: MEDICAL RECORDS

Subject: ISSUANCE OF MEDICAL CERTIFICATE (for OPD or

presently confined in the ward)
Estimate Transaction Time: 55 MINUTES

ACTIVITY # FLOWCHART

Start

Request for medical

1
certificate

Pay medical certificate

2 fee at the Cashier’s
Office

Request the attending

3 physician to sign the
Medical certificate

4 Receive medical
certificate

End
39

38

Section: MEDICAL SOCIAL SERVICE

Subject: ISSUANCE OF MEDICAL CERTIFICATE (for

discharged patients)
Estimate Transaction Time: 55 MINUTES

ACTIVITY # FLOWCHART

Start

Request for medical

1 certificate

Pay medical certificate

2
fee at the Cashier’s
Office

Request the attending

3
physician to sign the
Medical certificate

4 Receive medical
certificate

End
40

39

Section: MEDICAL SOCIAL SERVICE

Subject: PROCEDURE FOR REFERRAL TO MEDICAL SOCIAL

SERVICE FOR PATIENT ASSISTANCE
Estimate Transaction Time: 1HOUR & 20 MINUTES

ACTIVITY # FLOWCHART

Start

1 Seek/ask for assistance

2 Submit all pertinent

documents to the Medical

3
Comply with Social Worker’s

4 Present guarantee letter/ and

or assistance from donor to
Social Worker

5
Assistance is granted

End
41

40

Section: BILLING / PHILHEALTH SECTION

Subject: PROCEDURE FOR DISTANCE OF PATIENT

Estimate Transaction Time: 16 MINUTES

ACTIVITY # FLOWCHART

Start

1 Inquire from nurse when to transact

with Billing Section

2 Get statement of hospital bills from

Billing Section

3 Pay hospital bill to the cashier

(Pay Patient) or
Proceed to MSS for assistance on
payment of bill (service patient)

4 Return and present the OR to Billing

Section

5 Receive the discharge clearance

from Billing Section

Return to the nurse in the ward

6
and present discharge clearance
get the Discharge slip and
Discharge Plan

End
42

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Section: BILLING / PHILHEALTH SECTION

Subject: PROCEDURE FOR REFUND OF PCSO, EXCESS

PAYMENT/DEPPOSIT
Estimate Transaction Time: 10 WORKING DAYS

ACTIVITY # FLOWCHART

Start

Submit original official

1 receipt
to Billing Section

Receive check as refund

2 after presentation of (2)
valid identification cards
to cashier

End
43

42

Section: CASHIER

Subject: REFUND OF PAYMENT (Consultation Fee, Medical,

Laboratory and other Procedures)
Estimate Transaction Time: 1 HOUR & 14 MINUTES

ACTIVITY # FLOWCHART

Start

1 Request for refund of

Payment

2 Submit original OR with

justification for refund

3 Receive refund

End

Note: Refund of payment within the day will be refunded immediately after
presentation of original OR with justification.
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43

ANNEXES

A. PACD Patient Feedback/Complaint Form

B. PARU FORM

C. OPD FRONT-LINERS Patient Survey Form

D. In-Patient Satisfaction Survey Form

E. Emergency Room Patient Satisfaction Survey

Form

F. Panunumpa sa Watawat

G. Panunumpa ng Kawani ng Gobyerno

H. DOH Hymn

I. Awit ng Serbisyo Sibil

45

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Annex A
46

45

Annex B (page 1)
47

46

Annex B (page 2)
48

47

Annex C (front)
49

48

Annex C (back)
50

49

Annex D (front)
51

50

Annex D (back)
52

51

Annex E (front)
53

52

Annex E (back)
54

53

Annex F

PANUNUMPA SA WATAWAT

Ako ay Pilipino

Taos pusong Nanunumpa

Sa Watawat ng Pilipinas.

At sa Bansang Kanyang

Sinasagisag na may

Dangal, Katarungan at Kalayaan

Na Pinakikilos ng Sambayanang

MakaDiyos, Makatao,

Makakalikasan at Makabansa.
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54

Annex G
PANUNUMPA NG KAWANI NG GOBYERNO

Ako’y kawani ng Gobyerno.

Tungkulin ko ang maglingkod nang tapat at mahusay.
Dahil dito…
Ako’y papasok ng maaga at magtatrabaho ng lampas sa takdang oras
kung kinakailangan;
Magsisilbi ako nang magalang at mabilis sa lahat ng nangangailangan;
Pangangalagaan ko ang mga gamit, kasangkapan at iba pang pag-
aari ng pamahalaan.
Magiging pantay at makatarungan ang pakikitungo ko sa mga
lumalapit sa aming tanggapan;
Magsasalita ako laban sa katiwalian at pagsasamantala;
Hindi ko gagamitin ang aking panunungkulan sa sarili kong
kapakanan;
Hindi ako hihingi o tatanggap ng suhol;
Sisikapin kong madagdagan ang aking talino at kakayahan
Upang ang antas ng paglilingkod sa bayan ay patuloy na maitaas.
Sapagkat ako’y isang kawani ng gobyerno at tungkulin ko ang
maglingkod nang tapat at mahusay sa bayan ko at sa panahong ito;
Ako at ang aking mga kapwa kawani
Ay kailangan magkaisa tungo sa isang maunlad, masagana,
mapayapa, malusog at makakalikasang bansa.
Sa harap ninyong lahat;
Ako’y taos-pusong nanunumpa.
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Annex H

DOH HYMN

Lahat tayo’y magkabuklod

Upang baya’y itaguyod
Walang sawang naglilingkod
Sa nayon man o sa lungsod
Pilipino ang layunin
Kapwa tao’y tangkilikin
Pangarap ko’y Pilipinas
Sa mundo’y walang katulad

Chorus:
Kagawaran ng Kalusugan
Gabay namin kahit saan
Lagi naming gagampanan
Ang tungkuling sinumpaan
Laan sa’yo maging ang buhay
Upang tayo’y magtagumpay
Sa pagbuo ng iisang bansa
Na matatag at malaya.
57

56

Annex
Annex GI

AWIT NG SERBISYO SIBIL

Ang Serbisyo Sibil ng Bayan ko

Lingkod na tunay ngayon at kaylanman
Laging tumutulong, laging nagpapayo
At sa kawani ay syang patnubay.

Ang Serbisyo Sibil ay tanghalin

Ito ay ating dakilain
Maging tapat twina sa ating tungkulin
Paglingkurang lagi, bayang giliw.

Ang Serbisyo Sibil ay lingkod na tangi

Tayo na’t ito’y ating ipagbunyi
MABUHAY!

Ang Serbisyo Sibil ng bayan ko

Lingkod na tunay ngayon at kaylanman
Lagi tumutulong, laging nagpapayo
At sa kawani ay syang patnubay

Ang Serbisyo Sibil ay tanghalin

Ito ay ating dakilain
Maging tapat twina sa ating tungkulin
Paglingkurang lagi
Bayang Giliw.
58