Institutional Handbook of Policies and Operating Procedures

Policy 04.02.04
Section: Responsible Executive:

QUALITY IMPROVEMENT AND PATIENT SAFETY Alejandro C. Dizon, MD

Vice President & Head, Quality and Patient Safety and
Chief Quality Officer
Subject: Responsible Entity or Manager:

Environment of Care (EOC) Program Implementation Pearl M. Pagaduan

Associate Director, Quality and Patient Safety

I. Title
Environment of Care (EOC) Program Implementation

II. Definition of Terms

EOC Caretakers: These are associates coming from the following Functional Groups or departments: Quality and
Patient Safety, Facilities and Management Engineering, Biomedical Engineering, Infection Control and Housekeeping

EOC Point Persons: These are associates representing their Functional Groups in the implementation of the EOC
program

EOC Program: Hospital-wide quality program involving the total organization which promotes Cleanliness and
Orderliness, Safety, Maintenance, Infection Control, Resource Conservation in the hospital

III. Coverage
This policy shall apply to all units of the Medical Center, all lessees and concessionaires (i.e. Blue and Gold and Sweet
Tomato Grill, etc.), SLMC offices in the Medical Arts Building (MAB), Cathedral Heights Building Complex (CHBC) and
St. Luke’s College of Medicine-WHQM.

IV. Policy and Intent

To provide guidelines and mechanics in the implementation of the EOC program to ensure a safe, functional, and
supportive environment for patients, staff members & other individuals in the hospital.

A. QPS shall be responsible for the overall direction, implementation, monitoring and evaluation of the EOC Program.

B. The EOC Caretakers shall be the assigned quarterly inspectors, specifically to cover the following EOC disciplines:
EOC DISCIPLINE LEAD EOC CARETAKER
Cleanliness and Orderliness Housekeeping Department
Safety Facilities Management and Engineering
Maintenance Biomedical Engineering and Facilities, Facilities
Management and Engineering
Infection Control Infection Control Service
Resource Conservation Quality and Patient Safety
Self-Discipline Quality and Patient Safety

C. All EOC Caretakers shall undergo EOC Training to be able to know all the standards and inspection procedure.

D. All areas shall be inspected quarterly by the EOC Caretakers based on schedule and shall be evaluated/rated
according to the EOC standards. Areas shall be rated using the 3 pts.system (3=MET, 2= Partially Met, 1= Not
Met)

E. Each Functional Group Head must assign an EOC Point Person annually. The EOC Point Persons shall represent
their Functional Groups in the implementation of the EOC program.
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IHPOP Policy No. 04.02.04

F. The Functional Heads, together with the appointed EOC Point Persons, must formulate their own strategies in the
implementation of EOC program. They shall be responsible for monitoring of EOC compliance in their respective
Groups.

G. There shall be a monthly unit or cross-unit based inspection. The EOC Point Person shall also monitor compliance
to the monthly inspection. Accomplished EOC inspection form (ANNEX A) shall be submitted to QPS.

H. The Point Persons shall be responsible for preparing the Groups’ Quarterly EOC Reports, including actions taken
or action plans to address the findings and areas for improvements.

I. Areas with ongoing meetings, general cleaning, Code Blue and/or other activated codes shall not be exempted from
the inspection. These areas shall be revisited for inspection after the said activities.

J. Areas/Units undergoing renovation must be inspected based on the standards for renovation (Refer to related Policy
on Infection Control Measures for Renovation or Construction Projects).

K. QPS shall convene the point persons regularly for EOC updates, issues and concerns in each functional group. This
forum shall be the venue for updates, resolving issues and concerns and enhancement of the program.

L. The QPS attends and addresses any concerns/complaints pertaining to EOC process.

M. QPS shall ensure that standards are evaluated for its effectiveness through conduct of periodic reviews or as
necessary.

N. EOC Rating shall be part of the associates’ PPMCC (5% under Quality and Patient Safety KRA).

V. Procedures
Not Applicable

VI. Related SLMC Policies and Procedures

Policy No. Title
IHPOP Policy No. 05.04.03 Infection Control Measures for
Renovation or Construction Projects

VII. Related SLMC Documents and Forms

Annexes Title
ANNEX A EOC Inspection Form

VIII. References
JCIA Standards for Hospitals (Including Standards for Academic Medical Centers), 6th edition. (2017). Oakbrook
Terrace, Illinois.

IX. Dates Approved or Amended

Originated: March 2001
Reviewed with Changes: Reviewed without Changes:
March 2005
January 2009
October 2017
May 2018
Effective Date: May 29, 2018

X. Approval

Recommended by: Approved by:

Rafael C. Solis, MBA-H Arturo S. De La Peña, MD

Executive Vice President and Head President and CEO
Hospital Operations Group
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IHPOP Policy No. 04.02.04

XI. Contact Information

Alejandro C. Dizon, MD
Vice President and Head of Quality and Patient Safety
Chief Quality Officer
(02) 723-0101 ext. 5554

Pearl M. Pagaduan
Associate Director
Quality and Patient Safety
(02) 723-0101 ext. 5554