Office: of The Secretary

of the Philippines
Republic
Department of Health
OFFICE OF THE SECRETARY
January 12, 2021
DEPARTMENT CIRCULAR
No. 2021 - _DDll
FOR: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES;

DIRECTORS OF BUREAUS, SERVICES, AND CENTERS FOR
HEALTH DEVELOPMENT (CHD): MINISTER OF HEALTH -
BANGSAMORO AUTONOMOUS REGION IN MUSLIM
MINDANAO (MOM-BARMM); EXECUTIVE DIRECTORS OF
-
SPECIALTY HOSPITALS; CHIEFS OF MEDICAL CENTERS,

HOSPITALS AND SANITARIA; AND ALL OTHERS CONCERNED
SUBJECT: Submission of Integrated Hospital Operations and Management

Program (IHOMP) Self-Assessment Tool
All government and private hospitals are requested to submit the Integrated Hospital
Operations and Management Program (IHOMP) Self-Assessment Tool to
doh.hfdb.rpmd@gmail.com on or before February 15, 2021. The items/questions in the tool
shall be responded online through bit.do/BHPIHOMPSAT. The updated version of the
THOMP Self-Assessment Tool is attached in Annex A for reference.
The Health Facility Development Bureau (HFDB) of the Department of Health (DOH)
assumes technical leadership in the development of plans, programs, projects, standards and
policies and provision of coordination, technical assistance, capability building, and
consultations related to health facility planning, development, maintenance, management and
operation.
The Integrated Hospital Operations and Management Program (IHOMP), one of the flagship
programs of HFDB, enhances the provision of quality essential healthcare services in the
hospitals through the improvement of management systems and procedures within the
healthcare facility. The THOMP Self-Assessment Tool provides guidance for proper
assessment and evaluation of hospital operations and management and identification of
strengths and areas for improvement. The six (6) major components of the tool that set the
standards to be in place are: Governance, Ethics and Patients’ Rights, Quality Measurement
and Improvement, Patient Safety, Facility Safety and Emergency Management, and Resource
Management. The responses will ensure the continuous implementation of the program and
generate data and evidence for policy and standards development.
Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 651-7800 local 1113, 1108, 1135
Direct Line: 711-9502; 711-9503 Fax: 743-1829 e URL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
Moreover, government and private hospitals who submit the accomplished IHOMP Self-
Assessment Tool shall be given priorities to receive the HFDB Manual of Operations of
Different Hospital Services and shall be given regular updates on hospital-related policies,
standards and plans.
For queries and clarifications, you may contact Mr. Roderick M. Napulan, Division Chief, or
Mr. Erickson A. Feliciano, Development Management Officer IV, both of HFDB, at (02) 8651-
7800 local 1406.
For strict compliance.
By Authority of the Secretarg of Health:
WJ
LILIBETH C. DAVID, MD, MPH, MPM, CESO 1
Undersecretary of Health
Health Facilities and Infrastructure Development Team
Instructions: Please complete the required information below using hospital data covering January 1, 2020 - December 31, 2020.
For the IHOMP Assessment, the data should reflect implementation status as of December 31, 2020. ANNEX A
I. GENERAL INFORMATION
Authorized Bed Capacity
Region
(ABC) - By law
Authorized Bed Capacity
Address
(ABC) - Based on licensing
Name of Hospital Implementing Bed Capacity

(1BC) - Actual Capacity
Hospital Level Contact No.
Email Address
Il. HOSPITAL OPERATIONS

Total Number of Inpatients
Total number of
referral/s
from other Hospitals
Total Number of Senior Citizens Total number of referral/s
admitted (60 years old and above} to other Hospitals:
Yotal Number of Inpatient Bed Days

Total Number of Outpatient Visits Total Number of Deliveries
New Patient Normal Spontaneous
Re-visit C-Section
Bed Occupancy Rate %

Other
(BOR)
111. Deaths
Total Number of Deaths
Total Number of Neonatal Deaths
Total Number of Maternal Deaths
Gross Death Rate (%)
Net Death Rate {%)
Prepared by: Vetted and approved by:
Additional Requirements:
1. License to operate os of Dec. 31, 2020.
2. CHD validated IHOMP Tool {validated by CHD Heolth Facility Development Unit (HFDU), assessed and conducted within Jun. 2020-Feb. 2021)
3
Republic of the Philippine
DEPARTMENT OF HEALTH
HEALTH FACILITY DEVELOPMENT BUREAU
Integrated Hospital Operations and Management Program Self-Assessment Tool
Standards Required to
Data Source Points of Emphasis Data Gathered Remarks
Cl 4 points
Leadership: Do you Director’s/COH « Hospital Order
conduct Office e Minutes of Yes No
* Execom Meeting/(1) Meeting on File
eoManCom Meeting (1) e Attendance on File Yes No
¢ Financial Management ¢ How often?
Com Meeting (1)
e Gen Assembly (1) Yes No
Yes No
2 points
Is your Organogram Actual e Includes Key
displayed in a validation Officials (1) Yes No
conspicuous place e Pictures and names Yes No
and contact details
1)
. 2 points
Is your hospital’s Actual e Posted in a
Performance/Quality validation conspicuous place Yes No
Indicators Posted for
Public Information?
points
How is compliance to Management « Policy on
DOH Manual of monitoring Describe
Standards per service standards
area monitored? e Monitoring results
Presence of Policy e Manuals S points
Manual per service area Management accessible per
|
service area Yes No

Do you have an Management ¢ Covered bya 4 points
oversight of contracts? policy Yes No
How is it being done? Describe
|
1 point
Do you have policies Hospital ¢ Policies that Yes No
covering the beliefs and Institutional prevent Describe
culture of your patients? Manual of discrimination
Policies
HFDB Form 15 — Integrated Hospital Operations and Management Program (IHOMP) Self — Assessment Tool
Revision 1
July 19 2018
Page 10of9
*¥* This self-assessment tool was prepared by Health Facility Development Bureau {HFDB) — DOH.
Any means of reproduction of this tool, kindly seek approval of the HFDB prior use.
31
-

~

Se botn pave Data Source Points of Emphasis Cand Remarks

points
Actual validation e Patients’ Rights
Posted in Yes No
conspicuous places
Actual validation (D
e Anti-Deposit IRR Yes No
Actual validation posted in ER (1)
e Availability of
costs of medicines,
Ye¢§ No
supplies and
procedures (1)
What are your CMPS e Policies point

programs and
services that e Specific programs Describe
encourage patient and services
participation? implemented
points
Do you implement CMPS ¢ Is the Psychosocial
holistic approach to information Yes No
patient care? available in the
chart? (1)
Yes No
¢ Do you conduct
Multidisciplinary
case management
conferences? (1) Actual Data
e Rate of Therapeutic
Dietary Counselling
1 point
Discharge Planning CMPS/Clinical Rate of complete
Management/HIM discharge planning Actual Data
provided (Doctor,
Nurse, Dietician,
Social Worker) (1)
Page20of9
*** This self-assessment tool was prepared by Health Facility Development Bureau (HFDB) — DOH.
13
SE boiuove Data Source Points of Emphasis con d

Remarks
point
Do you have a system QMS Management ¢ Turnaround time
of responding to for resolving Actual Data
complaints? patients’
complaints (1)
1 point
Continuity of Care Nursing Manager e Rate of handovers
correctly done (1) Actual Data
e No. of Interagency point
HIM referral to higher
and lower facilities Actual Data
1)
e No. of referrals point
HIM accepted by the
hospital from Actual Data
lower or higher
facilities (1) |
Accessibility and 2 points

Equity MSW e Policy on
Identifying Yes No
indigent patients
|
1)
MSW/HIM e % of indigent Actual Data
patients w/
Philhealth and w/o
Philhealth (1/2)
MSW/HIM eo% of indigent Actual Data
patient provided
with specialized
care (1/2)
Empathy HIM/QMS e Turnover time for points
patient’s
registration and Actual Data
admission process
1)
Actual Data
|
HIM/QMS ¢ Waiting time for

consultation (1)
|
Institutional Policy |e Presence of policy

on understanding
and satisfying Yes No
special request of Describe
patients and family
1)
Page 3 of 9
2
Stand boin plave. Data Source Points of Emphasis Coes d Remarks

Privacy and 2 points
confidentiality eNames of patients Yes No
Privacy Officer are not displayed
for public
information (1/2) Yes No
e Patientrecordsare Describe
protected (1/2)
"Actual validation e Confidentiality is Yes No
observed in clinical How?
areas and
administrative
areas where
patient’s
information is
taken (1)
2 points
Do you implement QMS Team ¢ Documented Yes No
quality improvement Initiatives (1)
initiatives? e % of staff involve Actual Data
in the Quality
improvement
initiative of the
hospital (1)
Utilization/workload 2 points
Are the following Management/HIM measures |
Yes No-
indicators monitored e No. of inpatients Actual Data

and analysed? (1/2) Actual Data
e No. of outpatients
(1/2) Actual Data
¢ No. of procedures
(1/2) (surgical etc) Actual Data
¢ No. of diagnostic
tests(1/2)
Efficiency measures points
Management/HIM o Average length of Yes No
stay (1/2)
e Bed occupancy Provide
rate (1/2) actual data
» Day case rate (1/2)
e Operating theater
utilization (1/2)
Page 4 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau {HFDB) — DOH.
Se bempiae Data Source. Points of Emphasis Cond Remarks

QMS/HIM Quality/outcome 5 points
measures
o Unplanned Yes No
readmission
rates<xx days Provide
eoInfections (e.g. actual Data
MRSA and
Clostridium
Difficile)
¢ Patient falls
e Unplanned returns
to operating theater
e Needle-stick
juries
e Pressure sores
e Complications rate
e Caesarean rate
¢ Deaths
¢ Sentinel Events
Patient and Family 1 point

Experience QMS/management o Patient complaints Yes No
e Patient satisfaction Actual Data
eoCommendation
1 point
System of
monitoring, Description
frequency
Management How are these data 2 points
analysed and utilized Describe
for decision making?
Presence of a Patient Safety Policy 2 point

Committee Committee Head Yes No
Do you conduct 5 points

CMPS clinical Audit? (1) Yes No
Documentation? (2) Describe
Infection Prevention Overall hand hygiene 2 points
and Control compliance Actual Data
Coordinator
Page 5 of 9
2
bo ple In Data Source Points of Emphasis

What data are you
conta d
S points
Remarks
Infection collecting to reduce Describe

Prevention and risks to patient?
Control - ADR
Coordinator - Medication
Error
- Others (please
specify)
Quality 4 points
Nursing and HIM Documentation? Yes No
(i.e FDAR) Describe
¢ Are meals served points
Actual validation on time, at proper Yes No
temperature, Describe
attractive and
acceptable?
Actual validation ¢ Food is protected
from contamination
nd Spo lag
a
fa il
Do youhave a risk Documentation

Management Plan? QMS Unit available (1)
Health Emergency
and Disaster Disaster management
Management Unit/ Plan is available (1)
Emergency Dept.
Nutrition and Presence of Health 1 point
Dietetics Emergency Feeding Yes No
Department Plan (1)
1 point
Do you have a policy
Institutional Policy on how to address Yes No
patient or visitor who Describe
became violent? (1)
Do you have a Institutional 1 point
Preventive Policy/Engineering Policy available (1) Yes No
Maintenance and Facilities
program? Management
Institutional 2 points
Policy/Engineering Is there a system of Yes No
and Facilities reporting equipment Describe
Management failure (2)
Page 6 of 9
*** This self-assessment tool was prepared by Health Facility Development Bureau {(HFDB) — DOH.
betnpave
Healthy Environment
Data Source - Points of Emphasis Coa d
3 points
Remarks
¢ Cleanliness of the Yes No

Actual validation environment
(inside and outside
hospital premises)
(1)
Actual validation e comfortable Yes No

seating
arrangement in the
waiting area
provided (1)
Actual validation ¢ wheelchairs and Yes No

elevators provided
as necessary (1)
pes
Do you conduct
budget utilization Management/CMPS Documentation is Yes No
review? available (1)
Do you conduct 1 point

performance review Documentation is Yes No
Management/ available (1)
Hospital wide Planning office
Service level
Department/ division
Level
Section/ Unit level
Finance Service 3 points

Are the following e Charging System Yes No
|
Financial System in e Billing System Yes No
place: e Costing and Rate Yes No
Charging System setting
Billing System Procedures
Costing and Rate
setting Procedures
Page 7 of 9
1
{|
botnprove
Financial
Data Source
Finance Service
Points of Emphasis conta d
1 point
Remarks
Performance and e Cost per patient Actual Data

condition per day (1/2)
e Cost of
pharmaceutical in Actual Data
relation to the
total MOOE (1/2)
1 point
Availability of Pharmacy es % of filled Actual Data
Medicines? Department prescription (1/2)
eo % of unfilled
prescription (1/2)
eo
Emergency cart 1 point
Emergency have complete Yes No
Department medicine (1/2)
Nutrition and ¢ Compliance to 1 point
Dietetics the Php Yes No
Department 150/patient/day
meal allowance
(1)
Finance Service ®»
% of income 1 point
Income from Phil Health Yes No
(D
2 points
Wastage Nutrition and e Total amount of Actual Data
Dietetics wastage from
Department medicines, food,
reagents (1/2)
Pharmacy, e Do you havea Yes No
Laboratory and system of
Radiology, ND reducing
pilferage? (1/2)
e Do you practice Yes No
unit dosing? (1/2) |
)
e Is inventory
management in Yes No
place? (1/2)
e Ratio of point
Computer hardware IHOMU computers to Actual Data
admin support
staff (1)
Page 8 of 9
*** This self-assessment too! was prepared by Health Facility Development Bureau (HFDB) — DOH.
Se beinora Data Source Points of Emphasis cota d Remarks

Personnel Section eo Rate of Turnover 2 points
Compliance to health of nurses (1/2)
human resource e Doctors(1/2) Actual Data
standards o 9% of unfilled
positions (1)
Other significant concerns for technical assistance:
Name of Hospital:
Address:
Contact No. +639-
Email Address
Please submit the accomplished tool together with the following documentary evidences:
1. Institutional Manual
2. Hospital Statistical Report for the last three years
3. Other reports and documents supporting data gathered.
Page 90of9

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of the Philippines

January 12, 2021

FOR: ALL UNDERSECRETARIES AND ASSISTANT SECRETARIES;

SPECIALTY HOSPITALS; CHIEFS OF MEDICAL CENTERS,

SUBJECT: Submission of Integrated Hospital Operations and Management

For strict compliance.

By Authority of the Secretarg of Health:

Name of Hospital Implementing Bed Capacity

Hospital Level Contact No.

Il. HOSPITAL OPERATIONS

Yotal Number of Inpatient Bed Days

Bed Occupancy Rate %

Gross Death Rate (%)

Net Death Rate {%)

Prepared by: Vetted and approved by:

service area Yes No

Republic of the Philippine

HEALTH FACILITY DEVELOPMENT BUREAU

Se botn pave Data Source Points of Emphasis Cand Remarks

What are your CMPS e Policies point

SE boiuove Data Source Points of Emphasis con d

Accessibility and 2 points

HIM/QMS ¢ Waiting time for

Institutional Policy |e Presence of policy

Stand boin plave. Data Source Points of Emphasis Coes d Remarks

indicators monitored e No. of inpatients Actual Data

Se bempiae Data Source. Points of Emphasis Cond Remarks

Patient and Family 1 point

Presence of a Patient Safety Policy 2 point

Do you conduct 5 points

bo ple In Data Source Points of Emphasis

Infection collecting to reduce Describe

Do youhave a risk Documentation

¢ Cleanliness of the Yes No

Actual validation e comfortable Yes No

Actual validation ¢ wheelchairs and Yes No

Do you conduct 1 point

Finance Service 3 points

Performance and e Cost per patient Actual Data

Se beinora Data Source Points of Emphasis cota d Remarks

Other significant concerns for technical assistance:

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