CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

CONTEXT OF THE ORGANIZATION

NURSING SERVICE DIVISION

The Nursing Service Division is a vital component of the health care services, playing an important role

in providing direct, quality, safe, equitable and affordable nursing care in a 400-bed ISO-certified tertiary
hospital that caters to the whole population of the Negros Island Region. It is composed of more than
700 staff of nurses, nursing attendants and midwives, whose communication and interaction with one
another, with clients and others in the health care team, bring unique forms of knowledge, experience
and meaning to the context of nursing care. Moreover, the Nursing Service Division also operates under
a sequential and cyclical set of intellectual operations which are assessment (including nursing diagnosis),
planning, implementation and evaluation, within the parameters of professional standards, statutory
requirements and a code of ethics.

Challenged by the Department of Health mandate, “All for Health, Towards Health for All,” it aims
to provide both inpatient and outpatient services through the different clinical wards and special care
units, specifically made to cater to the individual, family and community of which it serves.
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
INTERESTED PARTIES & EXPECATIONS: Licensing & Reporting Requirements
NURSING SERVICE DIVISION

Interested Parties
Requirements Due date STATUS
(EXTERNAL/INTERNAL)

EXTERNAL (GENERAL
REQUIREMENTS FOR ALL
CLINICAL WARDS AND
SPECIAL CARE AREAS)

a. Department of Health Basic Life Support (BLS)

every 2 years
(DOH) Training

b. Professional
Regulation Commission PRC License every 3 years
(PRC)

EXTERNAL (INTENSIVE
CARE UNITS)

a. Department of Health Advanced Cardiac Life Every 2 years

(DOH) Support Training (ACLS)

AREA: PEDIATRICS
INTENSIVE CARE UNIT
(PICU)

Pediatric Advanced Life

Every 2 years
Support (PALS)
a. Department of Health
(DOH)
Neonatal Resuscitation
Every 2 years
Program (NRP)

AREA: NEONATAL
INTENSIVE CARE UNIT
(NICU)

a. Department of Health Percentage Report of

Newborn Screening Test, Monthly
(DOH)
BCG and Hepatitis B
 Vaccination for NICU

AREA: PERITONEAL
DIALYSIS

a. Department of Health Monthly census of

(DOH) patients diagnosed with QUARTERLY
ESRD (REDCOP)

Certification of PD Nurses Every 3 years

B. National Kidney
Certification of PD trained
Transplant Institute Every 2 years
Nurses
(NKTI)

C. Philippine Health Home Visit Monthly

Insurance Company
(PHIC)

CAPD Consultation Monthly

RECORD

D. Patient Home Visit Monthly

OPD Consultation Monthly

RECORD

AREA: HEMODIALYSIS

a. Department of Health 1. Water analysis

(DOH) result:

a. Bacteriological Monthly

b. Physical and
Bi-annual
Chemical

2. Personnel:

a. Qualified, trained
and competent
staff (ACLS) Every 3 years
b. RENAP
MEMBERSHIP
 c. Staff updated
serology (HBs Ag,
Bi-annual
HCV, HIV, Anti-
HBs)

d. Staff updated
immunization (flu,
Annually
pneumonia,
hepatitis B)

e. HD machine
updated Annually
calibration

C. Philippine Health
PHIC DIALYSIS Data Base
Insurance Company INITIAL treatment
ENROLMENT
(PHIC)

D. Renal Nurse
Association of the Accreditation Renewal Every 3 years
Philippines (RENAP)

E. NRL (NATIONAL
REFERENCE Water sample Every 6 months
LABORATORY)

INTERNAL (Basic
Requirements):

a. Nursing Service
24-hour Census Report Daily
Division Administration

Nursing Care Hour Daily

Schedule of Duties and

Weekly
Ward Assignment

b. Nursing Service Training Needs

Annually
Training Unit Assessment

Training Effectiveness Three months after the attended

Survey training
 IPCR (INDIVIDUAL
c. Human Resource and PERFORMANCE
BI-Annually
Management Office COMMITMENT &
REVIEW)

Personal Data Sheet (PDS) Annually

Statement of Assets,
Liabilities and Net Worth Annually
(SALN)

MONTHLY REPORT OF
MONTHLY
ATTENDANCE (MRA)

DTR MONTHLY (BI-MONTHLY J.O)

d. Hospital Information within 4 DAYS UPON DISCHARGE

Complete Patients' Charts
Management Section OF PATIENT

e. Document Controller Master list of Externally-

Quarterly
generated Documents

Work & Financial Plan

f. Budget & Finance Annually
(WFP)

Project Procurement
Annually
Management Plan (PPMP)
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

RISKS & OPPORTUNITIES

NURSING SERVICE DIVISION

INTERESTED PARTIES EXPECTATIONS RISK OPPORTUNITIES

(EXTERNAL/INTERNAL)

EXTERNAL:

1. Public/Clients

a. Patients >Delivery of good and 1.Incidence of medication errors Strengthen training

quality nursing care program on medication
services that are safe, management
efficient, effective and
affordable

2. Incidence of fall Strengthen training

program on safety
measures

3. Increase in the number of

nursing care delivery-related
injuries such as accidental
puncture/needle stick injuries
and splash incident

4. Increase rate of hospital- Strengthen

acquired infection implementation of
hospital policies to
decrease the rate of
hospital-acquired infection

5. Use of clinical and non-clinical

equipment that may cause
accidents and/or fire and
electrical hazard
 6. Incidence of missing patients Establish a consistent and
thorough security check,
particularly in the number
and identification of
people coming in and out,
in all entry and exit points
of the ward

7. Overcrowding of patients at Increase the hospital’s

wards and unavailability of official bed capacity.
rooms/beds

b. Family/Caregiver >Provision of safe and 1. Incidence of violence Strengthen the

quality nursing care including verbal and physical competency of staff
attack through in-service
education and training

>Inclusion/Involvement in 2. Increase in the number of Boost personnel

the provision of client written complaints knowledge on proper
care establishment of client
care and customer’s
relations

3. Incidence of legal suits

4. Increase in the rate of Device an effective way on

infection and/or cross- how to minimize or
contamination prevent an increase in the
rate of infection and/or
cross-contamination

2. Regulating Bodies

a. Department of >Compliance to 1. Forfeiture of the right to

Health (DOH) requirements practice profession

b. Professional 2. Suspension from duty or dis-

Regulation Commission allowance to perform certain
(PRC) nursing tasks

>Compliance to the 1. Non-renewal of license due to Secure accreditation from

recommended training lack of CPD (Continuing PRC as CPD provider
Professional Development) units.
3. VENDORS (Suppliers >Varied business 1. Unavailability of technical
and Bidders) opportunities support when needed

2. Increased risk of being tied up

to sub-standard equipment for
end-users are not well-versed in
providing specifications

3. Delay in procurement of
much-needed equipment
thereby hampering delivery of
intended patient care

4. Delayed delivery of needed

medical supplies and equipment

4. Volunteers (NGOs, >Accommodate and 1. Dissatisfaction resulting to Strengthen linkages with

Private facilitate their withdrawal or cessation of NGOs, private
Organizations/Individu programs/activities or voluntary support/services for organizations and
als) services. our institution individuals

5. Outsourced >Proper identification and 1. Delayed nursing care services

providers of preventive timely reporting of non-
and corrective functioning equipment
maintenance

INTERNAL

1. Employees >Conducive work a. Increased number of absences Provide a sustainable work

environment that environment that
promotes personal and promotes personal and
professional growth professional growth

b. Resignation/Transfer of nurses

2. Nursing Service >Compliance to standards 1. Unsafe nursing practice Update nurses’

Division Administration of nursing practice leading to incidence of professional competency
medication errors, patient
injuries and infection

2. Incidence of work-related
hazards
 >Compliance to 1. Delayed submission of reports
requirements

2. Inaccurate data in reports

3. Unavailability of reliable
system-generated reports

3. Nursing Service >Timely and accurate 2. Delayed planning and

Training Unit (CNETRU) submission of required implementation of training
documents programs

4. Hospital >Compliance to hospital 1. Non-compliance to hospital Awards and recognition for

Administration policies policies which can lead to deserving employees
sanctions, suspensions or
termination of employment

5. Other Departments:

a. Acute Care Units >Accommodation and 1. Compromised delivery of Facilitate the efficiency of
(Emergency provision of care to nursing care the admission and
Department and admitted patients discharge processes
Outpatient
Department)

b. Procurement (to > Good planning,

include Materials & anticipation and
1. Delayed provision of services
Management; assessment of pertinent
Properties & Supplies) needs in the area

> Good follow-up of

requested supplies and
equipment

c. Billing > Timely tagging of 1. Delayed discharges which can Improve discharge process
patient's disposition result to overcrowding in the specifically to reflect real-
wards and additional expenses time ward discharges
for the hospital

d. BioMed and >Responsible use of 1. Delayed provision of services

Engineering Facilities equipment and
Management infrastructure

>Proper identification and

timely reporting of non-
 functioning equipment

e. Pharmacy >Timely and accurate 1. Delayed provision of services

requisition of prescribed
medicines

>Timely and properly 2. Prolonged hospital stay

filled out documents such
as the Pharmacy Referral
Form (for non-PNDF
medicines) and Returned
Medicines Form (for
excess medicines to be
returned), Restricted
Antibiotics Form, ETC

f. Central Supply Room > Timely and accurate 1. Delayed and inaccurate
requisition of requisition including double
prescribed/pertinent tagging
supplies

2. Delay in the provision of

supplies which can result to
delay in the provision of services

g. Laboratory > Timely and accurate 1. Delay in collecting,

requisition of prescribed transporting and releasing of
laboratory procedures laboratory results leading to
delay in provision of services

> Easy to locate patients

in the wards

> Completely and

accurately filled out
laboratory request forms

> Properly and completely

labeled specimens such as
stool, urine and other
bodily fluids as prescribed

h. Blood bank Section > Timely and completely 1. Delayed issuance of blood
filled out blood request requests leading to delayed
forms provision of services

> Assistance/Support in 3. Decrease in the number of

client education regarding voluntary blood donors leading
voluntary blood donation to shortage in blood supply
i. DDIRS (Department > Timely and accurate 1.Delay or cancellation of the
of Diagnostic Imaging requisition of prescribed procedure
and Radiology radiology and imaging
Sciences) procedures

> Completely filled out 2. Delay/safety compromise in

request forms the conduct of patient transport

> Compliance to
preparation regimen as
prescribed per procedure

> Timely and safe conduct

of patient transport

j. Nutrition and > Timely and accurate 1. Failure to update patients' diet
Dietetics updating of prescribed
patients' diet and other
nutritional requirements

k. Pulmonary Station, > Timely, complete and 1. Delay in the provision of

Heart Station and accurate referral for needed services
Rehabilitative special procedures and/or
Medicine Department equipment prescribed for
the patient

l. Human Resource >Timely compliance to 1. Imposition of sanctions based

Office requirements on Civil Service Commission rules

m. Health Information > Timely compliance to 1. Delayed filing of PHIC claims

Management requirements

2. Sanctions or suspension of
employee benefits

3. Issuance of memorandum and

CAPA

n. MISCO-IHOMP > Thorough knowledge of 1. Delayed response and

navigating the Hospital provision of services
Information System (HIS)

> Timely and accurate

reporting of
malfunctioning software
and hardware

>Proper use of equipment

o. Quality > Compliance to ISO 1. Issuance of OFI or CARF

Management Services Standards
(QMS)

2. Failure in re-accreditation

p. Document Control > No obsolete or 1. Obsolete and uncontrolled

Committee uncontrolled copies of forms/documents in the area
forms/documents in the
area

2. Discrepancies in the master

list and the actual, available
forms/documents in the area

3. Issuance of CARF

r. Budget and Finance > Timely compliance to 1. Delayed submission or non-

Division requirements submission at all

2. Dis-allowance of request

3. Increased number of
supplemental budget requests

s. Security > Close coordination and 1. Confusion regarding their roles

open communication for and responsibilities
clear roles and
responsibilities

2. Poor crowd control

3. Inconsistent implementation
of hospital policies such as the
visiting hours and the one-
watcher policy

t. Linen and Laundry > Close coordination in 1. Inadequate provision of linen

order to provide clean
and adequate linen to
clients

2. Delayed delivery of linen

u. Housekeeping > Close coordination in 1. Dissatisfaction of clients due

order to provide safe, to delayed provision of services
orderly, satisfactory and
appropriate housekeeping
services, especially in
maintaining the 6 S

> Properly segregated and 2. Risk of being exposed to bio

labeled wastes hazardous and infectious wastes
 > Being well-informed of
the risks involved in the
disposal of the different
wastes

v. Medical Social > Prompt referral and 1. Delayed provision of financial

Services proper channeling of and social services that may lead
patients' financial and to delayed discharges
social needs

w. Quality and Safety > Coordination with QSU 1. Unsafe hospital environment Establish an effective way
Unit in order to maintain for both patients and employees to coordinate and adapt to
quality health care and the QSU policies in making
safe hospital environment the hospital environment
for both the patients and safe
the employees

2. Delay in the delivery of

planned nursing care

x. Public Information > Cooperation in handling Delayed referral or non-referral

and Assistance Desk issues and concerns at all
(PIAD)
 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL

RISK ASSESSMENT WORKSHEET

NURSING SERVICE DIVISION

Interested Parties Risk

Expectations Risk P I C
(EXTERNAL/INTERNAL) Rating

EXTERNAL:

1. Public/Clients

a. Patients >Delivery of good and 1.Incidence of medication errors

quality nursing care
services that are safe, 3 3 2 18
efficient, effective and
affordable

2. Incidence of fall 1 3 1 3

3. Increase in the number of nursing

care delivery-related injuries such as
3 3 2 18
accidental puncture/needle stick
injuries and splash incident

4. Increase rate of hospital-acquired

3 3 2 18
infection

5. Use of clinical and non-clinical

equipment that may cause accidents 1 3 3 9
and/or fire and electrical hazard

6. Incidence of missing patients 1 3 3 9

7. Lack of or unavailability of beds for

overflowing patients
2 3 2 12
b. Family/Caregiver >Provision of safe and 1. Incidence of violence in the clinical
quality nursing care wards due to family/caregiver 2 3 2 12
outbursts

>Inclusion/Involvement 2. Increase in the number of written

in the provision of complaints from patients/family 2 3 2 12
client care

3. Incidence of legal suits 2 3 2 12

4. Increase in the rate of infection

2 3 2 12
and/or cross-contamination

2. Regulating Bodies

a. Department of >Compliance to 1. Forfeiture of the right to practice

1 3 1 3
Health (DOH) requirements profession

b. Professional 2. Suspension from duty or dis-

Regulation Commission allowance to perform certain nursing 1 3 1 3
(PRC) tasks

3.Non-conformity to the requirements

1 3 1 3
set by the regulating body

3. VENDORS (Suppliers >Varied business 1. Unavailability of technical support

2 2 2 8
and Bidders) opportunities when needed

2. Increased risk of being tied up to

sub-standard equipment for end-users
2 2 2 8
are not well-versed in providing
specifications

4. Volunteers (NGOs, >Accommodate and 1. Dissatisfaction resulting to

Private facilitate their withdrawal or cessation of voluntary
1 2 1 2
Organizations/Individu programs/activities or support/services for our institution
als) services.

5. Outsourced >Proper identification 1. Delayed nursing care services

providers of preventive and timely reporting of
3 2 2 12
and corrective non-functioning
maintenance equipment
 2. Decreased hospital revenues 1 2 1 2

INTERNAL

1. Employees >Conducive work a. Increased number of absences

environment that
3 3 2 18
promotes personal and
professional growth

b. Resignation/Transfer of nurses 3 3 2 18

2. Nursing Service >Compliance to 2. Unsafe nursing practice leading to

Division Administration standards of nursing incidence of medication errors, 2 3 1 6
practice patient injuries and infection

2. Incidence of work-related hazards 1 3 2 6

>Compliance to 1. Delayed submission of reports

1 2 1 2
requirements

2. Inaccurate data in reports 2 2 2 8

3. Unavailability of reliable system-

2 2 2 8
generated reports

3. Nursing Service >Timely and accurate 1. Delayed planning and

Training Unit submission of required implementation of training programs 2 2 1 4
documents

4. Hospital >Compliance to 1. Non-compliance to hospital policies

Administration hospital policies which can lead to sanctions,
1 2 1 2
suspensions or termination of
employment

5. Other Departments:

a. Acute Care Units >Accommodation and 1. Compromised delivery of nursing

(Emergency provision of care to care
Department and admitted patients 3 3 2 18
Outpatient
Department)
b. Procurement (to > Good planning, 1. Delayed provision of services
include Materials & anticipation and
Management; assessment of 3 2 2 12
Properties & Supplies) pertinent needs in the
area

> Good follow-up of

requested supplies and
equipment

c. Billing > Timely tagging of 1. Delayed discharges which can result

patient's disposition to overcrowding in the wards and 3 2 2 12
additional expenses for the hospital

d. BioMed and >Responsible use of 1. Delayed provision of services

Engineering Facilities equipment and 3 2 2 12
Management infrastructure

>Proper identification
and timely reporting of
non-functioning
equipment

e. Pharmacy >Timely and accurate 2. Delayed provision of services

requisition of 3 2 2 12
prescribed medicines

>Timely and properly 2. Prolonged hospital stay

filled out documents
such as the Pharmacy
Referral Form (for non-
PNDF medicines) and
2 3 1 6
Returned Medicines
Form (for excess
medicines to be
returned), Restricted
Antibiotics Form, ETC

> Close coordination 3. Incidence of medication errors

with the clinical 3 3 2 18
pharmacists regarding
patients' medication
 regimen

4. Delay in the provision of medicines

3 3 1 9
or missing medication doses

f. Central Supply Room > Timely and accurate 1. Delayed and inaccurate requisition
requisition of including double tagging
3 2 2 12
prescribed/pertinent
supplies

2. Delay in the provision of supplies

which can result to delay in the 3 2 2 12
provision of services

g. Laboratory > Timely and accurate 1. Delay in collecting, transporting and

requisition of releasing of laboratory results leading
3 2 2 12
prescribed laboratory to delay in provision of services
procedures

> Easy to locate

patients in the wards

> Completely and

accurately filled out
laboratory request
forms

> Properly and

completely labeled
specimens such as
stool, urine and other
bodily fluids as
prescribed

h. Blood bank Section > Timely and 1. Delayed issuance of blood requests
completely filled out leading to delayed provision of 2 3 1 6
blood request forms services

>Prompt reporting and 2. Delayed reporting and Incomplete

proper documentation documentation of blood transfusion
2 3 1 6
of blood transfusion reactions
reactions
 > Assistance/Support in 3. Decrease in the number of
client education voluntary blood donors leading to
1 2 1 2
regarding voluntary shortage in blood supply
blood donation

i. DDIRS (Department > Timely and accurate 1.Delay or cancellation of the

of Diagnostic Imaging requisition of procedure
and Radiology prescribed radiology 2 3 1 6
Sciences) and imaging
procedures

> Completely filled out 2. Delay/safety compromise in the

1 3 1 3
request forms conduct of patient transport

> Compliance to
preparation regimen as
prescribed per
procedure

> Timely and safe

conduct of patient
transport

j. Nutrition and > Timely and accurate 1. Failure to update patients' diet 2 3 2 12
Dietetics updating of prescribed
patients' diet and other
nutritional
requirements

2. Delay in the delivery of prescribed

1 3 1 3
diet

k. Pulmonary Station, > Timely, complete and 1. Delay in the provision of needed
Heart Station and accurate referral for services
Rehabilitative Medicine special procedures
1 3 2 6
Department and/or equipment
prescribed for the
patient

l. Human Resource >Timely compliance to 1. Imposition of sanctions based on

1 3 1 3
Office requirements Civil Service Commission rules

m. Health Information > Timely compliance to 1. Delayed filing of PHIC claims / 2 3 1 6

Increase number of RTH (Return to
Management requirements Hospital) claims

2. Sanctions or suspension of
1 2 1 2
employee benefits

3. Issuance of memorandum and CARF 1 2 1 2

n. MISCO-IHOMP > Thorough knowledge 3. Delayed response and provision of

of navigating the services
3 2 2 12
Hospital Information
System (HIS)

> Timely and accurate

reporting of
malfunctioning
software and hardware

>Proper use of
equipment

o. Quality Management > Compliance to ISO 1. Issuance of OFI or CARF

2 2 1 4
Services (QMS) Standards

2. Failure in re-accreditation 1 2 1 2

p. Document Control > No obsolete or 1. Increase number of obsolete and

Committee uncontrolled copies of uncontrolled forms/documents in the
2 2 1 4
forms/documents in area
the area

2. Discrepancies in the master list and

the actual, available forms/documents 1 2 1 2
in the area

3. Issuance of CARF 1 2 1 2

r. Budget and Finance > Timely compliance to 1. Delayed submission or non-

1 3 1 3
Division requirements submission at all

2. Dis-allowance of request 1 3 1 3

3. Increased number of supplemental 3 2 2 12

 budget requests.

s. Security > Close coordination 1. Inconsistent implementation of

and open hospital policies resulting to poor
communication for crowd control, incidence of theft and 2 2 2 8
clear roles and violence (verbal and physical).
responsibilities

2.Possible occurrences of problems

concerning patients’ and personnel 2 2 2 8
security

t. Linen and Laundry > Close coordination in 1. Inadequate provision of linen

order to provide clean
3 2 2 12
and adequate linen to
clients

2. Delayed delivery of linen 3 2 2 12

v. Medical Social > Prompt referral and 1. Delayed provision of financial and
Services proper channeling of social services that may lead to
3 2 2 12
patients' financial and delayed discharges
social needs

w. Quality and Safety > Coordination in order 1. Unsafe hospital environment for
Unit to maintain quality both patients and employees
health care and safe
3 3 2 18
hospital environment
for both the patients
and the employees

2. Delay in the delivery of planned

3 2 2 12
nursing care

> Cooperation in
x. Public Information
handling issues and Delayed referral or non-referral at all 3 3 2 18
Assistance Desk (PIAD)
concerns

(Legend: P – Probability ; I – Impact ; C – Control )

 CORAZON LOCSIN MONTELIBANO MEMORIAL REGIONAL HOSPITAL
ACTION PLANNING WORKSHEET
NURSING SERVICE DIVISION

INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Patients 1. Incidence of medication errors Zero medication errors

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Implement the use of medication Nurses January 2, 2017 Daily per shift On-going
cards during
endorsement

2. Implement the use of revised Nurses January 2, 2017 Daily per shift On-going
Kardex during

3. Coordinate with the ICC and ICC Staff, Clinical January 2, 2017 Monthly Ongoing
Clinical Pharmacists for the utilization Pharmacists,
of their monthly reports on the Nurses, Doctors
following:
a. 7th day Antibiotics
b. Restricted Antibiotic Request
c. Patient’s Drug Profile
d. Near-expiry and excess
medications

4. Conduct unit in-service education CNETRU Ongoing Quarterly On-going

on medication management

5. Use of KPM 4.1 monitoring form: Unit Supervisors January 2017 Daily per shift On-going
Medication Error Monitoring Head Nurses
Checklist Staff Nurses
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

1. Incidence of fall Zero incident / accident

2. Use of clinical and non-clinical

equipment that may cause
accidents and/or fire and electrical
Patients hazard
Quality & Safety Unit
IPCT 3. Increase in the number of nursing Decrease the number of nursing
EFM care delivery-related injuries such care delivery-related injuries by
as accidental puncture/needle stick 10%.
injuries and splash incident

1. Incidence of violence including Decrease the incidence of violence

verbal and physical attack in the clinical wards due to
family/caregiver outbursts by 10%

Family / Care-giver 2. Increase in the number of written Decrease the number of written
complaints complaints from patients / family by
10%

Zero incidence of legal suits

3. Incidence of legal suits

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Conduct seminar / orientation / CNETRU, HEMB, Ongoing Quarterly Ongoing

training of personnel and newly hired IPCT, BIOMED
staff on the following:
* proper lifting and moving
* BOSH (Basic Occupational
Safety & Health)
* prevention of nursing-care
delivery related injuries
* end-user training on the
proper use and care of equipment
* customer / patient service
relations

2. Use of hub cutters / fish-hook Nurses Ongoing Daily per shift Ongoing
technique
3. Report promptly findings on safety Head Nurses, Unit Ongoing Monthly Ongoing
issues for appropriate action. Supervisors

4. Implement appropriate and Head Nurses, Unit Ongoing Monthly Ongoing

prompt actions on the findings and Supervisors
recommendations of the QSU.

5. Institute measures on the proper Head Nurses, Unit Ongoing Quarterly Ongoing
use of equipment and facilities. Supervisors

6. Monitor the functionality of Head Nurses, Unit Ongoing Daily per shift Ongoing
fixtures, furniture and infrastructure. Supervisors

7. Request for construction, Head Nurses, Unit Ongoing Ongoing

renovation and repair of fixtures, Supervisors
furniture and infrastructures
promptly.

8. Report damage in fixtures, Nurses Ongoing Monthly Ongoing

furniture and infrastructure
promptly.

9. Include in the 24-hour report of Head Nurses, Unit Ongoing Monthly Ongoing
the Rotating Supervisor all accidents Supervisors,
/ incidents including incidence of Rotating
family / caregiver outburst / Supervisors
complaints.

10. Compliance to the procedures set NSD Personnel Ongoing Monthly Ongoing
by Incident Report Committee and /
or the Quality Safety Unit

11. Compliance to PIAD policy on NSD Personnel Ongoing Monthly Ongoing

handling complaints / incident of
violence
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Patients 1. Increase rate of hospital-acquired Decrease the rate of hospital-

IPCT infection acquired infection by less than 1%

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Strict adherence to IPCT protocol NSD Personnel Ongoing Monthly Ongoing

2. Conduct in-service training on IPCT Ongoing Quarterly Ongoing

infection control measures

INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

1. Incidence of missing patients Decrease the number of patients

Patients who left without notice / absconded
by 2%.

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Revise the clearance slip NSD March 2017 Monthly To be

implemented

2. Reinforce orientation of hospital / NSD Ongoing Monthly Ongoing

ward policies to patients and
significant others

3.Request to assign security guards NSD Ongoing Daily Ongoing

on strategic places in the hospital Security Section
especially on high risk areas
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

1. Overcrowding of patients at 100% of patients with doctor’s

Patients wards and unavailability of rooms / order of “May Go Home”,
Admitting Section beds discharged within 2 hours from
Medical Social Service Section completion of requirements.
Billing Section

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Update information as to the Nurses Ongoing Daily Ongoing

availability of rooms/beds at wards. Admitting Section

2. Prompt disposition of admitted

Emergency Ongoing Daily per shift Ongoing
patients and going home clients
Department
Rotators and
Nurses

3. Reinforce patient’s / folk’s prompt

Nursing Service Ongoing Daily Ongoing
compliance of discharge
Division
requirements. (MDR, Certificate of
Personnel
Indigency, Birth Certificate, Marriage
Contract, Blood Clearance, MSS
Endorsement Letter, Personal Letter
to PCSO, PF of Attending Physicians
for private patients)

4. Check on the immediate

Nursing Service Ongoing Daily Ongoing
compliance of the following: Pre-
Division
form, Growth Chart, Newborn /
Personnel
Hearing Screening, Medical Abstract,
Linen Clearance, Discharge Summary
and Plan, Hospital Bill and Signed
SOA, Schedule of OPD Follow-up
Check- up for IM patients,
Accomplished Medicine and Supplies
Return Slip, Dietary Referral, Results
of Laboratory and Diagnostic Tests,
Final Diagnosis, Checking of Charges

5. Prompt referral and proper

Nurses Ongoing Daily Ongoing
channeling of patients’ financial and
social needs.
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

1. Forfeiture of the right to practice

Regulating Bodies (DOH and PRC) profession Zero incidence of non-conformity to
requirements set by the
2. Suspension from duty or dis- Professional Regulation Commission
allowance to perform certain (PRC) and the Department of Health
nursing tasks (DOH).

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Strict compliance to the Nursing Service Ongoing Monthly Ongoing

requirements set by the PRC and Division, HRMO
DOH.

2. Conduct in-Service
training/seminar on the practice Nursing Service Ongoing Quarterly Ongoing
of profession. Division

INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Acute Care Units (ED and OPD),

Procurement, Materials and
Management, Billing Section,
BioMed, Engineering Facilities and
Management, Central Supply Room, Zero delay in the provision of
Budget and Finance, Pharmacy, services due to wrong or delayed
Laboratory, Blood Bank Section, tagging or processing of request.
DDIRS (Department of Diagnostic Delay in the provision of health care
Imaging and Radiologic Sciences), services. 100% availability of supplies for
Nutrition and Dietetics, Pulmonary emergency / urgent use in the
Station, Heart Station and clinical units.
Rehabilitative Medicine
Department, MISCO-IHOMP,
Medical Social Services, Public
Information and Assistance Office
 Responsible
Action Plan Target Date Monitoring Status
Person/Group

Interested Parties: Procurement,

Materials & Management, Biomed,
Central Supply Section, Budget &
Finance

1. Prompt and correct tagging / NSD Personnel Ongoing Monthly Ongoing

processing of requests.

2. Utilize a standardized form in Unit Supervisors, January 2017 Monthly Ongoing

monitoring of the delivery of Head Nurses
medical supplies and equipment
requested.

3. Monitor supplies and stocks in the Unit Supervisors, Ongoing Monthly Ongoing
unit regularly (per shift) and Head Nurses
consistently.

4. Accomplish requisition of medical Unit Supervisors, Ongoing Monthly Ongoing

supplies and equipment judiciously Head Nurses
(maintain buffer stock level according
to demand per unit).

5. Institute measures on the proper Unit Supervisors Ongoing Quarterly Ongoing

care and handling of equipment. Head Nurse

6. Prepare PPMP and WFP Unit Supervisors, Ongoing Annually Ongoing

judiciously. Head Nurse

7. Accomplish the following Unit Supervisors, Ongoing Ongoing Ongoing

requirements promptly for the Head Nurse
purchase of equipment:

a. Purchase Request with unit cost

and specification
b. Justification Letter
c. Terms of Reference (when
necessary)
d. If not included in the PPMP submit
the following: Supplemental
PPMP/APP, Realignment Advise Form
e. Equipment Status Report for
replacement of equipment
8. Recommend provision of adequate Unit Supervisors, Ongoing Daily Ongoing
number of equipment at the Central Head Nurse
Supply Section commensurate to the
needs of all clinical units.

9. Recommend decentralization of NSO March 2017 Monthly To be

specific equipment per unit for implemented
traceability and accountability

10. Assign point person per unit Unit Supervisors, Ongoing Monthly Ongoing
responsible for monitoring of the Head Nurses
schedules of preventive and
corrective maintenance.

11. Use standardized corrective and Unit Supervisors, Ongoing Monthly Ongoing
preventive maintenance monitoring Head Nurses
form.

12. Implement regular monitoring of Unit Supervisors, Ongoing Monthly Ongoing

the functionality of the equipment Head Nurses
and materials.

Interested Party: Acute Care Units

(OPD and ED)

1. Facilitate timely disposition for ED Nurses, OPD Ongoing Monthly Ongoing

admitted and non-admitted patients. Nurses, Unit
Supervisors

2. Perform accurate triaging of ED & OPD Nurses, Ongoing Monthly Ongoing

patients. Unit Supervisors

3. Provide prompt and appropriate NSD Personnel Ongoing Monthly Ongoing

care based on patients’ priority
needs.

4. Prompt and accurate tagging of NSD Personnel Ongoing Monthly Ongoing

diagnostic procedures and laboratory
tests.
Interested Party: Pharmacy

1. Facilitate availability and Encoders, Unit Ongoing Monthly Ongoing

replacement of emergency Supervisors, Head
medicines. Nurses

2. Timely and accurate tagging of Encoders, Unit Ongoing Monthly Ongoing

medicines. Supervisors, Head
Nurses

3. Coordinate with Pharmacy Section Encoders, Unit Ongoing Monthly Ongoing

for purchase of prescribed PNDF Supervisors, Head
drugs if not available. Nurses

Interested Party: Blood Bank and

Laboratory

1. Prompt tagging of laboratory Nurses, Ongoing Daily Ongoing

requests. Laboratory
Personnel,
2. Reinforce instructions on the Midwives,
procurement of certificate of Nursing
donation as a clearance Attendants
requirement prior to discharge
once the blood unit is
transfused.

3. Reinforce instructions on the 72

hour blood retention policy after
the issuance of the Blood Cross-
matching results.

4. Reinforce patient and significant

others’ education on the Blood
Advocacy Program.

5. Coordinate with the Chief Medical

Technologist of the Clinical
Laboratory regarding modification
on the policy of outsourced
laboratory examinations.
6. Refer laboratory results promptly

7. Accomplish blood requests

promptly and completely and give
clear instructions to the watchers.

8. Compliance to NBBNETS (National

Blood Bank Network System)
procedure.

Interested Party: Department of

Diagnostic Imaging and Radiologic
Sciences

1. Correct and timely tagging of Nurses Ongoing Daily per Ongoing

requests. shift

2. Coordinate with DDIRS staff for Nurses, DDIRS Ongoing Daily per Ongoing
prioritization of patients to be Staff shift
examined.

3. Refer diagnostic imaging results Nurses, DDIRS Ongoing Daily per Ongoing
promptly. Staff shift

Interested Parties: Pulmonary

Station, Heart Station, and
Rehabilitative Medicine Department
Nurses Ongoing Daily Ongoing
1. Tag requests promptly.
Nurses Ongoing Daily Ongoing
2. Coordinate requests promptly.

Interested Party: MISCO-IHOMP Nurse Ongoing Monthly Ongoing

1. Coordinate with MISCO-IHOMP for Supervisors,
regular maintenance of the BIZBOX Head Nurses,
and monitoring of the functionality MISCO-IHOMP
of the local area networking. Staff

2. Report to MISCO-IHOMP relevant

concerns promptly
Interested Party: Nutrition and
Dietetics

1. Update immediately patient’s diet Nurses Ongoing Daily per Ongoing

as ordered. shift

2. Compliance to the policies of the Nurses Ongoing Daily per Ongoing

Nutrition and Dietetics Section shift

INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Health Information Management 1. Delayed filing of PHIC claims / 95% completion of admitted
Section increase number of RTH (Return to patient’s chart upon discharge
Hospital) claims

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Accomplish checklist on Nurses Ongoing Daily Ongoing

completeness of patient’s chart from
admission to discharge

2. Comply chart deficiencies within 4

Nurses Ongoing Daily Ongoing
days based on Medical Records QQA
(Qualitative Quantitative Analysis)
findings
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Employees/Nursing Service Division 1. Increased number of absences. Decrease the number of staff
Administration absences by 5 %.

2. Resignation / transfer of nurses Decrease the number of nurses who

to other agencies resigned/transferred to other
agencies by 5%

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Cascade comprehensively the Nursing Service Ongoing Monthly Ongoing

policy on personnel absences Division

2. Implement/Recommend sanctions Nursing Service Ongoing Monthly Ongoing

to personnel who incur the following Division
unauthorized absences: HRMO
a. Without Notice
b. Late Filing of application for leave
c. Doubtful Reason
d. Patterned/Planned Absences
e. Requested Off/Leave not granted

3. Implement reward system for Nursing Service 2nd Quarter of Bi-annual To be

personnel with perfect attendance Division 2017 implemented
and zero tardiness:
a. Monthly per Unit
b. Bi-annual Division-wide

4. Integrate attendance and tardiness Nursing Service May 2017 Bi-annual To be

in the performance evaluation of Job Division Evaluation implemented
Order personnel

5. Recommend promotion of Job Nursing Service Ongoing Ongoing

Order personnel with outstanding Division
performance to Plantilla position
 INTERESTED PARTIES
RISK OBJECTIVE
(EXTERNAL/INTERNAL)

Human Resource Management 1. Imposition of sanctions based on Zero incidence of violations of CSC
Office Civil Service Commission rules rules.

Responsible
Action Plan Target Date Monitoring Status
Person/Group

1. Cascade policies, rules and NSD Personnel, Ongoing Monthly Ongoing

regulations to personnel HRMO Staff

2. Conduct seminars / trainings on CNETRU Ongoing Bi-annually Ongoing

the following: PET
*CSC Rules
*Ethical and Professional
Responsibilities and accountability Annually Ongoing
*Personality Enhancement
*Service with a H.E.A.R.T

3. Recommend sanctions to Ongoing Ongoing Bi-annually Ongoing

personnel who violates CSC rules and
regulations

4. Recommend to PRAISE committee Ongoing Ongoing Annually Ongoing

personnel with meritorious
performance

Prepared by: Noted by: Approved by:

LUCIA D. ALARBA, RN, MN MARYBETH G. MARCIAL, RN, MN JULIUS M. DRILON, MD

Assistant Chief Nurse OIC – Chief Nurse Medical Center Chief II