Full Compliance with the Quality and Performance

Standards (Local and International)Champions:

Dr. Filipinas Rojo/Atty. Jhihann C. Hairun-NatividadMembers:

Karren Mae Masuhud; Celita P. Calma; Engr. Nicanor Daguro; Edsel Cariz Tiu; Eileen Joy

Maralli

CMZ Business Plan / BSC (2013-2015)Strategic Objective

Perspective Goal (Strategic Objective)

Tactical Objectives

Key Performance

Measure

Key Performance

Indicators (Metrics)

Champeons

Y1 Y2 Y3

Process Full compliance with the quality and performance standards (local and interna-tional)

Master Plan Deployment Evaluation /

Continual Improve-ment

Integrated Program / System

F (B/E)

SS(C)

LL(A) J.

Natividad/Dr. F. Rojo

*F= Laying of Foundation; S = Strengthening; L = Leading the Way**B = Beginning ; E = Expanding; C = Consistent; A = Advanced

CMZ Business Plan / BSC (2013-2015) Operational Objective

Perspective

Goal

(Operational

Objective)

Tactical Objectiv

e

Key Performan

ce Measures

Key Performance Indicators (Metrics)

Initiatives

Programs/ Projects

Champions /

Coordinators

Y1 Y2 Y3

Process Structured, comprehensive and integrated system for full compliance with local and international standards

Achieve full compliance with the quality and performance standards (local and international)

Compliance with integrated checklists –rating scales on quality and performance standards (local and international)

100% 100% 100% Full Compliance with Quality and Perfor-mance Standards Program

J. Natividad and F.

Rojo/

C. Calma, K.M.

Masuhud, N.

Daguro, E. Tiu,

E.J. Maralli

CMZ Business Plan - List of Focused Initiatives (2013 – 2015)

Initiatives Strategic /Operational Objectives

Y1 (2013) Y2 (2014) Y3 (2015)

Full Compliance with Quality and Performance Standards Program

To make the hospital fully compliant with quality and performance standards

Accreditation Office (for PQA and PhilHealth) created

Center of Excellence granted by PhilHealth in February 2013

Integrated Checklists of all the agreed standards (Balridge/PQA, PhilHealth, ISO, JCI, Investors in People) – a CMZ Handbook/Guide formulated

Deployment Plan formulated

Monitoring Plan formulated

Evaluation and Continual Improvement Program formulated

Clinical pathway implemented

Full installation of Automated Fire Sprinkler System

Review of Checklist on its relevance

Revision of Checklist, if necessary

Deployment

Monitoring and Evaluation

Waste Management Program – Waste Treatment Facility

Review of Checklist on its relevance

Revision of Checklist, if necessary

Deployment

Monitoring and Evaluation

CMZ Business Plan - Dashboard of Initiatives (2013 – 2015)

Name of Initiative

Objectives (KRAs)

Performance Measures:

Outcome /Target (KPIs)

Resources Timelines Persons-in-charge

Full Compliance with Quality and Performance Standards Program

To formulate a master design and development plan on establishing and developing a well-defined integrated system in which all the requirements of the local and international quality and performance standards are complied with.

Presence of a master design and development plan (MDDP) on establishing and developing a well-defined integrated system in which all the requirements of the following local and international quality and performance standards are complied with: PhilHealth Benchbook and PQA standards.-Presence of a document containing the MDDP approved by top management. - Presence of an integrated checklist on all the requirements of the standards

Staff

Budget

Document

March 30, 2013

Champions and members; Dr. Albert T. Tan

CMZ Business Plan - Dashboard of Initiatives (2013 – 2015)

Name of Initiative

Objectives (KRAs)

Performance Measures:

Outcome /Target (KPIs)

Resources Timelines Person-in-charge

Full Compliance with Quality and Performance Standards Program

To deploy the approved master design and development plan across and at all levels in the hospital..

Evidence of deployment of the approved MDPP.

Presence of a deployment plan – leadership, communication and education, with needed resources and infrastructure

Evidence of effective deployment across and at all levels in the hospital.

Staff

IT System

Budget

Document

April 30, 2013 Champions and members; Dr. Albert T. Tan

CMZ Business Plan - Dashboard of Initiatives (2013 – 2015)

Name of Initiative

Objectives (KRAs)

Performance Measures:

Outcome /Target (KPIs)

Resources Timelines Person-in-charge

Full Compliance with Quality and Performance Standards Program

To evaluate and continually improve the master design and development plan to ensure sustainable achievement of full compliance to the standards.

Presence of monitoring, evaluation, and continual improvement plan on the implementation of the MDPP.-Presence of monitoring, evaluation and continual improvement plan.- Evidence of effective implementation of the monitoring and continual improvement plan.

Staff

Budget

Document

June 30, 2013

Champions and members; Dr. Albert T. Tan

CMZ Strategic Plan (2013 to 2015)Balanced Scorecard (2013 to 2015)

Strategic Objective + Goal + Action Plan (Initiative) + Deployment Plans

Strategic Objective for CMZ (2013-2015)

Goal Action Plans Deployment Plans

Full compliance with quality and performance standards (local and international)

There is a structured, comprehensive and integrated system in which all the requirements of agreed local and international quality and performance standards are complied with and thereby promoting performance excellence for the hospital.

PhilHealth Benchbook: Year 1 : Center of Excellence

Philippine Quality Award:Year 1: Recognition for Commitment in Quality ManagementYear 2: Recognition for Proficiency in Quality ManagementYear 3: Recognition for Mastery in Quality Management, even PQA for Performance Excellence

(see Action Plan) Formulate Deployment Plan, for approval by top management, employing the following steps:

Identify stakeholders of the initiative – internal and external stakeholders

Communicate to stakeholders the initiative

Educate the stakeholders about the initiative

Implement action plan of the initiative, with resources allocated and infrastructure in place

Monitor, evaluate, and undertake continual improvement

Action Plan

Year 1 Year 2 Year 3 Remarks with persons-in-charge

Application for PhilHealth Benchbook

- Re-compute scores re: compliance

- Seek direction of the Board if the application is for Center of Excellence

- Monitoring of compliance through Mock Survey by QC

- Review of policies and revise according to relevance

- Formulate and finalize “lacking” policies

- Re-orientation

- Comply with application process

- Prepare for PhilHealth inspection

November 2012

December 2012

December 2012

December 2012

January 2013

January 2013

January 2013

February 2013

Action Plan

Year 1 Year 2 Year 3 Remarks with persons-in-charge

Planning

- Drafting of MDDP

- Finalization of MDDP

Starting on November 18, 2012

March 31, 2013

Champions, TTCP, EXECOM, TTCP staff members

Presence of an integrated checklist of all the agreed standards

- TTCP to meet to study standards, and study checklists of PhilHealth Benchbook and PQA

-Integration of standards into one checklist/ finalization of checklist - draft -final

December 2012

December 2012January 2013

Champions, TTCP, EXECOM, TTCP staff members, QC

Approval by Top Management of:- Checklist - MDDP

January 2013March 2013

Creation of Accreditation Office

March 2013

Action Plan

Year 1 Year 2 Year 3 Remarks with persons-in-charge

Deployment

- Presence of Deployment Plan

- Formation of internal training team

- Communication

- Education on standards

- Reinforcement on standards

April 2013

April 2013

April to May 2013

Every quarter

Every semester

Every quarter

Every semester

Every quarter

Every semester

Champions, EXECOM, TTCP staff members, QC, HRD

Implementation

Assistance

Starting May 2013

All year round All year round All year round

Initial Assessment 2nd Semester

Review of MDDP, Checklist, Deployment Plan

Filling in the gaps

2nd Semester

Action Plan

Year 1 Year 2 Year 3 Remarks with persons-in-charge

Monitoring All year round All year round All year round Champions, EXECOM, TTCP staff members, QC, HRD

Evaluation of compliance and Continual Improvement-Identification and training of internal auditors - Internal auditing

September

1st Semester

Once a year

September

Once a year

September

Once a year

Application for PQA

-Attendance at Preparatory Development CourseInvolving more officers and key personnel

1st quarter

Commitment Level of Recognition

Proficiency Level of Recognition

Mastery Level of Recognition

Champions, TTCP, Execom, Board