Online Orientation On Four Health Facility

Operation and Development Unit Programs

And Respective Self-Assessment Tools
May 2, 2024 | 9AM - 12AM | via Cisco Webex
doh.gov.ph
 Agenda
OLIVER JAYSON C. ORDONIO, MD, RMT, MPM-HG
Medical Officer IV
Head, HFODU
Republic of the Philippines
Department of Health
/doh.gov.ph
AGENDA
❖ Discussion of the programs below and it’s respective
Self-Assessment Tools:
○ Integrated Hospital Operations and Management Program
○ Infection Prevention and Control Program
○ Integrated People-Centered Health Services

Republic of the Philippines

Department of Health 3
/doh.gov.ph
 HFODU Focal Person

● Integrated Hospital
Operations and Management
Oliver Jayson C. Ordonio, MD, RMT, MPM-HG Program
Medical Officer IV
Head, HFODU ● Infection Prevention and
Control
● People-Centered Health
Services

Ms. Angelica Ann S. Bautista, RPh Ms. Jehan P. Hadjiusman, RPh, PharmD
Development Management Officer II Development Management Officer II

Republic of the Philippines

Department of Health 4
/doh.gov.ph
 Online Orientation On Four HFODU Programs And Respective Self-Assessment Tools
May 2, 2024 | 9AM - 12AM

Program
TIME ACTIVITY RESPONSIBLE PERSON/ OFFICE

08:30 – 09:00 AM Registration

Flow
Invocation HFODU

09:00 – 09:10 AM Acknowledgement of Participants

Ariel I. Valencia, MD, MPH, CESO III
Opening Message
Assistant Secretary of Health

09:10 - 09:15 AM Agenda and Objectives

Introduction of HFODU Focal Person and

09:15 - 09:20 AM
Alternate Focal Person
Integrated Hospital Operations and
09:20 - 10:00 AM
Management Program (IHOMP)
Infection Prevention and Control (IPC)
Program
● Issuances
10:00 - 10: 40 AM HFODU
● Infection Prevention and Control (IPC)
Manual
● IPC Tool
Integrated People-Centered Health
Services
10:40 - 11:20 AM ● Issuances
● Hospital Client Experience Survey
(HCES)
Open Forum, Agreements, and Ways
Republic of the Philippines 11:20 - 12:00 NN
Department of Health 5 Forward
/doh.gov.ph
 Online Orientation On Four HFODU Programs And Respective Self-Assessment Tools
May 3, 2024 | 9AM - 12AM

Program
TIME ACTIVITY RESPONSIBLE PERSON/ OFFICE

Registration
9:00 - 9:15 AM

Flow
Invocation and Acknowledgement of
Participants
9:15 - 9:30 AM Agenda and Objectives
Green and Safe Health Facilities
Program Overview
● Issuances
9:30 - 11:00 PM
● Green and Safe Health Facilities HFODU
Manual
● Green Viability Assessment Tool

11:00 - 11:15 AM Green Assessment Rating System

11:15 - 11:30 AM Guidelines for GVA Validation

Open Forum, Agreements and Ways

11:30 - 11:50 AM
Forward
Leda M. Hernandez, MD, MPH
11:50 - 12:00 NN Closing Message
Assistant Regional Director

Republic of the Philippines

Department of Health 6
/doh.gov.ph
 Integrated Hospital
Operations and
Management
Program
Ms. Angelica Ann S. Bautista, RPh
Development Management Officer II

Republic of the Philippines

Department of Health 7
/doh.gov.ph
 IHOMP
STRATEGIC
FRAMEWORK
Administrative Order No. 2022-0021
Revised Guidelines on the
Integrated Hospital Operations
and Management Program
(IHOMP)

bit.ly/dm2022-0021
Republic of the Philippines
Department of Health 8
/doh.gov.ph
What is IHOMP?

Standards (Health Facility Manuals)

Infection Prevention and Control Program
Patient Safety Program
Integrated People-Centered Care
Healthcare Waste Management Program
Ensures the implementation of standards and guidelines aimed to improve
efficiency and effectiveness of health care services
Republic of the Philippines
Department of Health 9
/doh.gov.ph
Strategic Framework of IHOMP
VISION: Quality, Safe, People-Centered, and Efficient
Hospital Operations in the Philippines by
2030.
MISSION: To ensure effective and efficient hospital
operation through the implementation of
standards, supported by continual innovative
system and technology improvement.
GOALS: Enhance the preventive and promotive role of
hospitals, both government and private,
through the improvement of management
systems procedures within the hospitals.
Republic of the Philippines
Department of Health 10
/doh.gov.ph
Strategic Framework of IHOMP
Objectives:
1. To implement standards and policies for the hospital operations management.
2. To standardize the systems and procedures of hospital operations including the flow of
information.
3. To fully utilize hospital data/ information for evidence-based decision making, clinical
management of patients and policy and standard development.
4. To enhance and expand hospital information systems, such as but not limited to Integrated
Hospital Operations and management Information System (IHOMIS), HOMIS Billing System
(HBSys), Universal Health Care Information System (UHC IS), etc., to address the growing
needs and linkages with other health facilities and information systems developed by other
NGAs.

Republic of the Philippines

Department of Health 11
/doh.gov.ph
Technical Assistance M&E Structures Advocacy
1. eLearning Modules Vestibulum
1. Health Facility 1. Vestibulum
Listing of Advocacy
congue
Profiling tempus congue tempus
activities

Facility Based Program Updates

Republic of the Philippines

Department of Health 12
/doh.gov.ph
Facility Based Program Updates
Technical Assistance COURSES related to HFDB-HFODU Programs

DOH ACADEMY
★ IHOMP
○ Basic course on Continuous Quality Improvement for
Health Facility
○ Nutrition Care Process for Clinical Nutritionist
“Education for Health Workers, Anytime, Anywhere!” Dietitians
○ Nutrition Care Process for Nurse in Health Facilities
e-Learning platform ○ Hospital Health Information Management
○ Management of the Hospital Emergency Department
○ Standards of Management of Hospital Finance Service
★ PATIENT SAFETY
○ Safe and Sound 1: Basic Course on Patient Safety and
Quality Improvement
★ INTEGRATED PEOPLE-CENTERED HEALTH SERVICES
ORIENTATION
○ Integrated People-Centered Health Services
Orientation on the Adoption of Hospital Client
Experience Survey
○ Integrated People-Centered Health Services
Orientation on the Adoption of Primary Care Facility
Client Experience Survey
★ HEALTH CARE WASTE MANAGEMENT
○ Healthcare Waste Management for COVID-19

Create Account, Enroll, Learn

and Earn CPD Points for Free
Republic of the Philippines
Department of Health 13
/doh.gov.ph
Facility Based Program Updates
M&E Frameworks
Hospital Compliance to Standards
- IHOMP Tool
❏ Pharmacy
❏ Nursing Transition To 1
❏ Nutrition and Dietetics Platform
❏ HHIM
❏ Finance Service
- Infection Prevention and Control
- Health Care Waste management
- People-Centered Care
- Patient Safety

Republic of the Philippines

Department of Health 14
/doh.gov.ph
Facility Based Program Updates
List of Advocacy activities
Advocacy Dates
World Social Work Day 2nd Tuesday of March
National Infection Prevention and Control Week 2nd Week of July
World Patient Safety Day September 17
Filipino Social Workers Day June 19
Nutrition Month Celebration July
Nursing Week 4th week of October

Republic of the Philippines

Department of Health 15
/doh.gov.ph
FYI: Recent Policy Issuance
DBM-DOH DBM-DOH AO AO 2021-0044
Eligibility for Social
JC 2023-2 JC NO. 3 2022-0020 Care, Medical &
Phase II of the Revised
OSSP of Level III
s.2022 Per Capita Budget for
In-patient meal
Financial
Assistance,and Point
Phase I Staffing Allowance
Updated standards for of Service
Standards for L3 Gov’t
organizational structure and Updates the budgetary meal
staffing pattern for Level III Hospitals Ensure financial risk
allowance to ensure that protection of the financially
Government Hospitals with Updated Standards on the food acquired, prepared, and incapable: and streamline
200-1,500 beds, includes Organizational Structure and served in government health the processes and set
staffing for Medical Service, Staffing Pattern of Level III facilities meet the realistic and objective
Optional Staffing and Government Hospitals with nutritional requirements of guidelines for the
HEDMu. 200-1,500 beds. It includes 5 patients and residents assessment of financial
organizational units. capability.

Republic of the Philippines

Department of Health 16
/doh.gov.ph
 IHOMP
PROGRAM
IMPLEMENTATION

Republic of the Philippines

Department of Health 17
/doh.gov.ph
GENERAL GUIDELINES:
All hospitals shall:

1. Be guided by the overall goal of IHOMP which is to

improve the efficiency and effectiveness of
health care services through the adoption of the
HFDB Manual of Standards.

2. Establish and implement IHOMP and shall conform

to the principles of CQI and Integrated
People-Centered Health Services in its
implementation.
Republic of the Philippines
Department of Health 18
/doh.gov.ph
GENERAL GUIDELINES:
All hospitals shall:

3. Ensure an organizational culture that supports

quality, collaboration and teamwork, flexible
bureaucracy, transparency and active involvement of
management.

4. Conduct and participate in Learning and

Development Interventions (LDIs) relative to the
comprehensive implementation of strategic technical
assistance offering both clear guidance and room for
emergent change and ensure implementation.
Republic of the Philippines
Department of Health 19
/doh.gov.ph
GENERAL GUIDELINES:
All hospitals shall:

5. Conduct periodic assessment and monitoring of

compliance to the standards, and functionality of
hospital operation to ensure continuity of
implementation of improvement.

6. Implement and maintain an integrated health

information system (iHIS) that conforms and
complies with the standards and rules set forth
under this policy.
Republic of the Philippines
Department of Health 20
/doh.gov.ph
ROLES AND RESPONSIBILITIES
All hospitals, both government and private shall:

1. Utilize the HFDB Manual of Standards to improve efficiency of

hospital operations and provide management support in its
implementation;

2. Incorporate IHOMP in their hospital development plan;

3. Maintain or create the IHOMP Committee or delegate

the function to the CQI or QMS Committees or its
equivalent;
Republic of the Philippines
Department of Health 21
/doh.gov.ph
ROLES AND RESPONSIBILITIES
All hospitals, both government and private shall:

4. Establish or strengthen the IHOMS or its equivalent;

5. Conduct regular meetings to discuss issues, concerns and other

matters on the implementation of the program and provide
feedback and advice to hospital management;

Republic of the Philippines

Department of Health 22
/doh.gov.ph
ROLES AND RESPONSIBILITIES
All hospitals, both government and private shall:

6. Ensure quality of documentation in order to:

a. Provide management with quality data to be utilized for
planning, program implementation, policy development and
evidence-based decision making;

b. Generate the hospital statistical report annually or as

necessary and other required data; and

c. Share good practices within the network.

Republic of the Philippines
Department of Health 23
/doh.gov.ph
ROLES AND RESPONSIBILITIES
All hospitals, both government and private shall:

7. Report and coordinate with the HFDUs for any issues concerning
IHOMP; and

8. Develop an action plan to address identified gaps or areas of

improvement of the hospital in terms of the implementation of the
standards and the program in general.

Republic of the Philippines

Department of Health 24
/doh.gov.ph
Administrative Order No. 2020-0034
Revised Guidelines on the
Implementation of Continuous
Quality Improvement (CQI) Program
in Health Facilities in Support of
Quality Access for Universal Health
Care

Republic of the Philippines

Department of Health 25
/doh.gov.ph
IHOMP TOOL

Republic of the Philippines

Department of Health 26
/doh.gov.ph
Integrated Hospital Operation and Management Program
1. Serves as a rapid assessment to assess the current
operations of health facility in terms of compliance
to the Manual of Standards

2. Identify gaps and/or problems encountered in the

implementation of the program and the HFDB Manual
of Standards
- Plan TA package for the region based on gap
- Serve as input to Hospital Development Plan (Internal
Analysis)

3. Used by KMITS as reference for providing IHOMIS+

IHOMP TOOL : IHOMP Tool doc,
bit.ly/IHOMPToolv2Sheets Republic of the Philippines
Department of Health 27
/doh.gov.ph
Self-Assessment Tools CHD Advisory No. 2024-5

Submission Guidelines
E-mail <[email protected]>

Republic of the Philippines

Department of Health 28
/doh.gov.ph
Self-Assessment Tools
Submission Guidelines
E-mail <[email protected]>

LINK: bit.ly/SATChecklist2024
Republic of the Philippines
Department of Health 29
/doh.gov.ph
What is new with the IHOMP Tool?

1. Removed redundancies with Licensing

Assessment Tool
2. Incorporated new policies and standards

Republic of the Philippines

Department of Health 30
/doh.gov.ph
IHOMP Tool Scoring
Score Total Score Classification Description
Area/Category Questions
Summary 100 Excellent Full compliance to the standards. Exhibits
efficiency in all areas/categories.
I. Governance 8 15

II. Ethics and Patient’s Rights 6 15 81 - 99 Very Highly adequate compliance to the
Satisfactory standards. Exhibits efficiency in most
III. Quality Measurement and areas/categories.
10 15
Improvement 75 - 80 Satisfactory Adequate compliance to the standards.
Exhibits efficiency in some
IV. Integrated People-Centered areas/categories.
3 10
Health Services
51 - 74 Fair Moderate or reasonable compliance to
V. Patient Safety 3 20 standards. Meets the required efficiency
but needs improvement.
VI. Facility Safety and 50 and Poor Low compliance to the standards. Tends
6 10
Emergency Management below to experience difficulty in several
areas/categories.
VII. Resource Management 9 15
- Scoring System is intended for prioritization for
TOTAL 100
Technical Assistance
- Not a Regulatory Metric
Republic of the Philippines
Department of Health 31
/doh.gov.ph
MENTAL HEALTH
BREAK

Q&A Link for comments & queries:

bit.ly/QnA-HFODUSATs-2024
Republic of the Philippines
Department of Health 32
/doh.gov.ph
Infection Prevention
and Control

Ms. Jehan P. Hadjiusman, RPh, PharmD

Development Management Officer II

Republic of the Philippines

Department of Health 33
/doh.gov.ph
Objectives of the Presentation
To provide background information to the new National
Standards in Infection Prevention and Control for Health
Facilities, 3rd Edition

To provide a brief overview of the contents of the National

Standards on Infection Prevention and Control in Health
Facilities, 3rd Edition

Republic of the Philippines

Department of Health 34
/doh.gov.ph
Administrative Order No. 2016-0002

National Policy on Infection

Prevention and Control in Healthcare
Facilities

Administrative Order No. 2022-0051

Revised National Policy on Infection

Prevention and Control in All Public and
Private Health Facilities

Republic of the Philippines

Department of Health 35
/doh.gov.ph
Administrative Order No. 2022-0051:
Revised National Policy on Infection Prevention and
Control in All Public and Private Health Facilities

Rationale

Objectives

Roles and Responsibilities

Republic of the Philippines

Department of Health 36
/doh.gov.ph
Administrative Order No. 2022-0051:
Revised National Policy on Infection Prevention and
Control in All Public and Private Health Facilities

Rationale

This Order aims to:

● Strengthen the healthcare service delivery by focusing
on sustainable, manageable, and critical interventions
that optimize available resources, supported by
evidence and sufficient groundwork for IPC which shall
include systems that will drive better executing of the
IPC program such as mechanisms for reporting and
feedback.

Republic of the Philippines

Department of Health 37
/doh.gov.ph
Administrative Order No. 2022-0051:
Revised National Policy on Infection Prevention and
Control in All Public and Private Health Facilities

Objective
This Order aims to:
● Provide guidance to all public and private health
facilities in the effective establishment,
implementation, monitoring and evaluation of the IPC
Program.

Republic of the Philippines

Department of Health 38
/doh.gov.ph
Administrative Order No. 2022-0051:
Revised National Policy on Infection Prevention and
Control in All Public and Private Health Facilities

Roles & Responsibilities

All Health Facilities shall:
1. Implement efficiently and effectively the IPC program in the health
facility
2. Establish, organize, monitor and support the activities of the IPC
Committee and the IPC Unit
3. Address efficiently and effectively all IPC concerns and issues
occuring at the healthcare facility level
4. Coordinate with the CHD about the status of IPC programs in
health facilities.

Republic of the Philippines

Department of Health 39
/doh.gov.ph
Administrative Order No. 2022-0051:
Revised National Policy on Infection Prevention and
Control in All Public and Private Health Facilities

Roles & Responsibilities

Centers for Health Development through the Health Facility
Development Unit (HFDU) and Ministry of Health - Bangsamoro
Autonomous Region of Muslim Mindanao (MOH-BARMM) shall:

● Advocate for the IPC program in all health facilities;

● Facilitate the annual celebration of National IPC Week in their
respective regions;
● Provide technical assistance to health facilities related to the program
implementation;
● Lead and facilitate the reporting system through the collection,
consolidation, validation, and analysis of data.

Republic of the Philippines

Department of Health 40
/doh.gov.ph
National Standards in Infection Control
for Healthcare Facilities (2021 Edition)

Part of the DOH HFDB Integrated Hospital Operations

and Management Program (AO No. 44-A s. 1999) and
Continuing Quality Improvement Program (AO No.
2006-0002)*

Department Circular No. 2021-0447 “Dissemination of

the Manual of National Standards in Infection
Prevention and Control for Health Facilities, Third
Edition”

*CQI with latest AO No. 2020-0034 Revised Guidelines on the Implementation of

Continuous Quality Improvement (CQI) Program in Health Facilities in Support of
Quality Access for Universal Health Care
bit.ly/IPCManual3rdEd

Republic of the Philippines

Department of Health 41
/doh.gov.ph
Health Facility
Profiling System
● Established in line with Administrative Order 2021-0032,
the Implementation of the Philippine Health Facility
Development Plan (PHFDP)
● Enables the identification of gaps in health facilities
towards the system-wide strengthening of health facility
networks
● Module: Infection Prevention and Control Assessment
Tool

Republic of the Philippines

Department of Health 42
/doh.gov.ph
YEAR 2020 Republic of the Philippines
Department of Health 43
/doh.gov.ph
YEAR 2021
Republic of the Philippines
Department of Health 44
/doh.gov.ph
YEAR 2022 Republic of the Philippines
Department of Health 45
/doh.gov.ph
YEAR 2023
Republic of the Philippines
Department of Health 46
/doh.gov.ph
Global Strategy on IPC
Prevent, Act, Coordinate

1. Prevent infection in health

care
2. Act to ensure IPC programmes
are in place and implemented

To substantially improve To provide strategic directions

healthcare quality and safety and catalyze political
by reducing the frequency of commitment to enable active IPC
infection and AMR acquired programmes for HAI and AMR
during health care delivery and reduction and prevention and
their burden on those who control of outbreaks.
access and provide health
care, including in the context
of health emergencies.

Republic of the Philippines

Department of Health 47
/doh.gov.ph
Global Strategy on IPC
Prevent, Act, Coordinate

Coordinate IPC activities with other areas and

3. sectors and vice-versa

To transform health care systems and service delivery in such a way that IPC is
implemented in clinical practice and within an enabling environment through WASH,
and coordinating with public health emergencies, universal health coverage, patient
safety, quality of care, AMR, occupational health, health promotion, immunization,
biosafety and biosecurity, and other public health-related programmes, and vice
versa.

Republic of the Philippines

Department of Health 48
/doh.gov.ph
 Manual Content:
Chapter 1: Standards on Management, Structure, Functions, and
Responsibilities
Chapter 2: Standards on Guidelines, Policies, and Procedures
Chapter 3: Infection Prevention and Control Education and
Training
Chapter 4: Healthcare-Associated Infection Surveillance
Chapter 5: Standards on Multimodal Strategies
Chapter 6: Standards on Monitoring, Audit and Feedback of
Infection Prevention and Control
Chapter 7: Standards on Workload, Staffing, and Bed Occupancy
at the Facility Level
Chapter 8: Standards on Built Environment, Materials, and
Equipment for IPC
Download:
bit.ly/IPCManual3rdEdition

Republic of the Philippines

Department of Health 49
/doh.gov.ph
 Revision of the IPC Standards in Health Facilities
2009 Edition 2021 Edition
1. Standards on Management, Structure, Functions 1. Standards on Management, Structure, Functions
and Responsibilities and Responsibilities
2. Standards on Guidelines, Policies, and 2. Standards on Guidelines, Policies, and
Procedures Procedures
3. Standards on Microbiology Services 3. Infection Prevention and Control Education and
4. Standards on Surveillance Training
5. Standards on Education and Training 4. Standards on Healthcare-Associated Infection
Surveillance
5. Standards on Multimodal Strategies
6. Standards on Monitoring, Audit, and Feedback of
Infection Prevention and Control
7. Standards on Workload, Staffing, and Bed
Occupancy at the Facility Level
8. Standards on Built Environment, Materials, and
Equipment for IPC
Republic of the Philippines
Department of Health 50
/doh.gov.ph
 51

Chapter 1
Department of Health
Republic of the Philippines

STANDARDS ON MANAGEMENT,
/doh.gov.ph

STRUCTURE, FUNCTIONS, AND

RESPONSIBILITIES
 52

Chapter 1
Department of Health
Republic of the Philippines

● There shall be an infection control

management structure under the Office
/doh.gov.ph

of Chief/Director of the Health Facility

with sufficient resources and clear lines
of responsibility.
● There shall be a functional IPC Program in
the healthcare facility with clearly defined
objectives that are lined with the prevention
of HAI and combating AMR.
Responsibilities of every health facility head:
● Establish, organize, monitor, and support the
IPC Unit
● Designate managers of the IPC Unit
● Ensure that the IPCU members are qualified and
trained
● Monitor or track records on IPC procedures and
reports 2% 3% 4%
● Address efficiently and effectively all IPC
concerns

Republic of the Philippines

Department of Health 53
/doh.gov.ph
 IPC Management Structure

● Have sufficient resources and clear lines of responsibility

● IPCU and IPCC shall work together to implement IPC program
and protocols in the health facility.
2% 3% 4%

IPCU IPCC

Republic of the Philippines

Department of Health 54
/doh.gov.ph
 IPC Committee
IPC Unit IPC Committee
● Responsible for the day-to-day ● Formulates and updates infection
infection prevention and control prevention and control policies,
activities guidelines and procedures
● Responses to urgent problems ● Designs the training
● Monitors compliance to IPC policies ● Prepares, reviews, and evaluates the
● Recommends IPCC actions progress of IPC Program
● Composed of the ff: ● Multidisciplinary committee
○ IPC Unit Head ○ Chief
○ IPC Nurse ○ Core Members
○ IPCS Officer ○ Auxiliary members

Republic of the Philippines

Department of Health
/doh.gov.ph
Organizational Structure
Republic of the Philippines
Department of Health
/doh.gov.ph
Use of IPCAT
All healthcare facilities shall have an Infection
Prevention and Control Assessment Tool (IPCAT)
containing guidelines on core components of IPC
programs that shall be implemented.

Republic of the Philippines

Department of Health
/doh.gov.ph
Infection Prevention and Control Assessment Tool

Republic of the Philippines

Department of Health
/doh.gov.ph
 59

Chapter 2
Department of Health
Republic of the Philippines

STANDARDS ON GUIDELINES,
/doh.gov.ph

POLICIES, AND PROCEDURES

Chapter 2
● IPCC shall initiate the development, implementation,
evaluation, review, and updating of the evidence-based
guidelines, policies, and procedures.
● There shall be guidelines for specific patient care areas
and
hospital auxiliary service departments/ units.
● There shall be guidelines on purchasing of
drugs/medicines, equipment, and supplies.

Republic of the Philippines

Department of Health 60
/doh.gov.ph
Antimicrobial Stewardship

AMS
IPCU Committee

AO No. 2019-0002
Republic of the Philippines
Department of Health 61
/doh.gov.ph
Chapter 2
● IPCU shall be responsible for creating, developing,
promoting, implementing, disseminating, and monitoring
adherence to the guidelines and policies.
● Guidelines are to be reviewed regularly using data
indicators and standardized forms.
● Routinely monitored and reported: Hand hygiene,
Surveillance of HAIs, Needle stick injury, AMR, Breaks in
IPC protocol, Respiratory hygiene and cough etiquette,
Environmental care
Republic of the Philippines
Department of Health 62
/doh.gov.ph
Microbiology Sections
● Shall adhere to the laboratory standards of their
institutions, in addition to AO No. 2021-0037.
● Reports shall be generated and submitted on
time.
● Standard protocols shall be followed on
collection, handling, and transport of specimens.
● These shall have an efficient and effective
Biosafety Program Management and Biosecurity
Program.

Republic of the Philippines

Department of Health 63
/doh.gov.ph
 64

Chapter 3
Department of Health
Republic of the Philippines

INFECTION PREVENTION AND

/doh.gov.ph

CONTROL EDUCATION AND TRAINING

Chapter 3
● There shall be adequate resources available
in the health facility for education and
❏ Staff to oversee
training activities.
❏ Allocated budgets
❏ Available and ● Training needs assessment
accessible ● Involvement of the IPCU in educational
venues course design
❏ Materials and
updates tools

Republic of the Philippines

Department of Health 65
/doh.gov.ph
Minimum IPC Training
● Basic Epidemiology of HAIs ● HCW infection risks, prevention and
● Hand hygiene immunization
● Isolation precaution ● Tuberculosis, HIV, Hepatitis B
● Decontamination, disinfection, and ● Emerging and Re-emerging
sterilization infections and pathogens
● Care of Environment and HCWM ● Rational antibiotic use
● Needle Stick Injuries and Blood and
Body Fluid Exposures

Republic of the Philippines

Department of Health 66
/doh.gov.ph
Chapter 3

There shall be tools to measure knowledge,

skills, and attitude of staff and trainees on IPC
protocols and procedures.

Republic of the Philippines

Department of Health 67
/doh.gov.ph
 Republic of the Philippines
Department of Health 68
/doh.gov.ph

Chapter 4
HEALTHCARE-ASSOCIATED
INFECTION SURVEILLANCE
Healthcare-Associated Infections
“An infection occurring in a patient during the process of care in a
hospital or other health care facility, which was not
present or incubating at the time of admission. Health
care-associated infections can also appear after discharge.
They also include occupational infections among staff.”

Republic of the Philippines

Department of Health 69
/doh.gov.ph
Chapter 4
● There shall be a defined program of
surveillance and reporting on, but not
limited to HAI, needle stick injuries, blood
and body fluid exposures, AMR, and breaks
in IPC.
● IPCU shall set the surveillance process and
collect and analyze data.

Republic of the Philippines

Department of Health 70
/doh.gov.ph
Chapter 4
MICROBIOLOGY

AMS COMMITTEE

IPCU
PHARMACY THERAPEUTICS
COMMITTEE

PHARMACY

Republic of the Philippines

Department of Health 71
/doh.gov.ph
 Republic of the Philippines
Department of Health 72
/doh.gov.ph

STRATEGIES
Chapter 5
STANDARDS ON MULTIMODAL
Chapter 5
● IPC Programs and activities shall be
implemented using multimodal strategies
and multi-disciplinary approach.
○ Shall have multimodal thinking
○ Shall identify champions for IPC
● The Five-step approach to IPC
improvement shall be followed
● The Five common elements of multimodal
strategies shall be implemented.
Republic of the Philippines
Department of Health 73
/doh.gov.ph
Five-Step Approach to IPC
Step 5
Step 1 05 Sustaining the
Preparation for Action program over the
long-term
01 04
Step 4
Step 2 Evaluate the Impact
Baseline Assessment
02 03 Step 3
Develop and execute the
plan
- Multimodal improvement strategy embedded in each
step for continuous improvement.
Republic of the Philippines
Department of Health 74
/doh.gov.ph
Five Elements of Multimodal Strategies
LEAVE IT BUILD IT
(Culture Change) (System Change)

IPC Program
SELL IT TEACH IT
(Reminders and Comms) (Training and Education)

CHECK IT
(Monitoring and Feedback)
Republic of the Philippines
Department of Health 75
/doh.gov.ph
 76

Chapter 6
Department of Health
Republic of the Philippines

STANDARDS ON MONITORING, AUDIT

/doh.gov.ph

AND FEEDBACK OF INFECTION

PREVENTION AND CONTROL
Chapter 6
● A well-defined monitoring plan with clear
objectives, targets and activities focused on
IPC indicators is in place based on priorities
identified by the institution/ facility.
● Reporting shall be done quarterly, but in
case of outbreaks, as necessary. Feedback
shall then be given in real-time.
● There are available IPC tools to collect data
in a systematic way.
Republic of the Philippines
Department of Health 77
/doh.gov.ph
 78

Chapter 7
Department of Health
Republic of the Philippines

STANDARDS ON WORKLOAD,
/doh.gov.ph

STAFFING, AND BED OCCUPANCY AT

THE FACILITY LEVEL
Chapter 7
● Bed occupancy rate at any given time shall
not exceed ABC.
● The standard Bed Occupancy Rate is at
80-85%.
● Appropriate staffing levels shall be
assessed according to patient workload
using national or international standards.
○ Minimum of 1 IPC doctor and 1 IPCN
○ 1 full-time IPCN: 100 hospital beds
Republic of the Philippines
Department of Health 79
/doh.gov.ph
Chapter 7
● Design of hospital wards shall be
according to the standard
designs set by the Department of
Health.
● Overcrowding shall be reduced
by optimizing operational
processes.

Republic of the Philippines

Department of Health 80
/doh.gov.ph
 81

Chapter 8
Department of Health
Republic of the Philippines

STANDARDS ON BUILT
/doh.gov.ph

ENVIRONMENT, MATERIALS, AND

EQUIPMENT FOR IPC
Chapter 8
● Safe and sufficient quantity of
water shall always be available
from an improved source.
● Minimum of two functional,
improved sanitation facilities
shall be available on-site.
● This shall be in accordance with
the HCWM Manual and WASH.
Republic of the Philippines
Department of Health 82
/doh.gov.ph
Chapter 8
● Functional hand hygiene
facilities shall always be
available at points of care/
toilets and include soap, water,
single-use towels or ABHRs.
● Sufficient and appropriately
labelled bins to allow for
healthcare waste segregation.
Republic of the Philippines
Department of Health 83
/doh.gov.ph
Ventilation - Natural or Mechanical
Throughout the facility, with 6-8 air changes per
functional windows hour

Airborne infection isolation 12 air changes per

rooms and Emergency hour
room triage areas

operating , procedure, or 15 air changes per

delivery rooms hour

Republic of the Philippines

Department of Health 84
/doh.gov.ph
Chapter 8
Sufficient and appropriate IPC
supplies and equipment, reliable
power/energy and adequate
lighting shall be available for
performing all IPC measures,
including all standard and
transmission-based precautions.

Republic of the Philippines

Department of Health 85
/doh.gov.ph
Next Steps for IPC HAI surveillance
● Development of national Policy
● Pilot of surveillance implementation
● HAI National PPS to determine baseline
HAI rates

Education and
Training
● Development of
DOHAcademy Course on the
IPC Manual and Basic IPC
Concepts

Monitoring and
Evaluation
● Validate and analyze IPCAT Results
● Revision of IPC Module in the HFP
● Annual review and report of IPC program

Republic of the Philippines

Department of Health 86
/doh.gov.ph
National IPC Week

● Proclamation No. 971 s. 2020 -

Declaring the Second Week of July of
Every Year as “National Infection
Prevention and Control Week”
● Theme for 2023
○ “Beyond the Pandemic: HAI-lighting
the Importance of IPC”

Republic of the Philippines

Department of Health 87
/doh.gov.ph
National IPC Week 2021 National IPC
National IPC Week
Week2022
2022

Batangas Medical Center Tagaytay Treatment & Rehab Center

Ospital ng Calaca San Pablo City General Hospital

Republic of the Philippines

Department of Health
/doh.gov.ph
National IPC Week 2023

Ospital ng Calaca Metro Balayan Medical Center

Republic of the Philippines

Department of Health
/doh.gov.ph
MENTAL HEALTH
BREAK

Q&A Link for comments & queries:

bit.ly/QnA-HFODUSATs-2024
Republic of the Philippines
Department of Health 90
/doh.gov.ph
 People-Centered
Health Services

Ms. Angelica Ann S. Bautista, RPh

Development Management Officer II

Republic of the Philippines

Department of Health 91
/doh.gov.ph
Administrative Order No. 2020-0003
Strategic Framework on the
Adoption of Integrated
People-Centered Health Services in
All Health Facilities

Section 6.B
The DOH shall issue a standardized client
experience survey that will measure the
responsiveness of each health facility,
encompassing the components of the IPCHS
Framework.

Republic of the Philippines

Department of Health 92
/doh.gov.ph
RATIONALE AND BACKGROUND
Commitment to the 69th World Health Assembly and the 31st ASEAN Summit to
implement IPCHS in accord with the national context.

Emphasizes the vision of Filipinos to enjoy a strongly-rooted, comfortable, and

secure life by 2040 through the Philippine Development Plan for 2017-2022, which
calls for enhancing the social fabric or malasakit, for people-centered, clean, and
efficient government.

Fourmula 1 Plus envision Filipinos as “among the healthiest people in Asia by 2040”
with a productive, equitable, and people-centered health system for universal
health care.

Malasakit Centers Act address one of the non-clinical outcome, namely

Responsiveness, through the adoption of the policy framework for integrated
people-centered health services.

Republic of the Philippines

Department of Health 93
/doh.gov.ph
Republic of the Philippines
Department of Health 94
/doh.gov.ph
 MALASAKIT PROGRAM COMPONENTS
FINANCIAL RISK
OUTCOME RESPONSIVENESS
PROTECTION
Providing Medical & Positive Patient and User Experience
GOAL
Financial Assistance

OPERATIONAL MALASAKIT CENTER IHOMP COMMITTEE PUBLIC HEALTH UNIT

UNIT
Harmonizes financial Oversees actions and performance External navigation to
assistance across different promoting Malasakit Experience within primary care facilities and
FUNCTION fund sources (one stop health facility including actions on coordination for national
shop) organization culture, infrastructure and population based programs
processes, and client engagement
MEDICAL SOCIAL HOSPITAL MANAGEMENT STAFF PATIENT NAVIGATORS
MAIN WORKER & TEAM AND PLANNING STAFF
STAFFING PARTICIPATING
AGENCIES

Republic of the Philippines

Department of Health 95
/doh.gov.ph
IPCHS Framework
Strategy 1 Strategy 2 Strategy 3

Ensure and promote Ensure appropriate Promote client

organizational culture infrastructure and engagement and
geared towards processes in health empowerment
responsiveness facilities

Republic of the Philippines

Department of Health 96
/doh.gov.ph
IPCHS Framework
Strategy 1
1. Equipping its staff with necessary skills/ training to
ensure good interaction with patients, their
caregivers and their families

2. HR shall assess their health facility staff on the

quality of their interaction with clients through
Ensure and promote patient feedback and recognition mechanism as
organizational culture patient care champions.
geared towards
responsiveness

Republic of the Philippines

Department of Health 97
/doh.gov.ph
IPCHS Framework
Strategy 2 1. Ensure that the Physical Condition will promote
healing by addressing the total sensory environment
2. Establish effective and efficient Patient Navigation
within and across Health Facilities
3. Employ patient flow analysis and data-driven facility
management in improving overall operations of the
Ensure appropriate facility
infrastructure and 4. Harmonization of processes to reduce redundancy of
processes in health work
facilities

Republic of the Philippines

Department of Health 98
/doh.gov.ph
IPCHS Framework
1. Mechanisms to ensure that the patients, their carers, and
Strategy 3 family are informed of their condition and are involved in
the decision making for their health
2. Mechanisms to create a participative environment for
patients, their carers, and family by engaging patient
groups in the development of policies
3. Incorporate patient experience to measure
Promote client responsiveness of health facilities
engagement and 4. Avenues for social responsibility programs to advocate
empowerment good health seeking behavior

Republic of the Philippines

Department of Health 99
/doh.gov.ph
Department Memorandum No. 2020-0426
Interim Guidelines on the Use of the
Standardized Client Experience Survey Tool
to Measure Responsiveness
○ Standardize what is being measured across the
different facilities
○ Standardize the process of collection
○ Standardize reporting

Department Memorandum No. 2023-0131

Interim Guidelines on the Use of the

Harmonized Hospital Experience Survey
(HCES) Tool to Measure Responsiveness

Republic of the Philippines

Department of Health 100
/doh.gov.ph
 POLICY GUIDANCE & MANDATES
AO No. 2020-0034
Revised Guidelines on the ARTA MC No. 2022-05
RA No. 11032 Implementation of Continuous Guidelines on the
Ease of Doing Business Quality Improvement (CQI) Implementation of the DM No. 2023-0068
and Efficient Government Program in Health Facilities in Harmonized Client 2023-2028 Hospital
Service Delivery Act of Support of Quality Access for Satisfaction Measurement Scorecard Indicators
2018 Universal Health Care (CSM) and Metadata

RA No. 11463 AO No. 2020-0003 DM No. 2020-0426 DM No. 2023-0131

Malasakit Centers Act Strategic Framework on Interim Guidelines on the Interim Guidelines on the
the Adoption of Use of the Standardized Use of the Harmonized
Integrated Client Experience Survey Hospital Client Experience
People-Centered Health Tool to Measure Survey (HCES) Tool to
Services in All Health Responsiveness Measure Responsiveness
Facilities

Republic of the Philippines

Department of Health
/doh.gov.ph
DM No. 2023-0131
SCOPE AND COVERAGE

➢ DOH hospitals
➢ Medical centers
Required ➢ Sanitaria
➢ GOCC hospitals
➢ LGU hospitals with Malasakit Centers
➢ Government
Encouraged
➢ Private hospitals

All frontline areas of the hospital

Areas measured?
Non-frontline service areas may utilize the CSM tool
(ARTA MC No. 2022-05)

Republic of the Philippines

Department of Health 102
/doh.gov.ph
DM No. 2023-0131
Questionnaire

Republic of the Philippines

Department of Health 103
/doh.gov.ph
Control No. - assigned by the health facility to
monitor trail of documents

Demographic Profile of the Client/Patient

Citizen’s Charter questions adopted from

ARTA CSM

Republic of the Philippines

Department of Health
/doh.gov.ph
 Strategy 2 Ensure appropriate
infrastructure and processes in
health facilities

Strategy 3 Promote Client

Engagement and Empowerment

ARTA CSM (8) Service Quality Dimensions:

1. Responsiveness
2. Reliability
3. Access and Facilities
4. Communication
5. Costs
Strategy 1 Ensure and promote
6. Integrity
an organizational culture geared
7. Assurance
towards responsiveness
8. Outcome

Republic of the Philippines

Department of Health
/doh.gov.ph
Survey Administration and Collection
● The hospital may assign a unique control ● Accomplishment of the HCES tool shall be
number on all printed and electronic survey self-administered and voluntary, It should
forms not be used as a prerequisite to any other
● The Quality Improvement Unit of the hospital service
or its equivalent shall facilitate the encoding, ● The tool shall be administered from January
analysis and submission of the reports to December of each year
● The designated personnel-in-charge shall ● The tool shall be given only after the the
sign a non-disclosure form (NDA) client has completed his/her transaction

“A transaction is considered complete when the

final step of the service availed of per the
Citizen’s Charter of the government agency is
accomplished”
(Reference: ARTA MC No. 2022-05)

Republic of the Philippines

Department of Health
/doh.gov.ph
Report Generation and Submission
Online Report Generator Health Facility Profiling System
(Google Sheets / Excel) DOH Data Collect Hub

➢ Offline/Online method used to encode, validate ➢ Online method used for encoding and
and generate HCES tool reports generation of reports
➢ Health facilities has to wait for the cascaded ➢ Health facilities may instantly view the Overall
Responsiveness Report Responsiveness Report through the dashboard

Republic of the Philippines

Department of Health 107
/doh.gov.ph
Health Facility Profiling System
(DOH Data Collect Hub)

Republic of the Philippines

Department of Health 108
/doh.gov.ph
hfpddc.doh.gov.ph

Republic of the Philippines

Department of Health
/doh.gov.ph
Health Facility Profiling System

Republic of the Philippines

Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health
/doh.gov.ph
Republic of the Philippines
Department of Health 116
/doh.gov.ph
Now that hospitals are directed to submit
reports through HFPS, what is the use of
online report generator?

● Compute for the minimum number of sample size

● ARTA CSM Analysis

Republic of the Philippines

Department of Health
/doh.gov.ph
Report Generation and Submission

● Submissions are due every January 15 of the following

year
● Reports encoded in the HFPS will be the basis of
reports starting 2024
● The HFDB shall generate an Annual Responsiveness
Report for dissemination

Republic of the Philippines

Department of Health
/doh.gov.ph
Translation and Review CES Form
Translation of the Tool Review of Forms and Processes

● English and Filipino translated tools ● HFDB and Malasakit Program Office
shall be used without modifying the (MPO) to review the forms and process
questions for collecting the survey
● Health facilities may send their
● May be translated into the appropriate suggestions and input for the
language or dialect used by the hospital improvement and more efficient
implementation through the HFDUs
● A copy of the translated form shall be ● HFDUs to consolidate suggestions and
submitted to the HFDB through the input for the improvement and submit
IPCHS Program email at to HFDB
[email protected]

Republic of the Philippines

Department of Health
/doh.gov.ph
Roles and Responsibilities

Health CHD and HFDB

Facilities MOH-BARMM
● Implement CES tool ● Monitor submissions ● Provide Capacity Building
● Submit responsiveness ● Provide technical ● Coordinate with HFDUs on
reports assistance monitoring and evaluation
● Validate and analyze ● Conduct capacity building ● Analyze and publish
results ● Provide feedback to the consolidated reports
● Act on recommendations health facilities ● Conduct implementation
reviews
● Provide recommendations

Republic of the Philippines

Department of Health
/doh.gov.ph
 Important Links for Cascading

Issuances DOH Academy HCES Tools

eLearning Module
https://bit.ly/IPCHS_Policies https://learn.doh.gov.ph/ https://bit.ly/IPCHS_Tools

Republic of the Philippines

Department of Health
/doh.gov.ph
121
WAYS FORWARD
Reminder:
Green and Safe Health Facilities - May 3, 2024 at 9AM-2:00PM

Republic of the Philippines

Department of Health
/doh.gov.ph
Reference/ Links:
SAT Checklist bit.ly/SATChecklist2024
2023 SAT Monitoring Tools 2023 Accomplished HFP Module Submission Monitoring Tool
HFODU_Assessment Tools Monitoring Checklist 2023
2024 SAT Monitoring Tool 2024_SAT Submission Monitoring Tool
DOH HFDB Manuals bit.ly/DOHHFDBManuals
HFP 2023 Orientation
Primary Care Facilities bit.ly/PCFHFPDrive23
Hospitals and Infirmaries bit.ly/HFP-AVDrive23
IPCHS
Issuances bit.ly/IPCHS_Policies
Tools bit.ly/IPCHS_Tools
DOH Academy learn.doh.gov.ph

Republic of the Philippines

Department of Health 123
/doh.gov.ph
Maraming Salamat po!

Republic of the Philippines

Department of Health
/doh.gov.ph

124