contentsnch.doh.gov.ph/images/pdf/handbook.pdf · contents introduction 2 ... republic act no. 9485...

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CONTENTS INTRODUCTION 2

MESSAGES

Medical Center Chief ……………………………………………………………………………… 3

Chief of Medical Professional Staff …………………………………………………………. 4

Chief Nurse …………………………………………………………………………………………… 5

Chief Administrative Officer ………………………………………………………………….. 6

HISTORY OF NATIONAL CHILDREN’S HOSPITAL 7

PAST AND PRESENT DIRECTORS OF NATIONAL CHILDREN’S HOSPITAL 12

VISION AND MISSION STATEMENTS 13

CITIZEN’S CHARTER – SERVICE PLEDGE 14

SERVICES OFFERED 15

ARTA COMMITTEE 20

POLICIES - COMPLIANCE TO ARTA PROVISIONS 21

Identification Card of Hospital Employees on Duty …………………………………. 22

Public Assistance Complaints Desk (PACD) …………………………………………….. 23

Procedure on Filing of Complaints ………………………………………………………….. 24

Procedure on Handling Patients Complaints …………………………………………… 25

Provision on Priority Service …………………………………………………………………. 27

FRONTLINE TRANSACTIONS 29

Out- Patient Department ……………………………………………………………………….. 30

Dental Service ………………………………………………………………………………………. 31

Department of Laboratory and Pathology Services …………………………………. 32

Radiology Section ………………………………………………………………………………….. 33

Pharmacy Section ………………………………………………………………………………….. 34

Medical Records ……………………………………………………………………………………. 36

Medical Social Service ……………………………………………………………………………. 38

Billing/ Philhealth Section ……………………………………………………………………… 40

Cashier ………………………………………………………………………………………………….. 42

ANNEXES 43

PACD Patient Feedback/ Complaint Form (ARTA FORM No.01) ………………. 44

PARU Form (NCH-F-MED-MSS-014) 45

OPD- Front-liners Patients Survey Form (NCH-F-GEN-003) …………………….. 47

In- Patient Satisfaction Survey Form (NCH-GEN-005) ……………………………... 49

Emergency Room Patients Satisfaction Survey Form (NCH-F-GEN-004) ….. 51

Panunumpa sa Watawat ………………………………………………………………………… 53

Panunumpa ng Kawani ng Gobyerno ……………... 54

DOH Hymn………………………………………... 55

Awit ng Serbisyo Sibil …………….. 56

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INTRODUCTION

Republic Act No. 9485 also known as The “Anti-Red Tape Act of 2007” was enacted by the Thirteenth Congress of the Philippines on June 2, 2007. It is “An Act to Improve Efficiency in the Delivery of Government Service to the Public by Reducing Bureaucratic Red Tape, Preventing Graft and Corruption, and Providing Penalties Thereof”.

Pursuant to Section 16 of the Anti-Red Tape Act of 2007, the Civil Service Commission has promulgated the Implementing Rules and Guidelines (IRR) which was published in the Philippine Star on August 21, 2008 and which took effect on September 5, 2008.

Under the law, each office or agency is tasked to perform the following within (1) year from effectivity of the IRR:

1. Identify its frontline services;

2. Undertake re-engineering of its transactions which includes limiting the number of signatories to (5) and providing a period within which transactions are action upon which should not be longer than (5) working days for simple transactions and (10) working days for complex transactions;

3. Set up service standards to be known as the CITIZEN’S CHARTER, including forming a task force to prepare said charter, to be presented on a billboard or other prominent announcement at the office handling the processes and services explained therein.

The National Children’s Hospital has initiated the formulation of its Citizen’s Charter through Hospital Order No. 2012- 044 creating the Anti-Red Tape Act (ARTA) Committee on February 16, 2012. The committee was given the responsibility to formulate the respective service standards to be known as the CITIZEN’S CHARTER which contains the following details:

1. The procedure to obtain a particular service;

2. The person/s responsible for each step;

3. The maximum time to conclude the process;

4. The document/s to be presented by the customer, if necessary;

5. The amount of fees , if necessary; and

6. The procedure for filing of complaints.

Through the CITIZEN’S CHARTER, patients of the National Children’s Hospital are made aware of the procedures for availing of the various frontline services or offices. Transparency in all hospital transactions will promote trust, client satisfaction and the delivery of quality service at all times.

The management and staff of the National Children’s Hospital commit, as reflected in our service pledge, to deliver quality patient care. We promise to uphold at all times fairness, honesty and integrity in all our transactions with our fellowmen.

MA. LUISA F. REYES, MD, FPSP Head, ARTA COMMITTEE January, 2013

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The Lord’s greatest commandments are: to love God above all and to love our neighbor

as we love ourselves. As an employee of the government, we serve the public, our neighbors.

Also, in the bible, the Lord said “whatever you did for one of the least brothers of mine, you did

for me.” (Mt. 25:40)

In the preamble of our constitution, there are sixteen (16) Filipino values mentioned:

faith in God, unity, patriotism, work, respect for life, respect for law and government, truth,

justice, freedom, love, equality, peace, promotion of the common good, concern for the family

and future generations, concern for the environment and order. Every Filipino, whether rich or

poor, can do something to help our country.

The National Children’s Hospital manned by competent men and women with faith in

God, love of country and love of neighbor, will continuously serve the public with integrity,

efficiency, effectiveness and compassion.

I congratulate the ARTA Committee headed by Dr. Ma. Luisa F. Reyes for coming up with

this Citizen’s Charter handbook, documenting our pledge of commitment for quality and honest

service to the public.

Mabuhay and God bless us all!

Republic of the Philippines

Department of Health NATIONAL CHILDREN’S HOSPITAL

MESSAGE

EPIFANIA S. SIMBUL, MD, FPPS, CEO VI Medical Center Chief II

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It is my personal privilege to commend the Anti- Red Tape Act Committee for coming up

with the First National Children’s Hospital Citizen’s Charter Handbook. Congratulations!

The Handbook would not only serve as a guide to the frontliners of our institution. This

would foremost benefit all of us who provide quality efficient and prompt health services to our

clients in accordance with our hospital’s standards, patient satisfaction and commitment from

the organization and the public.

Keep up the good work!



MESSAGE

ALICIA T. TALEON, MD, FPPS Chief of Medical Professional Staff II

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The stigma of corruption has been deeply embedded both in our history and present

times. It triggers many depressing emotions and scenarios. It destroys the harmony between

the government and the people resulting to partition – leading to stagnation. In a divided

country, penetration of progress and advancement is difficult. As a consequence, people tend to

live continuously in inconvenience.

Along with these is the incessant struggle towards rectification among individuals and

groups. These efforts have been given birth to the Anti Red Tape Act (ARTA). The legislative act

that provides the direction towards good governance thereby, eliminating graft and corruption

practices. It is both evidence and an innovation.

An evidence that as government employee we are serious in our pledge to serve our

countrymen with integrity and accountability in all of our actions. As a product of innovation, it

guides government agencies and employees as well to provide quality service underscoring the

promptness and accuracy in the delivery of the service.

In the health care service like our institution, accessibility and equity are the essential

factors to be taken into consideration in order to ensure that the inherent dignity and worth of

men is preserved.

This ARTA manual serves as an inspiration to continuously pour our best efforts for the

interest of our clients. As we follow the tenets of ARTA, we embrace change. As we change, we



MESSAGE

DAISY L. LLARENAS, RN, MPA, MAN Chief Nurse

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Apart from the effort of myself, the success of any project depends largely on the

encouragement and guidelines set.

I would like to take this opportunity to express my gratitude to the people who have

instrumental in the successful completion and implementation of this NCH ARTA Manual,

chaired by Dr Ma. Luisa F. Reyes. Thank you is not enough for this tremendous support and

help accorded to the management and employees of the hospital in easing the work flow

processes.

The guidance and support received from all the members of the committee who

contributed and who are contributing to this project were vital for the success of this project.

This ARTA Manual of NCH will assist us all to achieve high quality services through

timely access, efficiency and effectiveness.

Job well done! Congratulations!



MESSAGE

REYNALDO C. SALAZAR, M.P.A. Chief Administrative Officer

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to become what people now recognize as the National Children’s Hospital. With the abolition of the

ECA, the Clinic became part of the Social Welfare Commission.

By virtue of Commonwealth Act No. 705 in October 1945, the Indigent Children’s Clinic

attained its hospital status as the Indigent Children’s Hospital and in December of the same year, Dr.

Peregrino H. Paulino was designated Chief of the Hospital. This event can be spoken of as the turning

point. From its temporary quarters at San Rafael Street, the hospital was transferred to a two-storey

house at 715 Gastambide Street, Sampaloc, Manila in 1947. This building, however, proved

inadequate for the fast growing hospital. And being at the commercial hub of Manila, the danger of

fire became an ever increasing threat. The locale itself was far from ideal. The Director, Dr. Peregrino

H. Paulino, in his intense desire and ambition to see a better and modern hospital solicited the help

of former Secretaries of Health as well as the officials of the executive and legislative branches of the

government. This effort saw its reward when the late President Elpidio Quirino issued Presidential

Proclamation No. 439 assigning the Mori Bicycle Compound at Espan a Extension in Quezon City to

be the future site of the Indigent Children’s Hospital.

In 1952, Republic Act No. 731 changed the name of Indigent Children’s Hospital to NATIONAL

INDIGENT CHILDREN’S HOSPITAL. Republic Act 948, in 1953, was passed appropriating funds for

the construction of the hospital building. Subsequently, Republic Act No. 1340, dated June 16, 1955

amended Republic Act No. 731 changing the name of National Indigent Children’s Hospital to its

present name –The NATIONAL CHILDREN’S HOSPITAL.

July 28, 1955 shines out as a memorable day for the National Children’s Hospital for it was on

that day that the cornerstone of the new building was laid. The construction of the building started

The History of

NATIONAL CHILDREN’S HOSPITAL

On February 11, 1945, the Philippine

Civilian Assistance Unit, a relief agency, later

placed under the Emergency Civilian

Administration (ECA) established an Indigent

Children’s Clinic in the building of the defunct

Bureau of Public Welfare at San Rafael Street,

Manila, under the leadership of Dr. Victoria

Kalaw-Linan to take care of the war refugees,

the sick and undernourished children. This

was the humble beginning of what blossomed

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in December, 1955. Finally, on April 26, 1958, the first modern hospital building of the National

Children’s Hospital was inaugurated.

On July 1, 1960, Dr. Jose C. Joven was appointed as Chief of the Hospital. He ordered the

landscaping of the grounds and the regular painting of the buildings. Aside from the improvements

in the physical facilities of the hospital, the professional and service areas were given top priority.

During his tenure, the hospital expanded even more. The hospital services offered was proof that the

organization can stand side by side with other leading medical centers during that time.

One aspect of hospital development which also deserves mention is the Nutritional

Rehabilitation Program where the Malnutrition Ward gained much attention. Grants for graduate

studies along this line were obtained allowing some of its doctors to further studies abroad.

In August of 1976, the administration of the hospital changed hands with the appointment of

Dr. Cristina de Joya-Agregado as the incoming Chief. Under her management, the organizational

structure of the hospital was at once reviewed and revised. The objectives of the hospital were

fashioned to jive with the over-all thrust of the “New Society” under the Marcos administration. The

increasing number of patients found the need to increase the hospital’s bed capacity. Thus, in 1977,

an additional 3rd floor of the main building was constructed. Subspecialty care units were

established including the Intensive Care Unit, Neonatology Unit and a Surgical Unit. The hospital

slowly became recognized also as a training hospital, thus, the increased number of student

affiliates. The Pediatric Residency Training Program started and was accredited by the Philippine

Pediatric Society as Phase I and II in 1981.

April 16, 1988 marked a new era in the history of National Children’s Hospital when Dr. Ma.

Isabelita S. Vital-Gozon assumed the position of Medical Center Chief. Armed with enthusiasm and

extraordinary vitality, Dr. Gozon did not waste any time and started propelling the hospital towards

the vision of becoming an excellent “Center of Wellness”. The chief faced the challenges head-on and

for more than a decade, NCH has steadily grown and evolved to become an institution whose noble

mission is to ease the suffering of children from malnutrition, the dreaded respiratory and

gastrointestinal diseases and other chronic diseases like tuberculosis, leukemia and others. NCH

became known for its Hydrocephalus Center hence referrals from all over the country were being

served. Also under Dr. Gozon’s administration, working conditions including a clean, orderly

physical surroundings and supportive employees have become commonplace, giving everyone a

chance to work with an elevated morale. Some of the physical upgrading of the hospital facilities

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were the installation of the communication facilities, renovation of the conference rooms and

improvement of water system of the hospital. A 1000 square meter lot adjacent to the hospital was

acquired to give way for the future expansion of its services. The upgrading of training and

continuing education was also given special attention. Postgraduate Course in Pediatrics started in

1991, then was conducted annually chaired by the department’s competent consultants.

In February 2002, Dr. Marieta R. Siongco was appointed as the new Chief of Hospital. Under

her leadership, Total Quality Management (TQM) Program was organized and launched. This

became a priority program for the hospital. Quality Circle Teams were created in all services and

departments. Weekly TQM meetings were conducted to review, write and standardize various

processes. This empowered the workers to actually evaluate and improve on their own work

processes.

In September 18, 2006, Dr. Robert Enriquez became the new Medical Center Chief. During

this time the hospital was at the forefront thrust of DOH towards ensuring quality assurance and

patient safety in hospitals under the stewardship of the Secretary of Health, Francisco T. Duque III.

With this thrust, the entire hospital under the guidance and direction of TQM, worked together and

achieved the “Center of Excellence” accreditation from PHILHEALTH on July 10, 2010. The National

Children’s Hospital became the first government hospital to achieve the highest accreditation given

by PHILHEALTH which is valid from May 1, 2010 to April 30, 2013.

Under Dr. Enriquez’s headship, construction of a new six-story medical arts building

(Building 4) with an estimated cost of Php 119,000,000.00 was started in the 1000 sq. meter vacant

lot. This new building will provide new space for the following: Outpatient Department, Doctor’s

Clinics, Dental Services, Imaging Services such as X-ray, CT Scan, Pharmacy Complex and additional

patient wards and training rooms. Other areas of the hospital in the older buildings were improved

and renovated to provide a better environment of care for the patients and for the staff as well. The

following were done such as repainting of the interior of all the wards, façade of the hospital and all

exterior, asphalt overlay of the parking lot, renovation of OPD waiting area, re-roofing of the 7th

floor Building 3), improvement of the Multipurpose Conference Hall sound system, upgrading of the

PABX System and improvement of other offices.

Hospital programs and trainings were further strengthened by upgrading quality training of

pediatric residents and other hospital staff. The continued medical education through postgraduate

courses and daily conferences are already institutionalized. The Pediatric Residency Training

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Program accredited by the Philippine Pediatric Society was upgraded to Level III and a Fellowship

Program in Pediatric Surgery was started. New hospital programs/services were started such as the

Touch Therapy Institute (first of its kind in the Philippines), Drug Dependent Treatment and

Rehabilitation for minors and the strengthening of the Tuberculosis Control Program through the

Public-Private Mix Directly Observed Therapy Short Course (PPMD-DOTS). Cardiac Surgeries for

congenital heart defects were also started. Networking and collaboration with donors was

strengthened providing the hospital with expensive medical equipment like the Neuroendoscope

and Heart-Lung Machine.

Due to the untimely demise of Dr. Enriquez, a new Medical Center Chief, who is also the

former Chief of Medical Professional Staff, Dr. Epifania S. Simbul took over the headship of the NCH

on June 1, 2011 up to the present time. Under Dr. Simbul’s leadership, the hospital continued its

pursuit of continuously improving all facets of hospital operations.

Working further on or enhance the previous achievements, the hospital staff continued to

work to sustain and deliver excellent patient care. In the first year of Dr. Simbul’s term, the hospital

received the RED ORCHID AWARD, the highest award given to institutions for the efforts in

maintaining 100 % Tobacco Free Environment, GOLD AWARD for OSPITAL NA MALINIS AT

MABANGO given by the Department of Health, the Philippine Society for Quality Health Care

(PSQUA) PARTNER in QUALITY AWARD and the GAWAD KALASAG , 2nd place , for Best Medical

Institution advocating Disaster Risk Management (National Government Hospital Category) given by

the Office of Civil Defense on December 12, 2012.

Continuous Quality Improvement (CQI) through Quality Improvement Studies (QIS) was

institutionalized in NCH and pioneered by the Nursing Service. A total of 12 Quality Improvement

Studies were done for the period of 2011 and 2012. Other areas such as the Department of

Laboratory and Pathology Services also started to do QIS by making a study on the turn-around-time

(TAT) of laboratory results.

The Hospital Patient Safety Program was created to ensure safety of patients in the

environment of care. The Patient Safety Manual was approved on January 11, 2012 and a hospital

wide orientation was conducted in the month of February. Full implementation of the Patient Safety

Program was started in May, 2012. To measure effectiveness of the program a 2nd Safety Climate

Survey was conducted on August 13-17, 2012. The second survey showed a safety climate measure

of 74% (+21.8% increase compared to the baseline of 52.5% in 2010). The Clinical Pathway for the

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top ten (10) leading causes of admissions were reviewed and updated including the cost. Continues

monitoring of its implementation and relevance is being done.

The Nursing Service, through the Chief Nurse, Daisy Llarenas , Training Officer Ma. Lenore

Pasol and Ms. Claire Batulan, were the forefront contributors in the development of the NURSE

CERTIFICATION PROGRAM of the Department of Health. The Nurse Certification Program will

accredit competency of nurses in Pediatric Nursing Specialty. There were fourteen (14) NCH nurses

accredited as assessors for this program during its launching in November 23, 2012. Training

modules to prepare all nurses for this nurse certification were crafted and are also available.

FACILITIES renovation and /or improvement continued in the different areas of the hospital

such as the renovation of the 4th floor (Building 2), completion of the new Medical Arts Building

(Building 4) through the assistance of DPWH, completion of the new Operating Room Complex

through the assistance of Hyundai Asia Resources, Inc. Budget from the DOH provided for the

construction of new three story hospital building to replace the old three story building (Building 1)

to start in 2013. The retention and utilization of the hospital income have contributed to the

procurement of more equipment, medical supplies and other needs for the operation of the hospital.

Twenty thirteen (2013) will be an exciting and challenging year for as the hospital prepares

for ISO 9001: 2008 Certification and shortly after for ISO 15189 Medical Laboratory Accreditation.

Fellowship Programs in Pediatric Subspecialties like Hematology, Pulmonology, Infectious Disease,

Neurology and Pediatric Anesthesia will be developed. More Researches will be encouraged and

supported to make NCH a center for pediatric research. Collaboration and networking with partner

organizations locally and internationally will be continued and enhanced for more comprehensive

and continuous improvement of delivery of services to our patients with public-private partnership.

With the dedication and commitment of management and all the hospital staff, this will surely

become a reality for National Children’s Hospital.

National Children’s Hospital has continually grown, evolved and expanded with the changing

times. The hospital has been the frontrunner in the care of pediatric patients, in different stages of

life and different types of diseases. Although almost 90% of patients are indigent, they have never

been deprived of admission despite financial constraints. The delivery of services for indigent

patients is done through innovation, sourcing out of funds and sponsorship, collaboration with

government and non government organizations and individuals. Through the years, this edifice has

been and will always be a living testament of loving quality patient care and concern for all Filipino

children.

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The Past and Present Directors of National Children’s Hospital

PEREGRINO H. PAULINO, MDPEREGRINO H. PAULINO, MD JOSE C. JOVEN, MDJOSE C. JOVEN, MD CRISANTA DE JOYACRISANTA DE JOYA--AGREGADO, MD, FPPS, MHAAGREGADO, MD, FPPS, MHA

MA. ISABELITA S. VITALMA. ISABELITA S. VITAL--GOZON, MD, FPPSGOZON, MD, FPPS MARIETA R. SIONGCO, MD, FPOGS, CESO VMARIETA R. SIONGCO, MD, FPOGS, CESO V ROBERT S. ENRIQUEZ, MD, MHA, CESO IVROBERT S. ENRIQUEZ, MD, MHA, CESO IV

December 1945 to November 1959December 1945 to November 1959 November 3, 1959 to August 3, 1976November 3, 1959 to August 3, 1976 August 27, 1976 to October 30. 1987August 27, 1976 to October 30. 1987

April 16, 1988 to November 19, 2001April 16, 1988 to November 19, 2001 February 28, 2002 to December 16, 2005February 28, 2002 to December 16, 2005 September 18, 2006 to December 29, 2010September 18, 2006 to December 29, 2010

EPIFANIA S. SIMBUL, MD, FPPS, CEO VIEPIFANIA S. SIMBUL, MD, FPPS, CEO VI

June 1, 2011 to presentJune 1, 2011 to present

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Recognized as an excellent pediatric hospital in the whole of Asia in the next decade.

Kilalang pinakamahusay na pambatang pagamutan sa buong Asya sa susunod na

dekada.

Provide the best Pediatric healthcare based on the tradition of excellence in service, research and training of future leaders in child care.

Magbigay ng pinakamahusay na paggagamot ayon sa kinamulatang galing sa serbisyo, at masusing pananaliksik at paghubog sa mga mamumunong dalubhasa sa larangan ng paggagamot sa kabataan.

VISION

MISSION

Original mission and vision statements: 2005

1st revision October 2012

TQM/MANCOM approval: January 3, 2013

Implementation date: January 2, 2013

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We, the management and staff of the National

Children’s Hospital believe in the inherent dignity

and worth of all men.

We shall work for the best interest of all

patients-in and out, sick and well, and provide at

all times quality health care.

We pledge to commit that we shall give utmost

importance to the well-being of all those we serve.

CITIZEN’S CHARTER

Approved: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI

Medical Center Chief

Date of Approval: December 20, 2012

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CLINICAL SERVICES OFFERED

1. GENERAL PEDIATRICS

Emergency & Ambulatory Pediatrics MA. LOUISA U. PERALTA, MD, FPPS ANA LIZA H. DURAN, MD, FPPS CECILIA C. DIZON, MD, DPPS

Well & Sick Baby, Children & Adolescents CECILIA C. DIZON, MD, DPPS

Immunizations Mon – Fri (8am-4pm)

CECILIA C. DIZON, MD, DPPS

2. PEDIATRIC SUBSPECIALTIES

CARDIOLOGY Mon – Fri (8am-12nn)

JUAN G. REGANION, MD, DPPS

DERMATOLOGY Tues & Thurs (1pm-4pm)

CARLOS E. PAGUIO, MD, FPPS

ENDOCRINOLOGY Thurs (8am-10am)

WILSON C. CUA, MD, FPPS

GASTROENTEROLOGY & NUTRITION Fri (1pm-4pm)

GRACE R. BATTAD, MD, FPPS

HEMATOLOGY Fri (1pm-4pm)

ROSALINA P. ANASTACIO, MD, FPPS

INFECTIOUS DISEASES Daily 24/7

CYNTHIA A. AGUIRRE, MD, FPPS CECILIA C. DIZON, MD, DPPS

INTENSIVE CARE Daily 24/7

GENER T. BECINA, MD, FPPS MA.LOUISA U. PERALTA, MD, FPPS

NEONATOLOGY Wed (1pm-4pm)

JOSE B. SALAZAR, MD, FPPS

NEPHROLOGY Thurs (1pm-4pm)

NAOMI P. GROSPE, MD, DPPS

ONCOLOGY Fri (1pm-4pm)

AMY GOLETA- DY, MD, FPPS

PULMONOLOGY Mon- Fri (8am-4pm)

AGNES R. MENDOZA, MD, FPPS

CHILD DEVELOPMENT CENTER

Neurology – Wed (1pm-4pm) MARIETTA M. DIAZ, MD, FPPS

Neuro-Dev’t Pediatrics – Tues (8am- 12nn) JOCELYN A. EUSEBIO, MD, FPPS

Psychiatry – Tues (8am-12nn) PORTIA V. LUSPO, MD, FPPS

Rehabilitation Medicine Thurs (8am- 12nn)

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ENDOCRINOLOGY Thurs (8am-10am)

WILSON C. CUA, MD, FPPS

NEPHROLOGY Thurs (1pm-4pm)

NAOMI P. GROSPE, MD, DPPS

3. SURGERY

GENERAL PEDIATRIC SURGERY Daily (8am-4pm)

DELFIN B. CUAJUNCO, MD, FPCS, FPSPS ANTONIO DR. CATANGUI, MD, FPCS, FPSPS HERMOGENES RD. REGAL, MD, FPCS, FPSPS

LEANDRO L. RESURRECCION, MD, FPCS, FPSPS JOSE MODESTO B. ABELLERA III, MD, DPCS

CONGENITAL HEART SURGERY FRANCISCO M. PERALTA, MD, FPATACSI

ENT- HEAD and NECK SURGERY Mon (8am- 12nn)

MA. GRACIA C. MACIAS, MD, FPSO-HNS

NEUROSURGERY – Tues (1pm-4pm) ALFREDO L. TAN, MD, FPCS, FAFN CHARLESTON T. YEO, MD, DPBS

OPTHALMOLOGY Thurs (2pm-4pm)

ORTHOPEDICS Thurs (8am-5pm)

LEO O. OLARTE, MD, FPCS, FPOA, FPSA

4. ANESTHESIA

JOSELITO T. MORETE, MD, DPCS DIVINA P. SERRANO, MD, DPBA SYLVIA C. ACOSTA, MD, DPBA JULIET E. CRUZ, MD, DPBA

2-D ECHO – Mon & Wed (8am-11am) JUAN G. REGANION, MD, DPPS

DENTAL – Mon-Fri (8am-4pm) ALBERT J. UBAT, DMD

EMILILIA B. BASCO, DMD PILAR A. LLARENA, DMD

DIABETES EDUCATION CLINIC

Fri (1pm-3pm)

ALICIA T. TALEON, MD, FPPS

DRUG DETOXIFICATION

(By appointment)

WENCESLAO A. KIAT, MD, DPPS

INTERNAL MEDICINE

Mon & Wed (1pm-4pm)

TEODORO B. RAMOS, MD, FPCP, FPCC

NEWBORN SCREENING – Daily

MA. DOLORES B. CRUZ, MD, FPPS

PRIVATE-PUBLIC MIX D.O.T.S.

Daily (8am-4pm)

MYRNA T. VALENCIA, MD, FPPS

TOUCH THERAPY

Daily (10am & 3pm)

MA. DOLORES B. CRUZ, MD, FPPS

SMOKING CESSATION CLINIC

For employees

Mon (1pm – 4pm)

TEODORO B. RAMOS, MD, FPCP, FPCC

For Patients / Parents

Fri (1pm – 3p)

AGNES R. MENDOZA, MD, FPPS

JUDITH G. MILAN, MD, FPPS

5. OTHER CLINICAL SERVICES

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DIAGNOSTIC SERVICES

1. LABORATORY – Daily 24/7

BLOOD BANKING

HEMATOLOGY LORNA B. LIOANAG, MD, DPSP

CLINICAL CHEMISTRY & SEROLOGY

CLINICAL MICROSCOPY & PARASITOLOGY

DRUG TESTING

MICROBIOLOGY MA. LUISA F. REYES, MD, FPSP

HISTOPATHOLOGY & CYTOLOGY CARMEN S. MANALAYSAY, MD, FPSP

2. RADIOLOGY – Daily 24/7

X-RAY & ULTRASOUND TERESITA T. ESTABILLO, MD, FPCR MARIO T. MILO, MD, FPCR

3. OTHER DIAGNOSTIC SERVICES

ELECTROCARDIOGRAM (ECG)

ELECTROCEPHALOGRAM (EEG) Daily MARIETTA M. DIAZ, MD, FPPS

ARTERIAL BLOOD GAS (ABG) ICU – Daily

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National Children’s Hospital implements the following provisions of the

Anti-Red Tape Act

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NCH ARTA COMMITTEE INITIATIVES and ACCOMPLISHMENTS

Regular meetings of the ARTA Committee. Conducted (6) meetings for 2012.

Identified the various frontline services of the hospital.

Documented the procedure or steps on how to avail of the needed services, the responsible persons and the actual time required for each of the transactions.

Recommended to EXECOM a new process flow for the OPD Consultations with the objective of improving efficiency and reduce waiting time (approved by EXECOM awaiting completion of needed renovation to be done by engineering).

Formulated and recommended a new PATIENT IDENTIFICATION CARD (approved and implemented Jan 2013).

Formulated the hospital’s SERVICE PLEDGE ( approved and posted in hospital premises)

Crafted the ARTA Handbook of NCH which will contain our Citizen’s Charter.

Provision of Priority Services to patients (pediatrics) accompanied by the elderly, disabled and pregnant.

Addressed all the recommendations stated in the NCH ARTA Report Card.

Crafted hospital policies to fully comply with ARTA Provisions.

MA. LUISA F. REYES, MD, FPSP ARTA Coordinator

Members: CECILIA C. DIZON, MD, FPPS - Emergency Room /Out Patient Department ESTRELLA L. ALEJO, RSW - Medical Social Service ALBERTO J. UBAT, DMD - Dental Section EVELYN A. GONZALES, RPh - Pharmacy Section TERESITA LANTIN - Cashier GEMMA R. SUAREZ - Medical Records/Admitting Section MYRNA M. DELA ROCA - PhilHealth/Billing Section

Contributors: (OPD Nurses)

LORETA C. VIDUYA, RN IMELDA DEVERATURDA, RN JULIETA MATEO, RN

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POLICIES

(Compliance to ARTA Provisions)

Identification Card of Hospital Employees on Duty

Public Assistance Complaints Desk

Procedure for Filing of Complaints

Procedure for Handling Patient Complaints

Provision of Priority Service for Children accompanied by Pregnant Individuals, Persons with Disability and the Elderly

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Department of Health

National Children’s Hospital

IDENTIFICATION CARD OF HOSPITAL EMPLOYEES ON DUTY

ARTA PROVISION: All officers or employees transacting with the

public shall be provided with an official identification card which

should be worn during office hours or during their tour of duty.

GUIDELINES:

1. All employees within the premises of the hospital while on duty are required to wear their

official identification card.

2. Frontline employees, especially those administering direct patient care, are required to

introduce themselves to patients prior to any procedure or any form of engagement .

3. Trainees are also required to wear their official identification cards and likewise introduce

themselves to patients prior to any transaction or engagement.

Prepared by:

MA. LUISA F. REYES, MD, FPSP

Head, ARTA Committee

Approved by: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI


Date approved: December 10, 2012

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DEPARTMENT OF HEALTH


PUBLIC ASSISTANCE COMPLAINTS DESK

To comply with ANTI-RED TAPE ACT (ARTA) provisions the NATIONAL CHILDREN’S

HOSPITAL shall provide a Public Assistance Complaints Desk in a conspicuous location

preferably in the lobby of the hospital.

GUIDELINES:

1. The Public Assistance Complaints Desk will be manned by hospital staff from the

Administrative Service on a daily rotation basis.

2. A monthly schedule of the officer of the day will be made and approved by the Chief

Administrative Officer and the Medical Center Chief.

3. The officer of the day will physically man the desk from 8am-5pm.

4. The officer of the day is expected to provide assistance to all concerns, inquiries and

complaints of patients.

5. A logbook will be provided where all patient complaints are recorded as they come.

6. The logbook will be submitted to the TQM-CQI office at the end of the day for safekeeping.

7. All complaints will be handled according to set guidelines.

Prepared:



Recommending Approval: REYNALDO SALAZAR

Chief Administrative Officer



Date of Approval: December 10, 2012

Date of Implementation: January 1, 2013

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PROCEDURE FOR FILING OF COMPLAINTS

A patient may file a complaint through any of the following means:

A. PARU (Patient Assistance Reaction Unit)

A.1 PARU is in the office of the Medical Social Service Section (MSS).

A.2 Responsible person is the head of the MSS or any designated medical social worker.

A.3 Complainant is given a PARU Complaint Form to write his complaint directly or they can be assisted by the

medical social worker in documenting the complaint.

A.4 The complaint is handled by the head of the medical social worker and referred directly to appropriate service/

department or section heads for resolution.

B. PUBLIC ASSISTANCE COMPLAINTS DESK

B.1 Public assistance desk is located in the main lobby of the hospital.

B.2 Person responsible is the officer of the day.

B.3 Complainant is given a form to accomplish directly or can be assisted by the officer of the day.

B.4 Complaints are recorded in a logbook.

B.5 Officer of the day refers complaint report to appropriate hospital officers.

C. TQM –CQI Office

C.1 Complainant can accomplish a patient survey form available in all frontline areas of the hospital.

C.2 The accomplished survey form is dropped in any patient satisfaction survey box (orange boxes) located in (10)

areas of the hospital.

C.3 Admitted patients can also write their complaints in the patient satisfaction survey form given to them prior to

discharge.

Prepared by:



Approved by : EPIFANIA S. SIMBUL, MD, FPPS, CEO VI


Date of approval: December 10 , 2012

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PROCEDURE FOR HANDLING PATIENT COMPLAINTS

GENERAL GUIDELINES :

1. Attend immediately to patient complaints as soon as they are brought to your attention.

2. Respect complainant’s point of view and adopt a tolerant understanding approach to the

concerns being verbalized.

3. Assure patient that the hospital welcomes complaints as a mechanism to improve on the

delivery of our services.

4. Inform patient that an officer of the hospital will immediately look into his concern and that he

will be given a feedback on the investigation and action/s taken pertaining to his/her

complaint.

5. Refer immediately to designated hospital official the verbalized concern/ complaint.

SPECIFIC GUIDELINES :

1. PARU COMPLAINTS

A. All PARU Complaints will be handled by the head of the Medical Social Service or her

designated representative.

B. All complaints should be properly documented using the official PARU forms.

C. Complainant can write directly his complaint or the medical social worker can assist if

requested.

D. Complaints are processed according to established PARU Policies and Procedures.

E. Resolution of complaint is sought immediately.

F. If resolution cannot be done immediately, assure complainant that a feedback will be given

on his/her complaint (secure a contact tel. number or address to be used for feedback

purposes and make sure you get back to the patient as promised)

2. PUBLIC ASSISTANCE/COMPLAINTS DESK

A. All complaints received by the officer of the day will be recorded in a designated logbook.

B. Complainant will be given a form to accomplish by the person himself or he may seek

assistance of the officer of the day.

C. Officer of the day classifies the complaint as to whether it belongs to the MEDICAL

SERVICE, NURSING SERVICE or ADMINISTRATIVE SERVICE.

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D. The officer of the day will immediately refer the complaint to the appropriate hospital

official as follows:

D.1 Medical Service - CMPS or designated representative

D.2 Nursing Service - Chief Nurse or Assistant Chief Nurse

D.3 Administrative Service - Chief Administrative Officer or designated representative

E. Hospital official immediately attends to the complaint, documents resolution and action

taken and informs the complainant.

3. TQM-CQI OFFICE

A. The TQM-CQI Office officially administers and is responsible for the patient satisfaction

surveys conducted in the entire hospital.

B. There are (3) patient satisfaction forms used in the hospital:

B.1 Out Patient Front-liners Survey Forms

B.2 Emergency Room Survey Form

B.3 In-Patient Survey Form

C. The accomplished survey forms are dropped in designated drop boxes located in many

areas of Hospital (orange boxes). The accomplished survey forms are collected by TQM

office twice a week. A weekly report is prepared by TQM and copies are given to the

different areas of the hospital. Negative feedbacks/comments are addressed through an

ACTION PLAN which will be formulated by the service/department/section/unit

concerned. All action plans should be documented.

D. If patient writes his/her name/contact telephone number/ address on the survey form, a

written feedback on the actions taken pertinent to the complaint will be given.

Prepared by:





Date approved: December 10, 2012

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DATE: February 8, 2013 TO: ALL HOSPITAL EMPLOYEES RENDERING FRONTLINE SERVICES TOPIC: PROVISION OF PRIORITY SERVICE Effective immediately the hospital shall implement the PROVISION OF PRIORITY SERVICE to patients who are accompanied by senior citizens (matatanda), pregnant (buntis) and the disabled (maykapansanan). A signage will be displayed in all frontline service areas for the information of our patients. All hospital staff are required to implement this priority service consistently to fully comply with the Anti- Red Tape Act of 2007 (Republic Act No. 9485). Thank you. MA. LUISA F. REYES, MD, FPSP Head, ARTA Committee

Approved: EPIFANIA S. SIMBUL, MD, FPPS, CEO VI Medical Center Chief

Anti- Red Tape Act (ARTA) Committee

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Out-Patient Department

Daloy ng Konsultasyon sa Out Patient Department

Dental Service

Steps in the Availment of Dental Health Services

Laboratory Department

Procedure in Requesting for Laboratory Examinations and Submission of

Specimens

Radiology Section

Procedure in Requesting for Radiologic Examinations

Pharmacy Section

Procedure in Filling Prescriptions for Sponsored Transactions

Procedure in Filling Prescriptions Cash Basis

Medical Social Service

Procedure for Referral to Medical Social Service for Patient Assistance

Billing/PHILHEALTH Section

Procedure For Discharge of Patient

Procedure for Refund of PCSO, Excess Payment/Deposit

Medical Records Section

Issuance of Medical Certificate

Request for Abstract/Photocopy of Results (discharge patient)

Cashier

Refund of Payment (Consultation Fee, Medical, Laboratory and other

procedures)

FRONTLINE TRANSACTIONS

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Section : OUT –PATIENT DEPARTMENT

DALOY NG KONSULTASYON SA OUT PATIENT DEPARTMENT

Estimate Transaction Time: 30 MINUTES to 4 HOURS

Kumuha ng Triage Form sa guard

Start

Pumunta sa Triage Area para makunan ng temperatura, pulso at iba pa

Magbayad sa Cahier

End

Pumunta sa Registration Area para magpalista at ipakuha ang chart sa

records section

Dalhin ang resibo at pumunta sa Height and Weight area at magpakuha ng taas

at timbang

Pumunta sa waiting area at maghintay sa tawag ng doktor

Pumunta sa Consultation Room kung saan tinawag ng doktor

Sagutin ang Patient’s Satisfaction Survey Form para sa ikakaganda ng serbisyo ng National Children’s

Hospital at ihulog sa suggestion box

ACTIVITY # FLOWCHART

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Section : DENTAL

STEPS IN THE AVAILMENT OF DENTAL HEALTH SERVICES Estimate Transaction Time: 1 HOUR & 20 MINUTES

Proceed to TRIAGE AREA for evaluation

End

Start

Proceed to OPD Medical Records Section (old patients)

Proceed to Dental Section for examination and treatment

Pay at the cashier for services rendered


1

2

3

4

New Patient

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Section : LABORATORY

Subject : PROCEDURE IN REQUESTING FOR LABORATORY EXAMINATIONS AND SUBMISSION OF SPECIMENS

Estimate Transaction Time: 32 MINUTES


1

2

3

4

Present laboratory request to the

End

Start

Pay at the cashier

Cashier near OPD Reception 8am – 3pm

Cashier in front of ER or at the Pharmacy section, 3 pm - onwards

Return O.R. & Laboratory request to

Submit specimen and or wait for

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Section: RADIOLOGY

Subject: PROCEDURE IN REQUESTING FOR RADIOLOGY EXAMINATIONS



1 2 3 4 5

Present x-ray request to Radiology office

End

Start

Pay at the cashier. 1. Cashier near OPD Reception 8am–

3pm. 2. Cashier in Pharmacy section located

Return O.R. & x-ray request to Radiology office

Proceed to x-ray room for the procedure

examination

Come back for release of official result as instructed

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Section: PHARMACY

Subject: PROCEDURE IN FILLING PRESCRIPTIONS SPONSORED TRANSACTIONS



1 2

3

End

Start

Receive medicines

Inquire on the maximum amount that

can be availed

Present prescription signed by the

physician to the

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Section: PHARMACY

Subject: PROCEDURE IN FILLING PRESCRIPTIONS CASH BASIS


Present the prescription to the

pharmacist

Pay to the Cashier

End

Start

Receive medicines

Present OR and prescription to the

pharmacist


1

2

3

4

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Section: MEDICAL RECORDS

Subject: REQUEST FOR ABSTRACT / PHOTOCOPY OF RESULTS (for discharged patients)



1

2

3

4

Request for Abstract/photocopy of results

Start

Give information needed

Receive requested abstract/photocopy of

result

End

Fill out request for Access to Medical Record Form

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Section: MEDICAL RECORDS

Subject: ISSUANCE OF MEDICAL CERTIFICATE (for OPD or presently confined in the ward)


Request for medical certificate

Start

Pay medical certificate fee at the Cashier’s

Office

Receive medical certificate

End

Request the attending physician to sign the Medical certificate


1

2

3

4

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Section: MEDICAL SOCIAL SERVICE

Subject: ISSUANCE OF MEDICAL CERTIFICATE (for discharged patients)



1

2

3

4

Request for medical certificate

Start

Pay medical certificate fee at the Cashier’s

Office

Receive medical certificate

End

Request the attending physician to sign the Medical certificate

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Section: MEDICAL SOCIAL SERVICE

Subject: PROCEDURE FOR REFERRAL TO MEDICAL SOCIAL SERVICE FOR PATIENT ASSISTANCE

Estimate Transaction Time: 1HOUR & 20 MINUTES


1

2

3

4

5

Seek/ask for assistance

Start

Submit all pertinent documents to the Medical

End

Assistance is granted

Present guarantee letter/ and

or assistance from donor to

Social Worker

Comply with Social Worker’s

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Section: BILLING / PHILHEALTH SECTION

Subject: PROCEDURE FOR DISTANCE OF PATIENT Estimate Transaction Time: 16 MINUTES


1 2 3 4 5 6

Inquire from nurse when to transact with Billing Section

Start

Get statement of hospital bills from Billing Section

End

Pay hospital bill to the cashier (Pay Patient) or

Proceed to MSS for assistance on payment of bill (service patient)

Return and present the OR to Billing Section

Receive the discharge clearance from Billing Section

Return to the nurse in the ward and present discharge clearance

get the Discharge slip and Discharge Plan

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Section: BILLING / PHILHEALTH SECTION

Subject: PROCEDURE FOR REFUND OF PCSO, EXCESS PAYMENT/DEPPOSIT

Estimate Transaction Time: 10 WORKING DAYS


1 2

Submit original official receipt

to Billing Section

Start

Receive check as refund after presentation of (2) valid identification cards

to cashier

End

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Section: CASHIER

Subject: REFUND OF PAYMENT (Consultation Fee, Medical, Laboratory and other Procedures)

Estimate Transaction Time: 1 HOUR & 14 MINUTES


1 2 3

Note: Refund of payment within the day will be refunded immediately after presentation of original OR with justification.

Request for refund of Payment

Submit original OR with justification for refund

End

Start

Receive refund

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A. PACD Patient Feedback/Complaint Form B. PARU FORM C. OPD FRONT-LINERS Patient Survey Form D. In-Patient Satisfaction Survey Form E. Emergency Room Patient Satisfaction Survey

Form F. Panunumpa sa Watawat G. Panunumpa ng Kawani ng Gobyerno H. DOH Hymn I. Awit ng Serbisyo Sibil

ANNEXES

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Annex A

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Annex B (page 1)

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Annex B (page 2)

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Annex C (front)

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Annex C (back)

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Annex D (front)

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Annex D (back)

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Annex E (front)

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Annex E (back)

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PANUNUMPA SA WATAWAT

Ako ay Pilipino

Taos pusong Nanunumpa

Sa Watawat ng Pilipinas.

At sa Bansang Kanyang

Sinasagisag na may

Dangal, Katarungan at Kalayaan

Na Pinakikilos ng Sambayanang

MakaDiyos, Makatao,

Makakalikasan at Makabansa.

Annex F

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PANUNUMPA NG KAWANI NG GOBYERNO

Ako’y kawani ng Gobyerno.

Tungkulin ko ang maglingkod nang tapat at mahusay.

Dahil dito…

Ako’y papasok ng maaga at magtatrabaho ng lampas sa takdang oras

kung kinakailangan;

Magsisilbi ako nang magalang at mabilis sa lahat ng nangangailangan;

Pangangalagaan ko ang mga gamit, kasangkapan at iba pang pag-

aari ng pamahalaan.

Magiging pantay at makatarungan ang pakikitungo ko sa mga

lumalapit sa aming tanggapan;

Magsasalita ako laban sa katiwalian at pagsasamantala;

Hindi ko gagamitin ang aking panunungkulan sa sarili kong

kapakanan;

Hindi ako hihingi o tatanggap ng suhol;

Sisikapin kong madagdagan ang aking talino at kakayahan

Upang ang antas ng paglilingkod sa bayan ay patuloy na maitaas.

Sapagkat ako’y isang kawani ng gobyerno at tungkulin ko ang maglingkod nang tapat at mahusay sa bayan ko at sa panahong ito;

Ako at ang aking mga kapwa kawani

Ay kailangan magkaisa tungo sa isang maunlad, masagana, mapayapa, malusog at makakalikasang bansa.

Sa harap ninyong lahat;

Ako’y taos-pusong nanunumpa.

Annex G

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DOH HYMN

Lahat tayo’y magkabuklod

Upang baya’y itaguyod

Walang sawang naglilingkod

Sa nayon man o sa lungsod

Pilipino ang layunin

Kapwa tao’y tangkilikin

Pangarap ko’y Pilipinas

Sa mundo’y walang katulad

Chorus:

Kagawaran ng Kalusugan

Gabay namin kahit saan

Lagi naming gagampanan

Ang tungkuling sinumpaan

Laan sa’yo maging ang buhay

Upang tayo’y magtagumpay

Sa pagbuo ng iisang bansa

Na matatag at malaya.

Annex H

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Annex G Annex I

AWIT NG SERBISYO SIBIL

Ang Serbisyo Sibil ng Bayan ko

Lingkod na tunay ngayon at kaylanman

Laging tumutulong, laging nagpapayo

At sa kawani ay syang patnubay.

Ang Serbisyo Sibil ay tanghalin

Ito ay ating dakilain

Maging tapat twina sa ating tungkulin

Paglingkurang lagi, bayang giliw.

Ang Serbisyo Sibil ay lingkod na tangi

Tayo na’t ito’y ating ipagbunyi

MABUHAY!

Ang Serbisyo Sibil ng bayan ko

Lingkod na tunay ngayon at kaylanman

Lagi tumutulong, laging nagpapayo

At sa kawani ay syang patnubay

Ang Serbisyo Sibil ay tanghalin

Ito ay ating dakilain

Maging tapat twina sa ating tungkulin

Paglingkurang lagi

Bayang Giliw.

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