quality excellence in healthcare_phapi_baguio_14sept19

Quality and Excellence in Healthcare: Best Practices

REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg

LUZON REGIONAL MANAGEMENT SEMINARPrivate Hospitals Association of the Philippines

September 19, 2014Baguio Country Club


Greetings and SalutationsFrom

REYNALDO O. JOSON, MD, MHA, MHPEd, MSc Surg0918-804-03-04

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Quality and Excellence in Healthcare: Best Practices“Setting the Bar of Excellence in Healthcare”

Main Contents • Aiming for best practices in quality and

performance excellence in hospitals• How to aim for best practices in quality and

performance excellence in hospitals• Examples of best practices in quality and

performance excellence in hospitals






DelimitationsSpecifications

Operational definitions


“Quality” - “degree to which a set of inherent characteristics fulfils requirements.” [ISO]

• Degree: refers to a level to which a product or service satisfies. ~depending upon level of satisfaction, excellent

good poor



• Inherent characteristics: those features that are a part of the product or service and are responsible to achieve satisfaction.



• Requirements: refer to needs of customer, organization and other interested parties (e.g. regulatory bodies, suppliers, employees, community & environment). – expectations may be stated, generally

implied or obligatory.


“Performance Excellence” - an integrated approach to organizational performance management that results in

(1)delivery of ever-improving value to customers and stakeholders, contributing to organizational sustainability;

(2)improvement of overall organizational effectiveness and capabilities; and

(3)organizational and personal learning.

[Baldrige / PQA Criteria for Performance Excellence]


“Best Practice” – a formally documented method or techniquethat has been institutionalized in the hospital andthat has consistently shown performance

excellence results at least if not yet proven superior to those achieved with other means and

which can be or is being used as a benchmark by other hospitals.

[ROJoson]


• Aiming for best practices in quality and performance excellence in hospitals


“Setting the Bar of Excellence in Healthcare or Hospitals,” theoretically means putting standards of excellence in hospitals at a certain level in the continuum of excellence or defining the standards or criteria of excellence.


Setting the bar may either be raising or lowering, it but usually raising, when one is talking of bar of excellence.


• Various levels of excellence • Rating scale or categorization varies from

one evaluating organization to another.


• Categorization:–low, medium, high, and highest levels of

excellence.


• Categorization:–gold, platinum, and diamond levels with

diamond being the highest level being used by Accreditation Canada International.


• Categorization:–Center of Safety, Center of Quality, and

Center of Excellence previously used by PhilHealth.


• Categorization by the Philippine Quality Awards: – Level 1, Recognition for Commitment to Quality

Management (just beginning quality journey; planted seeds of quality and productivity);

– Level 2, Recognition for Proficiency in Quality Management (achieved significant progress in building sound process);

– Level 3, Recognition for Mastery in Quality Management (demonstrated superior results; role model in the Philippines);

– Level 4, Philippine Quality Award for Performance Excellence (highest level of excellence; national and global role model).

Aiming for best practices in quality and performance excellence in hospitals

All hospitals should continually aim for the highest level of quality and performance excellence.


If a hospital has a documented “Journey towards Excellence” program with at least some positive evaluation results, then that hospital can say or boost that it has one “Best Practice” and this “Best Practice” is considered to be the Parent, either Mother or Father, Best Practice.

Aiming for best practices in quality and performance excellence in hospitalsProgram

med Journey of Excellence

Parent Best Practice


MDH and CMZ have set the bar of quality and performance excellence and they are still continually aiming for the highest level.


Aiming for highest level of quality and performance excellence does not just mean getting more certificates from external reputable standard-bodies but more importantly, strategy should be to have more documented specific best practices aside from the Parent Best Practice.


Presence of a documented comprehensive set of “Best Practices” (as I have defined it) - ultimate single criterion to say that - a hospital has achieved the highest bar or level of quality and performance excellence!!!


Presence should be validated and affirmed by a Level 4 PQA and a reputable external hospital standard accrediting body that puts emphasis on documented best practices and benchmarking.

ROJ’s message in: “Aiming for Best Practices in Quality and Performance Excellence in Hospitals.”


Welcome feedback and queries


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• How to aim for best practices in quality and performance excellence in hospitals

How to aim for best practices in quality and performance excellence in hospitals

Subtopics• Processes of developing a “Best Practice”• Comprehensive set of “Best Practices” in a

Hospital• Strategies to have a documented

comprehensive set of “Best Practices” in a hospital


Processes of developing a “Best Practice”

• Decide on a management system that will be developed into a “Best Practice.”

One can choose from the list that I will provide later.

For examples, communication management system and strategic planning management system.



• Formulate a design and development plan or blueprint – systematic approach in planning of

management system –deployment and implementation –evaluation, review, and continual improvement –management review and independent audit



In the management system plan, adopt / adapt with innovations best practices from other institutions if there are.



Use systems approach (looking at and managing

the hospital as a whole)alignment (promoting consistency of all plans,

processes, evaluations, actions of component systems to support whole hospital’s goals)

integration (making all components function as an interconnected unit)



In the evaluation, always include timelines and measurements with key performance indicators.



• Track the implementation of the management system plan.


Processes of developing a “Best Practice”• Evaluate results of implementation for at

least 3 years in terms of – level (current level of performance based on

formulated key performance indicators)– trends (rates of performance improvements and

sustainability of good performance)– comparison (performance relative to

appropriate comparisons such as other similar hospitals and benchmarks or hospital industry leaders)



All the above must be formally and completely and accurately documented!!!



If management system plan has been implemented for at least 3 years and has consistently shown performance excellence results, then it can be considered as a “Best Practice” for the hospital.

Once publicized, can be used as a benchmark by other hospitals.




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Comprehensive set of “Best Practices” in a Hospital

Aside from developing “Journey towards Excellence” program as the Parent Best Practice, hospital should develop other specific “Best Practices.”



List of “Best Practices” - comprehensive - all hospitals should develop as part of the “Journey towards Excellence.” - at least 25



I formulated this list using as references • PQA Criteria for Performance Excellence • international hospital health care standards

particularly on patient-care• ROJ’s steadfast strategic objectives for

hospitals• Others



Using PQA Criteria for Performance Excellence as Reference:

• Leadership• Strategic Planning• Customer Focus• Measurement, Analysis, Knowledge

Management • Workforce Focus• Operations Focus

Develop One Best Practice per Category


Comprehensive set of “Best Practices” in a HospitalUsing international hospital patient care standards as

reference:• Patient Safety• Access to Care and Continuity of Care• Patient and Family Rights• Assessment of Patients• Care of Patients• Anesthesia and Surgical Care• Medication Management • Patient and Family Education• Hospital Infection Control

Develop One Best Practice per Category



Systems perspective in governanceIntegrated value-based health care servicePhysician engagement (patronage and loyalty)Maximal utilization of services with controlled expenses and lossesCustomer delightFull compliance with the quality and performance standards (local and international)Integrated IT-enabled operations systemStaff engagementLearning organizationCSR program with tangible social impact

ROJ’s Recommended Steadfast Strategic Objectives for Hospitals

Develop one Best Practice per Category



ROJ Additional Recommended Must-Have Management System or Program for Hospitals:

• Communication Management System



ROJoson’s Recommendation:At least 25 documented “Best Practices” which all hospitals should develop as part of “Journey towards Excellence” Program




[email protected]


Strategies to have a documented comprehensive set of “Best Practices” in a hospital

What top management and senior leaders should do?

• Leadership strategy• Management strategy• Communication strategy• Education strategy



• Leadership Strategy –Commitment –Motivation–Support–Role model



• Management Strategy–Technical competence in the processes of

developing “Best Practice”



• Communication Strategy –Clear communication–Close-loop communication– Information–Alignment and integration– Engagement of staff to the project “Best

Practices”



• Education Strategy– Education, coaching, mentoring on developing

“Best Practices” to all hospital staff


Subtopics• Processes of developing a “Best Practice”• Comprehensive set of “Best Practices” in a

Hospital• Strategies to have a documented

comprehensive set of “Best Practices” in a hospital

ROJ messages: “How to Aim for Best Practices in Quality and Performance Excellence in Hospitals.”




[email protected]


• Examples of best practices in quality and performance excellence in hospitals


“Best Practice” – a formally documented method or techniquethat has been institutionalized in the hospital andthat has consistently shown performance

excellence results at least if not yet proven superior to those achieved with other means and

which can be or is being used as a benchmark by other hospitals.

[ROJoson]

Examples of best practices in quality and performance excellence in hospitals

Disclosure:• Not fully matured• Being implemented for at least 3 years

(institutionalized) – level of commitment at least, proficiency at most (not yet mastery)



• Governance and Leadership• Strategic Planning • Balanced Scorecard• Safety Promotion and Disaster Preparedness • Financial Management • Continual Improvement Program (MDH)• Corporate Social Responsibility Program (MDH)


• Strategic Planning • Balanced Scorecard

TPOR1: Journey towards performance excellence of MDH and CMZ

Strategic Planning ConferencesEvery 3 years since 1999

With a structured frameworkWith Annual Planning Conferences

Strategic Planning ConferencesEvery 3 years since 2009

With a structured frameworkUsing Baldrige / PQA Criteria

TPOR1: Journey towards performance excellence of MDH and CMZ

Balanced ScorecardSince 2004

Performance management and evaluation tool

Balanced ScorecardSince 2009

Performance management and evaluation tool


Welcome requests for more info


[email protected]


Presence of a documented comprehensive set of “Best Practices” (as I have defined it) - ultimate single criterion to say that - a hospital has achieved the highest bar or level of quality and performance excellence!!!


Thank you for your attentionWelcome feedback, queries, and requests for info and assistance


[email protected]

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