benchbook scoring

guidelines Accomplishing the Benchbook

Self-assessment Forms

2010 edition

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BENCHBOOK SCORING GUIDELINES

INTRODUCTION ------------------------------------------------------------------------------------- 2

CHAPTER I: THE BENCHBOOK INDICATORS -------------------------------------------- 4

A. Indicators ----------------------------------------------------------------------------------------------------------------4

B. Evidences ---------------------------------------------------------------------------------------------------------------5

C. Code ----------------------------------------------------------------------------------------------------------------------9

CHAPTER II: BENCHBOOK SELF-ASSESSMENT FORMS -------------------------- 11

A. Self-assessment and Survey Tool ------------------------------------------------------------------------------ 11

B. Score Sheet ----------------------------------------------------------------------------------------------------------- 11

C. Self-assessment Summary --------------------------------------------------------------------------------------- 14

CHAPTER III: CONDUCT OF SELF-ASSESSMENT/SURVEY ------------------------ 16

A. The PhilHealth Survey Process ---------------------------------------------------------------------------------- 16

B. Hospital Self-assessment ----------------------------------------------------------------------------------------- 21

CHAPTER IV: COMPUTATION OF SCORES --------------------------------------------- 22

A. Self-assessment and Survey Tool ------------------------------------------------------------------------------ 23

B. Score Sheet ----------------------------------------------------------------------------------------------------------- 24

C. Self-assessment Summary --------------------------------------------------------------------------------------- 28

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BENCHBOOK SCORING GUIDELINES INTRODUCTION The Benchbook lays out the new standards for quality of care that PhilHealth will use for accrediting hospitals into the National Health Insurance Program. The Benchbook represents a shift from the old standards that govern only inputs to health care into the new standards that also evaluate processes and outcomes of care. The Benchbook is divided into seven performance areas: (1) Patient Rights and Organizational Ethics, (2) Patient Care, (3) Leadership and Management, (4) Human Resource Management, (5) Information Management, (6) Safe Practice and Environment and (7) Improving Performance. Each performance area is divided into sub-areas except for Patient Rights and Improving Performance. The sub-areas are broken down into several standards with one or several criteria to each standard; one or several indicators to each criterion; and one or several evidence to each indicator.

• Goal: declares the overall intent of the standards under it; picture of the desired-for situation targeted by a performance improvement program

• Standard: delineates the best possible condition that should exist in the organization for it to attain quality performance; sets the maximum achievable performance expectations for activities that affect the quality of care

• Criterion: lays down specific actions that need to be done to meet the standard • Indicators: measurable variables or characteristics that can be used to determine the

degree of adherence to a standard or achievement of quality goals • Core indicators : characteristics that should be present for a hospital to

function as a facility providing care, treatment and diagnosis in a manner that is safe and efficient for the patients and its staff

• Evidence: proof of compliance to the indicator which may be: document, interview or observation

Since commitment to quality begins within the organization, PhilHealth employed a different process in the new accreditation system using the Benchbook. Hospitals will now be required to conduct a self-assessment as a requirement in the application for accreditation. The self-assessment allows the hospital to evaluate itself and discern clearly its strengths and areas in which improvements can be made. The self-assessment culminates in planned improvement actions which are then monitored for progress.

Figure 1. The Benchbook accreditation process

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The new accreditation system using the Benchbook starts with the self-assessment by the hospitals. The hospitals will set their own schedule (date and frequency) and process for the conduct of the self-assessment. The hospitals have to accomplish the Benchbook Self-assessment and Survey Forms which consist of three parts:

1. Self-assessment and survey tool 2. Score sheet 3. Benchbook self-assessment summary

All three documents along with the PhilHealth application form for accreditation and other documentary requirements for accreditation, once accomplished, are submitted to the PhilHealth Regional Office (PhRO). Once the documents are assessed as complete and the hospital has paid the corresponding fees, the PhRO and the hospital shall agree on the schedule of the PhilHealth survey. Once conducted, the results of the PhilHealth survey are forwarded to the Accreditation Committee and the PhilHealth president for decision.

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CHAPTER I: THE BENCHBOOK INDICATORS A. Indicators

The seven performance areas of the Benchbook, including the goals, standards and criteria have been published and disseminated as early as 2004. The indicators and evidences came out a few years later, in 2009, after several workshops and consultations with various stakeholders. In these workshops, the indicators, which measure the adherence to the standards, were formulated for each criterion or standard (if the standard has no criterion). Indicators can be categorized as either qualitative or quantitative. 1. Qualitative indicators ask for the presence or absence of the listed evidences.

Examples are as follows: • 1.2.a.1 Presence of policies regarding active participation of patients and

families in health care decisions

• 2.5.5.b.2 Presence of resources allocated for training, supervision and evaluation of professionals who administer drugs

• 6.3.2.b.1 core

Presence of a coordinated system-wide procedure for isolation of nosocomial infections

2. Quantitative indicators, on the other hand, ask for the proportion of a certain

population that meets the requirements of the indicator, hence sampling is usually employed. These indicators have corresponding formulas for computation stated in the evidence. A few examples are:

• 1.1.a.1 core

All patient charts have signed consent.

• 2.2.3.b.1 Percentage of charts with unique identifiers for each patient

• 6.1.2.d.1 Percentage of personnel who understand and fulfill their role in safe practice

During several workshops with stakeholders, core indicators were also identified. These are characteristics that should be present for a hospital to function as a facility providing care, treatment and diagnosis in a manner that is safe and efficient for the patients and its staff. Core indicators are mandatory/non-negotiable. The hospitals must comply with all 51 core indicators from all the seven performance areas. Table 1 shows a summary count of core indicators with corresponding examples for each of the seven performance areas.

Table 1: Summary of indicators and core indicators per performance area

Performance Area Indicators CORE

Indicators Example of CORE

indicator

1. Patient Rights and Organizational Ethics

19 1 All patient charts have

signed consent

2. Patient Care 112 15

All patients have comprehensive history and PE within 24 hours from admission

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Performance Area Indicators CORE

Indicators Example of CORE

indicator

3. Leadership and Management

14 3

Proof of creation of all committees within the organization which includes terms of reference for membership

4. Human Resource Management

27 2

Presence of policies and procedures for credentialing and privileging of staff

5. Information Management

15 3 Presence of policies and

procedures on filing and retrieval of charts

6. Safe Practice and Environment

38 25

Presence of generator/emergency light, water system, adequate ventilation or air conditioning

7. Improving Performance 12 2 Presence of Quality

Improvement Program TOTAL 237 51

B. Evidences

There may be one or several evidences or proofs of compliance under one indicator. The evidence may come in any of the following types:

1. Document

The documentary requirements of the benchbook may come in a variety of forms. Policies and procedures comprise the majority of the documents. Licenses, logbooks, memoranda, issuances, reports and minutes of meetings are other examples. The documents are classified further into document review, chart review and document: o Document review

These are general documents relevant to the whole hospital. These include the licenses and permits from regulatory agencies, contracts or memoranda of agreement, minutes of meetings, hospital-wide policies and procedures, memoranda and issuances, etc. These are prepared by the hospital prior to the PhilHealth survey, properly identified as to which standard they belong to, and placed in a suitable, conveniently located room where the surveyors can review them. Examples are shown in Table 2.

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Table 2. Sample of indicators with document review as part of evidence CODE INDICATOR EVIDENCE

1.4.a.1 Presence of policies for routinely determining and improving the level of patient satisfaction

DOCUMENT REVIEW 1. Policies for routinely determining

and improving the level of patient satisfaction

2. Patient satisfaction questionnaire/survey or patient satisfaction survey results or documentation of actions to address the identified gaps

2.1.1.b.1 core

Presence of facilities consistent with clinical service capability based on DOH license in accordance with the hospital’s level (e.g. level 2 – surgical capability, level 3 – ICU, level 4 – teaching and training hospital) CORE

DOCUMENT REVIEW 1. List of services available 2. DOH License OBSERVATION Look at the facilities, structure,

manpower, equipment and supply. Check if the service capability of the hospital is in accordance with the hospital level.

o Chart review

These are randomly chosen patient charts or medical records (medical and surgical) from the medical records office of the hospital. Examples are shown in Table 3. Table 3. Sample of indicators with chart review as part of evidence

CODE INDICATOR EVIDENCE

2.3.3.d.3 core

All patients for surgery have undergone pre-operative anesthetic assessment CORE

CHART REVIEW Patient chart from medical records (surgery

patients) Note: Look for pre-operative anesthetic

evaluation in the patient chart. Pre-operative assessment should be done for patients requiring more than local anesthesia.

Formula: Number of patients with pre-

operative anesthesia/ Number of patients for surgery reviewed x 100

2.5.5.c.2 Percentage of charts with orders for drug administration that were made by licensed doctors

CHART REVIEW Doctor’s orders in patient charts from medical

records Orders that were made by interns should be countersigned by licensed residents or consultants

Formula: Number for charts with orders for

drug administration made by licensed doctors/number of charts reviewed x 100

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o Document

These are specific documents relevant to specific areas of the hospital: wards, emergency room (ER), out-patient department (OPD), intensive care unit (ICU), operating room (OR), pharmacy, laboratory, imaging, medical records, facilities and maintenance, human resources and others. These may include logbooks, licenses of personnel, protocols, clinical practice guidelines, operations manual, etc and exclude documents that are applicable to the whole hospital, which are categorized under “document review” discussed earlier. Patient charts will also be assessed in some areas – wards, ER, etc. This is separate from “chart review” done for patient charts or medical records already stored in the medical records office. Examples are shown in Table 4. Table 4. Sample of indicators with document as part of evidence

CODE INDICATOR EVIDENCE 2.2.2.c.1 Percentage of patients

correctly assigned to the clinical services appropriate to their needs

DOCUMENT Patient chart from ward and ICU Note: Determine if the service the patient

is admitted to coincide with the patient’s chief complaint and working diagnosis.

Formula: Number of patients correctly

assigned to the clinical services appropriate to their needs/total number of patients interviewed x 100

6.1.1.c.2 core

Presence of operations manuals of the medical equipment CORE

DOCUMENT Operations manuals for the medical

equipment

2. Interview

To validate the implementation and monitoring of certain policies, procedures or programs of the hospital, the surveyors will interview leaders, doctors, nurses, other hospital staff as well as patients and their families or caregivers. Examples are shown in Table 5. Table 5. Sample of indicators with interview as part of evidence

CODE INDICATOR EVIDENCE 1.5.a.2 Presence of

programs on improving staff awareness on codes of professional conduct and other statutory standards

DOCUMENT REVIEW Documents related to implementation of the program e.g. copy of lectures on professional conduct and related topics INTERVIEW Ask staff (HR) about the programs on awareness on codes of professional conduct and other statutory standards

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CODE INDICATOR EVIDENCE

2.1.1.c.1 Percentage of patients who are aware of the services provided by the hospital

INTERVIEW Ask patients or relatives/caregivers from ER and OPD if they are aware of the clinical services offered and times of availability Note: Ask only about the services relevant to the patient or caregiver Formula: Number of respondents who are aware of the services/number of respondents x 100

3.1.3.x.1 core

Proof of the creation of all committees within the organization which includes the terms of reference for membership CORE

DOCUMENT REVIEW Proof of the creation of all committees which includes the terms of reference for membership e.g. memo, office order, etc. INTERVIEW Ask leaders what the committees in their hospital are and ask for the order that created these committees

3. Observation

Certain structures (signages, facilities, equipment, supplies, etc) and some procedures (hand hygiene, drug administration, etc) will also be observed. Examples are shown in Table 6.

Table 6. Sample of indicators with observation as part of evidence

CODE INDICATOR EVIDENCE

2.1.1.a.1 Presence of signages, posters and other information materials/media detailing the clinical and ancillary services offered and hours of availability

OBSERVATION 1. Look for signage/s of services offered

or presence of flyers, posters, pamphlets about the services offered and the hours of availability at the ER, OPD, lobby and hospital perimeter

2. The hours of availability are indicated in the signage/s , flyers, posters or pamphlets at the ER, OPD, lobby and hospital perimeter

3. “PhilHealth accredited” signage, if applicable

5.2.1.a.1 Percentage of charts retrieved within the standard set by the organization

OBSERVATION Ask the records keeper to retrieve charts, then note the actual length of time of retrieval Formula: Number of charts retrieved within the time interval set by the organization /number of charts asked to be retrieved x 100 Note: If the organization has not set a time interval, use 15 minutes.

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CODE INDICATOR EVIDENCE

6.3.3.a.1 core

Presence of policies and procedures on the prevention and treatment of needle stick injuries and safe disposal of needles CORE

DOCUMENT REVIEW 1. Policies and procedures for prevention

and treatment of needle stick injuries 2. Policies and procedures on proper

handling and safe disposal of sharps/needle sticks

INTERVIEW Interview hospital staff on how they handle and dispose needles OBSERVATION Presence of receptacles for proper disposal of sharps

C. Code

For easier reference, each of the 237 indicators of the Benchbook is assigned alphanumeric codes, which are based on the levels or divisions of the benchbook indicators – performance area, sub-area, standard, criterion and indicator. The code may be 4 or 5 characters depending on whether the performance area has a sub-area or none. Both patient rights and organizational ethics and improving performance have only one sub-area under them and thus have only 4 characters in their codes as follows:

Figure 2. Four-character code

The other performance areas – patient care, leadership and management, human resource management, information management and safe practice and environment, all have 2 or more sub-areas under them, hence the codes are as follows:

Figure 3. Five-character code

Note also that in both cases, the criterion is always represented by a letter code. This will be of importance during the discussion of the scoring system later on.

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As mentioned, the performance areas have one or several sub-areas. Each sub-area is further divided into one or several standards; the standards into criteria; and criteria into indicators. However, there are cases when the standard does not have a criterion under it such as in patient care, leadership and management, safe practice and environment and improving performance. In these instances, the standard serves as the criterion and the criterion is represented by an ‘x’ in the code. Examples are shown in Table 7.

Table 7. Sample of indicators with ‘x’ in indicator code

CODE Standard Criterion Indicator

2.7.1.x.1 core

The discharge plan is part of the patient’s care plan and is documented in the patient chart.

All charts have discharge plans.

CORE

3.1.4.x.1 core

The organization’s management team regularly assesses its own performance and the performance of the organization.

Presence of evaluation and monitoring activities to assess management and organizational performance.

CORE

6.3.4.x.1 core

When needed, the organization reports information about infections to personnel and public health agencies.

Presence of policies and procedures on reporting of infections to personnel and public health agencies

CORE 7.5.x.1 Managers and staff evaluate

the effectiveness of the quality improvement program and take action to address any improvements required.

Proof of evaluation of the quality improvement program

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CHAPTER II: BENCHBOOK SELF-ASSESSMENT FORMS A. Self-assessment and Survey Tool

The self-assessment to be conducted by the hospitals utilizes the same tool that will be used during the PhilHealth accreditation survey. This tool, called the Self-assessment and Survey Tool, contains the goals, standards, criteria, indicators and evidences under each performance area. The self-assessment and survey tool has eight columns as shown in Table 8. The first column, ‘CODE,’ contains the unique alphanumeric code for each indicator and the tags for the core indicators. The second, third and fourth columns contain the STANDARDS, CRITERIA and INDICATORS respectively. The standards and criteria that appear in the self-assessment and survey tool are the same standards and criteria that were published in the “Benchbook on Performance Improvement of Health Services” (PhilHealth, 2004). The next two columns, labeled ‘HOSP’ and ‘PHIC,’ contain blank spaces, which shall be used to indicate compliance to the evidence marked with a check ‘�’ or noncompliance marked with an ‘x’. The evidences are listed in the 7th column. The last column, 8th, labeled ‘REMARKS’ may be used by the hospital and surveyor for comments and explanations. The self-assessment and survey tool is divided into 15 sections representing 3 process areas (document review, chart review and leadership interview) and 12 hospital areas (wards, ER, OPD, ICU, OR, pharmacy, laboratory, imaging, medical records, facilities and maintenance, human resources and others). These sections contain all the applicable indicators, which means that an indicator may be found in one or several sections. This also means that the indicators are not arranged successively from 1.1.a.1 (the first indicator under patient rights) to 7.7.x.1 (last indicator of improving performance). In Table 9, a sample page from the masterlist (the complete listing of all indicators of the benchbook), the sixth column labeled ‘SECTION’ indicates the applicable sections (or process/hospital areas) where an indicator may be appropriated (the applicable sections may also be found in the fifth column of the Score Sheet – refer to Table 10). To illustrate, Indicator 2.2.1.b.1 is found in one section of the self-assessment and survey tool only – the document review section (section 1). Indicator 2.2.1.b.2, on the other hand, can be found in 5 sections: ER (section 5), OPD (section 6), wards (section 4), imaging (section 9) and laboratory sections (section 10). For reference, the labels for each section are found on the upper right hand corner of each page of the Self-assessment and Survey Tool.

B. Score Sheet

The score sheet will be used to document consolidation of the findings from the survey of the different hospital areas including the document review, chart review and the leadership interview. As shown in Table 10, the score sheet has eight columns. As in the self-assessment and survey tool, the first column contains the alphanumeric code for each indicator. But in contrast with the self-assessment and survey tool, the indicators in the score sheet are arranged successively starting with the first indicator of patient rights to the last indicator of improving performance, much like in the masterlist found in Table 9.

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Table 8. Sample page of Self-assessment and Survey Tool – Document Review Section

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Table 9. Sample page of masterlist of Benchbook indicators showing the applicable sections per indicator

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The second (HOSP) and third (PHIC) columns contain blank spaces which correspond to the evidences listed in the fourth column (EVIDENCE) and shall be used to mark (as � or X) the consolidated findings per indicator. The sixth column (SECTION) lists the applicable sections per indicator and shall serve as a guide for the survey team as to which sections to consolidate for each indicator. The hospital and the PhilHealth surveyor shall indicate the appropriate scores in the seventh (SELF-ASSESSMENT SCORE) and eight (SURVEYOR SCORE) columns respectively, by encircling the corresponding number (1, 2, 3 or 4). For this, the hospital and the surveyor may refer to the scoring scale found at the bottom left corner of each page of the score sheet as shown in Table 10. This will be further elucidated in the discussion of the scoring. The last column, REMARKS, may be used by the hospital for comments and explanations for non-applicability of certain evidences or indicators in their setting and by the surveyors for comments and explanations regarding differences of scores with the self-assessment. Equivalent evidences found in the hospital which fulfill the requirements of the indicator may also be recorded here. Proportion of samples interviewed for certain evidences may also be written the REMARKS column. This will be discussed further in Chapter IV. A.

C. Self-assessment Summary The hospitals will use the Benchbook Self-assessment Summary, the third of the Benchbook Self-assessment Forms, to document the scores of the hospital in the different performance areas and their compliance with the core indicators. The first seven rows of the first table ask for the general profile of the hospital. In the last row, the hospital, based on their scores in the different performance areas will need to choose which of the accreditation awards they want to apply for. The requirements for the different accreditation awards will be discussed at length in the section on Computation of Scores. Computations for the numbers and percentages needed for the second and third tables will be explained in the Chapter IV.

Figure 4. Benchbook Self-assessment Summary

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Table 10. Sample page of the Score Sheet

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CHAPTER III: CONDUCT OF SELF-ASSESSMENT/SURVEY

A. The PhilHealth Survey Process The following process shall be utilized by PhilHealth during the accreditation survey. The hospitals may employ the same process for self-assessment or they may opt to devise their own system. PhilHealth and the hospital shall agree on the schedule of the survey. The hospital on the other hand, shall prepare the necessary documents – policies and procedures, licenses and permits, logbooks, charts, etc. before the survey. To facilitate the survey process, the hospital shall tag or label their policies with the corresponding codes of the indicators that they apply to. Also, the management team and relevant hospital personnel (committee heads and members, program heads, etc) should be available during the survey for interview. The survey shall be done by a team of at least three surveyors regardless of the level of care (Levels I, II, III and IV). The team leader should be a doctor while the rest of the team may be allied medical professionals or other technical staff. The 15 sections of the Self-assessment and Surveyor Tool shall be divided among the three surveyors depending on their competencies and expertise. The survey process will generally proceed as follows:

1. Opening conference

The survey team meets with the hospital management and briefly discusses the survey process. The hospital shall orient the survey team regarding the general layout of the hospital and introduce the hospital coordinator to the survey team. The hospital coordinator shall assist the surveyors throughout the duration of the survey.

2. Document review session

Table 11. Sample of Section 1 – Document Review Section taken from the Self-Assessment and Survey Tool

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Policies and procedures, permits and licenses, logbooks, charts, contracts, memoranda, etc. shall be prepared and placed by the hospital in a suitable, conveniently located room (from hereon shall be referred to as the document review room) where the surveyor team can go through them. The first section of the self-assessment and survey tool – the document review section (see Table 11), shall be used and filled out by all surveyors during this time. However, only evidences marked as document review should be assessed at this point. Indicators with evidences marked as document, interview, chart review or observation shall be assessed in other sections. The other sections – wards, laboratory, leadership interview, etc, with evidences marked as ‘document review’ should also be filled out at this point. An example can be found in Table 12. The procedures in asepsis for indicator 6.3.2.b.3 and both policies and procedures for indicator 6.3.3.a.1 will be part of the documents prepared by the hospital prior to the survey and placed in the document review room and should be assessed by the surveyors during the document review session.

Table 12. Sample of Section 10 – Laboratory Section taken from the Self-Assessment and Survey Tool. Evidences marked as document review in all sections of the self-assessment and survey tool should be assessed during the document review session. The rest of the evidences will be assessed during the tour of the different hospital areas.

3. Presentation of hospital’s quality improvement program The management team or the Quality Assurance Committee shall present the hospital’s quality improvement (QI) program to the survey team. Questions or clarifications regarding the QI program especially those pertaining to the indicators on Improving Performance (refer to Table 13) should be addressed during this session.

4. Leadership interview session The management team consists of the hospital director, or chief of hospital or chief health officer together with the administrative officer and/or service/department heads. Clarifications regarding the documents reviewed during the document review session shall be discussed. The second section of the tool – the leadership interview section (see Table 14) shall be used and answered at this point. Questions for the management team as enumerated in the different indicators (and corresponding evidences) from section 2 (leadership interview) should be raised.

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The survey team leader should take charge in interviewing the management team; however, anyone from the survey team may ask questions. Also, one member of the survey team should be assigned to mark (as � or X) the responses of the management team in section 2 of the self-assessment and survey tool. Evidences labeled as ‘document review’ such as policies and procedures or permits and licenses, etc. should have been assessed during the document review session.

Table 13. Sample of Section 1 – Document Review Section taken from the Self-Assessment and Survey Tool.

Table 14. Sample of Section 2 – Leadership Interview Section taken from the Self-Assessment and Survey Tool

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5. Tour of hospital facilities Armed with the section tools assigned to them, the surveyors shall now tour the hospital facilities – wards, ER, OPD, ICU, OR, pharmacy, laboratory, imaging, medical records, facilities and maintenance, human resources and others or whichever are applicable. Each surveyor should go to his/her assigned hospital area to look at documents, interview doctors, nurses, patients and other staff and observe for presence or absence of certain facilities/equipment and the practice of hospital policies and procedures. The surveyor should mark the findings (as � or X) in the appropriate sections of the self-assessment and survey tool (fifth column for hospitals and sixth column for PhilHealth surveyors). Evidences labeled as ‘document review’ such as policies and procedures or permits and licenses (see Table 15 and 16) should have been assessed during the document review session. The surveyors need only assess the applicable hospital areas. For example, in a primary hospital that does not have an operating room or an intensive care unit (ICU), sections 7 (ICU) and 8 (operating room) need not be filled out.

Table 15. Sample of Section 4 – Wards Section taken from the Self-Assessment and Survey Tool

Table 16. Sample of Section 5 – Emergency Room Section taken from the Self-Assessment and Survey Tool

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The chart review is part of the sections distributed to the surveyors and is also a part of this session. Charts for chart review shall be taken from the medical records section. The charts shall be reviewed by an assigned surveyor in the document review room using Section 3 – Chart Review of the self-assessment and survey tool. An example is shown in Table 17.

Table 17. Sample of Section 3 – Chart Review Section taken from the Self-assessment and Survey Tool *For surveys lasting more than a day, the survey team should conduct wrap up meetings at the end of each day to discuss significant findings, problems and difficulties. The problems or issues encountered should be discussed by the survey team with the hospital through the coordinator at the start of the following day during the daily hospital briefings.

6. Surveyor meeting After filling out all applicable sections of the self-assessment and survey tool, the surveyors can already meet at the document review room to discuss and consolidate their findings. First on the agenda is the finalization of the findings in all of the sections of the self-assessment and survey tool. The surveyors should make sure that all blanks have been answered in all sections assigned to them. Compliance (�), noncompliance (X) or non-applicability (NA) of each evidence should have been assessed and documented (fifth column for hospitals and sixth column for PhilHealth surveyors). Details on how to score will be discussed under the Chapter IV. After finalizing the findings for each evidence, the survey team can now begin consolidating the findings for each indicator. The survey team has to go through each indicator, using the fifth column of the score sheet (SECTIONS) as guide on what sections they should consolidate. After consolidating the �’s and the X’s, the survey team should score each indicator (1, 2, 3 or 4) using the scoring scale (refer to Chapter IV for a more detailed discussion). The score should be indicated in the

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sixth and seventh columns (SELF-ASSESSMENT SCORE and SURVEYOR SCORE respectively) by encircling the corresponding number. Comments and notes should be documented in the REMARKS column. There is no need for the survey team to compute for the percentage of compliance of the hospitals at this point. They do, however, need to summarize the general findings for presentation during the closing conference. Important points to include are core indicators not complied with, high performing or low performing hospital areas and the general performance on the different Benchbook performance areas. In contrast, the hospitals using this same process for their self-assessment need to do the computations and fill out the third part of the Benchbook forms – Benchbook Self-assessment Summary.

7. Closing conference Again, the survey team meets with the hospital top management and summarizes the findings of the survey. Percentage compliance for each performance area and the accreditation award achieved by the hospital is not part of the summary given to the hospital. The results of the survey will be forwarded to the Accreditation Committee for deliberation. The recommendations are forwarded to the PhilHealth president for decision.

B. Hospital Self-assessment

The self-assessment is a venue for the hospital to assess its own strengths and weaknesses and evaluate what it already has and what it still needs. It is an evaluation of the hospital’s own performance measured against the standards, criteria and indicators of the Benchbook. Also, it allows the hospitals to demonstrate to the PhilHealth surveyors their level of achievement of the Benchbook indicators. The process described in The PhilHealth Survey Process under Chapter III: Conduct Of Self-Assessment/Survey may be adopted by the hospital or they may devise their own way of conducting the self-assessment and accomplishing the Benchbook and Self-assessment and Survey Forms. Should the hospital choose to adopt the PhilHealth survey process, then the first step is to form a self-assessment survey (SAS) team of three who will conduct the survey. The SAS team may consist of employees from the hospital or independent quality/technical experts commissioned by the hospital. The SAS team shall simulate the PhilHealth survey – review the documents of the hospital, interview the top management, tour the entire hospital facility, interview doctors, patients and nurses and review patient charts, and in the process accomplish the Benchbook and Self-assessment and Survey Forms (self-assessment and survey tool, score sheet and self-assessment summary). The hospital management should decide, based on the results of the self-assessment, which accreditation award to apply for. For the detailed discussion of the accreditation award and scoring, please refer to Chapter IV. The hospitals need to do the self-assessment at least once a year, in time with the application for accreditation. However, the hospitals may choose to do it more frequently depending on their targets.

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CHAPTER IV: COMPUTATION OF SCORES For the Benchbook accreditation, the hospitals will need to compute for their percentage of compliance. Depending on their computed scores, the hospitals may apply for and be given any of the following awards (Table 18): center of excellence, center of quality or center of safety. The minimum award a hospital may be given is the center of safety award. To qualify as center of safety, the hospital must have 100% compliance to all applicable CORE indicators (from all 7 performance areas) and 60% compliance to patient’s rights and organizational ethics, 60% compliance to patient care and 60 % compliance to safe practice and environment. For center of quality, the hospital must comply with 3 more performance areas: leadership and management, human resource management and information management. Also, there is a higher percentage requirement: 75% for each of the six enumerated performance areas. For the highest award – center of excellence, the hospital needs 90% compliance to each of the seven performance areas. For all three awards, the hospital must comply with 100% or all of the applicable CORE indicators. A summary of the accreditation awards is in Table 18.

Table 18. Summary of Accreditation Awards AWARD REQUIREMENTS

Center of Excellence Compliance to 100% of CORE indicators AND 90% Compliance to each of the 7 performance areas

Center of Quality

Compliance to 100% of CORE indicators AND 75% Compliance to each of the following:

• Patient’s Rights and Organizational Ethics • Patient Care • Leadership and Management • Human Resource Management • Information Management • Safe Practice and Environment

Center of Safety

Compliance to 100% of CORE indicators AND 60% Compliance to each of the following:

• Patient’s Rights and Organizational Ethics • Patient Care • Safe Practice and Environment

In case a hospital does not meet the requirements for the minimum accreditation award (center of safety), it is not automatically denied accreditation. If the percentage compliance of the hospital to each of the safety standards – patient rights and organizational ethics, patient care and safe practice and environment, is at least 50% and the hospital has complied with at least 70% of the CORE indicators, then the hospital may be given provisional accreditation. Additional requirements for provisional accreditation include a temporary plan of action to address the gap and a plan for attainment of the minimum accreditation award including the time of achievement. The hospitals given provisional accreditation shall be monitored by their respective PhilHealth Regional Offices and will be given 6 months to correct the deficiencies. The hospital will be assessed at the end of six months and shall be given the appropriate accreditation decision. The computation of percentage compliance for each performance area involves a series of steps which starts with the consolidation of findings from all 15 sections (or whichever are applicable to the hospital) of the self-assessment and survey tool during the surveyor meeting (see Chapter III)

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The succeeding section discusses in detail the procedure for the computation of the percentage compliance for each performance area. A. Self-assessment and Survey Tool

The first step in the computation of scores is the finalization of findings for each evidence in all sections of the self-assessment and survey tool. All blanks should have been filled in. Generally, for qualitative indicators (refer to Chapter I), a ���� is used to indicate compliance with the evidence; an X to indicate noncompliance; and NA to indicate that the evidence is not applicable to the hospital. However, some evidences of qualitative indicators require the surveyor to get samples. In these cases, the proportion of samples evaluated expressed as fraction is indicated in the REMARKS column. Table 19 shows examples of such evidences. In indicator 1.5.a.2, the remarks column indicates that during the self-assessment of the hospital, 5 HR staff were interviewed and all 5 satisfactorily validated the presence and the implementation of programs of the hospital on awareness on codes of professional conduct (HOSP – 5/5). During the PhilHealth survey, however, only 4 of the 5 interviewed were able to validate the programs (PHIC – 4/5). Nonetheless, the hospital still gets a � for the evidence. For evidences of qualitative indicators that require a sample, a hospital area is said to be compliant if more than 50% of the samples satisfy the requirements of the evidence. Thus in the example, indicator 1.5.a.2, the hospital area was considered compliant (�) because 80% of the staff were able to validate the program.

Table 19. Sample of Qualitative Indicators Requiring Samples For quantitative indicators (refer to Chapter I), instead of a � or an X, the proportion of samples evaluated expressed as fraction is indicated in the blank space under the HOSP (for hospitals) and PHIC (for PhilHealth surveyors) columns. This is illustrated in Table 20.

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Table 20. Sample of Quantitative Indicators

B. Score Sheet

The second step is the consolidation of findings from all the 15 sections of the self-assessment and survey tool. The surveyor team will go through each indicator and agree, based on the findings during the tour of the different areas and guided by column 5 (SECTION) of the score sheet (see Table 10), on the score for every indicator. An indicator may be appropriated in one or more sections and should be consistently implemented in all those sections. To consolidate findings for each indicator, the surveyors (SAS team or PhilHealth) should: 1. Look at each enumerated section and make sure all applicable blank spaces are

filled in. Column 5 of the score sheet shows all the applicable sections per indicator (Table 10).

2. For each section, count the number of evidences complied with (����) by the hospital. 3. Determine which among the enumerated sections has the lowest ratio of complied

evidences (����’s) versus the available evidences (����’s + X’s) (Figure 5). Note that if an evidence is not applicable in that section (NA), then this is not included in the total count of evidences for that indicator in that section, hence is not included in the formula.

Figure 5.

When determining the section with the lowest ratio based on the formula in Figure 5, only 13 sections are considered –chart review, wards, emergency room, OPD, ICU, operating room, imaging, laboratory, human resource, medical records, pharmacy, facilities and maintenance and others. The document review and the leadership interview sections are never considered unless they are the only sections enumerated for that indicator. An example is shown in Tables 21 to 24. Indicator 1.2.b.1 is evaluated in 4 sections: document review, ER, wards and ICU (refer to Table 26, fifth column). Notice that in Table 21, only the document review was assessed. The findings in the document review session, as recorded in the document review section, apply to the same evidences found in the other sections. Therefore, the same findings (���� for policies

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and procedures on involvement of patients and their families in making decisions on their health care…) may be noted in all sections (document review, ER, wards and ICU). This also means that the document review evidences need not be assessed in the other enumerated sections once evaluated during the document review session. However, the findings are recorded in all the applicable sections. To determine the section with the lowest ratio, each section is assessed individually. For 1.2.b.1, only 3 of the 4 sections are considered. The document review section is not part of the sections considered during consolidation.

Table 21. Sample of Section 1 – Document Review

Table 22. Sample of Section 4 - Wards

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Table 23. Sample of Section 5 – Emergency Room

Table 24. Sample of Section 7 – Intensive Care Unit In Table 22 (Section 4 – Wards), of the three evidences enumerated, all of which are applicable in the area, only two of the three evidences have been complied with (����). In Table 23 (Section 5 – ER), only two of the three evidences are applicable and both have been complied with. In Table 24 (Section 7 – ICU), all three evidences are applicable but only two of the three have been complied with. To summarize:

Table 25. Summary of findings for Indicator 1.2.b.1 (Based on Tables 21 to 24)

Section Ratio [����/(���� + X)] Source

Section 1 – Document review Not considered Table 21 Section 4 – Wards 2/3 Table 22 Section 5 – ER 2/2 Table 23 Section 7 – ICU 2/3 Table 24

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The lowest ratio based on the findings is 2/3 – wards and ICU (Table 25). In such cases when two or more sections have equivalent ratios, any of the sections may be used for recording to the score sheet. In Table 26, Section 4 – Wards (Table 22) was used.

Table 26. Sample of Score Sheet showing the consolidated findings and the self-assessment score for a qualitative indicator For quantitative indicators, as was discussed in Chapter IV. A, instead of ����’s and X’s, the proportion of samples evaluated expressed as fraction is indicated in the blank. In consolidating therefore, the section with the smallest fraction is selected.

Table 27. Sample of Section 5 – Emergency Room

Table 28. Sample of Section 6 – Outpatient Department

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Table 29. Sample of Score Sheet showing the consolidated findings and the self-assessment score for a quantitative indicator.

4. Input the findings from the selected section into columns 2 – HOSP (for SAS team) or

3 – PHIC (for PhilHealth surveyors). 5. After consolidating the findings, the hospital can now be scored per indicator. For

this, the scoring scale is used as a reference (Table 30).

Table 30. The Scoring Scale

For qualitative indicators, the number of ����’s is divided by the total number of evidences for the indicator (Evidences marked as not applicable are not included in the count). The quotient is then converted to percentage and the equivalent score is determined based on the scoring scale. For quantitative indicators, the fraction is converted to percentage and the corresponding score is determined using the scoring scale. In Table 26, 1.2.b.1, a qualitative indicator, has three evidences and 2/3 or 66.67% has been complied with. Based on the scoring scale, the indicator score is 3, hence, 3 is encircled. In Table 29, 2.1.1.c.1, a quantitative indicator, has only one evidence with 5/10 compliance (Figure 20) or 50%. Using the scoring scale, the equivalent score is 3.

C. Self-assessment Summary

The Self-assessment Summary, the last of the three parts of the Benchbook Self-assessment Forms (see Figure 4), is accomplished by the hospital only. This form will show the final percentage compliance of the hospital for each performance area and thus will serve as their guide in determining which accreditation award to apply for. The following are the steps to get the percentage compliance for each performance area:

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1. Compute for the score for each criterion.

The criterion score is the average of all the core and non-core indicator scores, (also known as the self-assessment score or the surveyor score) under that criterion. It is thus necessary to determine which indicators are under which criterion. As mentioned in Chapter I: Benchbook Indicators under C. Code, the letter codes always denote the criterion. The letter codes are used to identify the criterion and the indicators under it. Each change in the letter code denotes a different criterion. For example, in Table 31, which shows the performance area Improving Performance, 7.1.x.1 is the lone indicator for criterion 7.1.x; 7.2.a.1, 7.3.x.1, 7.4.x.1, 7.5.x.1 and 7.7.x.1 are also all lone indicators for their criterion – 7.2.a, 7.3.x, 7.4.x, 7.5.x and 7.7.x respectively. In contrast, criterion 7.2.b and 7.6.x both have 3 indicators under them – 7.2.b.1, 7.2.b.2 and 7.2.b.3 and 7.6.x.1, 7.6.x.2 and 7.6.x.3, indicated by the boxes. To get the average of the indicator scores, the sum of the indicator scores is computed and then divided by the number of indicators and can be summarized as follows:

2. Get the sum of all the criterion scores for each performance area. 3. Count the number of applicable criteria for each performance area. Criteria that are

not applicable for the hospital should not be included. 4. Compute for the maximum possible score for each performance area.

The maximum possible score is computed as follows:

5. Compute for the percentage compliance per performance area or performance area score. The formula for the performance area score is:

The steps are repeated until all performance area scores for all seven performance areas have been computed. The results are then recorded in the Benchbook Self-assessment Summary. SAMPLE COMPUTATION: The step-by-step process of computing the performance area scores will be illustrated using the sample score sheet in Table 31. Table 31 shows the hypothetical self-assessment scores of a hospital for the last performance area of the Benchbook – Improving Performance.

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Table 31

Step 1: For criteria with lone indicators, the criterion score is equivalent to the indicator score: Criterion score = indicator 1 ÷ 1

= indicator 1 Hence, the indicator scores for 7.1.x.1, 7.2.a.1, 7.3.x.1, 7.4.x.1, 7.5.x.1 and 7.7.x.1 (which are all lone indicators) will also be the criterion scores (refer to Table 31). For 7.2.b and 7.6.x, the computation is as follows: 7.2.b = (7.2.b.1 + 7.2.b.2 + 7.2.b.3) ÷ 3

= (3 + 3 + 1) ÷ 3 = 7 ÷ 3 = 2.33

7.6.x = (7.6.x.1 + 7.6.x.2 + 7.6.x.3) ÷ 3

= (4 + 1 + 1) ÷ 3 = 6 ÷ 3 = 2

A summary for the computation of criterion scores is found in Table 32.

Table 32. Summary of Criteria Scores

CODE SELF-ASSESSMENT

SCORE CRITERION

SCORE

7.1.x.1 core

4 4

7.2.a.1 4 4 7.2.b.1 3

2.33 7.2.b.2 3 7.2.b.3 1 7.3.x.1 3 3 7.4.x.1 3 3 7.5.x.1 1 1 7.6.x.1 core

4 2

7.6.x.2 1 7.6.x.3 1 7.7.x.1 3 3

Steps 2 and 3:

Steps 2 and 3 are straightforward. The sum of all the criterion scores is:

Sum of criterion scores = 4 + 4 + 2.33 + 3 + 3 + 1 + 2 + 3 = 22.33

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The total number of criteria for improving performance is 8. Criteria with ‘x’ codes which technically don’t have criteria are also counted because in these instances, the standard serves as the criterion.

Step 4: As counted in step 3, there are 8 criteria for improving performance. The maximum possible score is computed as follows:

Maximum Possible Score = 8 x 4 = 32

Step 5:

The performance area score is computed as follows:

Performance Area Score = (22.33 ÷ 32) x 100 = 0.6978 x 100 = 69.78 %