Department of Health BUREAU OF HEALTH FACILITIES AND … · Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES ANNEX – E A.O. No. 2012-0012 B. Quality Management Quality

Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

ANNEX – E A.O. No. 2012-0012

ANNUAL HOSPITAL STATISTICAL REPORT

YEAR 2014

Name of Hospital: DR.JOSE FABELLA MEMORIAL HOSPITAL Street Address : Lope De Vega Sta Cruz ,Manila

Municipality: __________________ Province ____________________ Region: National Capital Region___________

Contact No.: 7345561 Fax Number: __________________________________

Email Address: ____________________________________________________________________________________

(PLEASE FILL OUT ALL ITEMS. PUT N/A IF NOT APPLICABLE.)

I. GENERAL INFORMATION

A. Classification

1. Service Capability

Service capability: Capability of a hospital/other health facility to render administrative, clinical,

ancillary and other services

General: Specialty: (Specify)

[ ] Level 1 Hospital [ ] Treats a particular disease (Specify):___________

[ ] Level 2 Hospital [ ] Treats a particular organ (Specify):_____________

[ ∕ ] Level 3 Hospital (Teaching/ Training) [ ] Treats a particular class of patients (Specify):_____

[ ] Others (Specify):____________

Trauma Capability: [ ] Trauma Capable [ ] Trauma Receiving

2. Nature of Ownership

Government: Private:

[ / ] National –DOH Retained/ Renationalized [ ] Single Proprietorship/Partnership/Corp.

[ ] Local (Specify): [ ] Religious

[ ] Province [ ] Civic Organization

[ ] City [ ] Foundation

[ ] District [ ] Others (Specify):________________

[ ] Municipality

[ ] DND/ DOJ

[ ] State Universities and Colleges (SUCs)

[ ] Others (Specify):_________________

HOS-Stat Report Form Revision:02

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Page 1 of 16



ANNEX – E A.O. No. 2012-0012

B. Quality Management

Quality Management/ Quality Assurance Program: Organized set of activities designed to

demonstrate on-going assessment of important aspects of patient care and services

[ ] ISO Certified (Specify ISO Certifying Body and

area(s) of the hospital with Certification) Validity Period ____________

[ ] International Accreditation Validity Period ____________

[ ] PhilHealth Accreditation Validity Period: December 31, 2015

[ / ] Basic Participation

[ ] Advanced Participation

[ ] PCAHO Validity Period ____________

C. Bed Capacity/Occupancy

1. Authorized Bed Capacity: 700 beds

Authorized bed: Approved number of beds issued by BHFS, the licensing agency of DOH.

2. Implementing Beds: 496 beds

Implementing beds: Actual beds used (based on hospital management decision)

3. Bed Occupancy Rate (BOR) Based on Authorized Beds: _______%

(Total Inpatient service days for the period)**

(Total number of Authorized beds) x (Total days in the period) X 100

Bed Occupancy Rate: The percentage of inpatient beds occupied over a period of time. It is a

measure of the intensity of hospital resources utilized by in-patients.

Inpatient Service days: Unit of measure denoting the services received by one in-patient in one 24

hour period.

**Inpatient Service days (Bed days) = [(Inpatients remaining at midnight + Total admissions) – Total

discharges/deaths) + (number of admissions and discharges on the same day)].

Bed Occupancy Rate (BOR)

A. Based on Authorized Bed

Including Newborn = 167.96%

Excluding Newborn=73.24%

B. Based on Implementing Bed

Including Newborn = 237.03%

Excluding Newborn=103.36%


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ANNEX – E A.O. No. 2012-0012

II. HOSPITAL OPERATIONS

A. Summary of Patients in the Hospital

For each category listed below, please report the total volume of services or procedures performed.

*Inpatient: A patient who stays in a health facility while under treatment.

*Bed day: Bed used for a continuous 24 hours by an inpatient.

Inpatient Care

Number

Total number of inpatients (admissions, including newborns)

54,322

Total Discharges (Alive)

52,089

Total patients admitted and discharged on the same day

96

Total number of inpatient bed days (service days)

429,128

Total number of inpatients transferred TO THIS FACILITY from another

facility for inpatient care

2,457

Total number of inpatients transferred FROM THIS FACILITY to another

facility for inpatient care

31

Total number of patients remaining in the hospital as of midnight last day of

previous year 563


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ANNEX – E A.O. No. 2012-0012

B. Discharges

Kindly accomplish the “Type of Service and Total Discharges According to Specialty” in the table

below.

Type

of

Service

No of

Pts

Total

Length

of

Stay/ Total No. of

Days Stay

Type of Accomodation

Non- Philhealth

Philhealth

H

M

O

O

W

W

A

Pay

Service

Charity

Total

Pay

Service

Total

Member

/

Depend

ent

Indi-

gent

Obstetrics 23,736 131,423 236 20,146 20,382 754 2,227 350 3,331 - 23

Gynecology 786 14,938 30 - 30 98 562 80 740 - 16

Pediatrics 1,321 9,645 - 714 714 - 523 81 604 - 3

Surgery: 11 74 - 11 11 - - - - - -

Pedia

Adult

Others, Specify

TOTAL 25,854 156,080 266 20,871 21,137 852 3.312 511 4,675 - 42

Total Newborn

-Pathologic 8,738 31,051 - 3,366 3,366 - 4,613 731 5,344 - 28

-Non-Pathologic 18,383 242,005 - 13,758 13,758 - 4,061 537 4,598 - 27

Grand Total 52,975 429,136 266 37,995 38,261 852 11,986 1,779 14,617 - 97

CONDITION ON DISCHARGE

Type

of

Service

R/I

T

H

A

U Deaths

Discharges

< 48 hrs > 48 hrs Total

Obstetrics 23,630 13 30 51 - 7 5 12 23,736

Gynecology 780 1 - 1 - 0 4 4 786

Pediatrics 1,231 5 6 - - 36 43 79 1,321

Surgery: 11 - - - - 11

Pedia

Adult

Others, Specify

TOTAL 25,652 19 36 52 - 43 52 95 25,854

Total Newborn

-Pathologic 6,531 - 614 - - 318 469 787 7,932

-Non-Pathologic 19,185 - - - - 2 2 4 19,189

Grand Total 51,368 19 650 52 - 363 523 886 52,975

* R/I – Recovered/Improved T- Transferred U – Unimproved

H- Home Against Medical Advice A – Absconded D – Died (died upon admission)


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ANNEX – E A.O. No. 2012-0012

1. Average Length of Stay (ALOS) of Admitted Patients

Total length of stay of discharged patients (including Deaths) in the period = _________________

Total discharges and deaths in the period

Average length of stay: Average number of days each inpatient stays in the hospital for each episode

of care.

Including Newborn = 7.92 days

Excluding Newborn =5.47 days

2. Ten Leading causes of Morbidity based on final discharge diagnosis

For each category listed below, please report the total number of cases for the top 10 illnesses/injury.

Cause of Morbidity/Illness/Injury Number ICD-10 Code

(Individual)

1. Spontaneous Delivery by Low Risk

10,166 O80.0

2. Delivery by Cesarean Section

6,296 O82.0

3. Spontaneous Delivery by High Risk

3,504 O90.0

4. Complete Abortion ( all types )

1,247 O03.9

5. Neonatal Pneumonia

1,227 P23.1

6. Potentially Septic

873 P36.9

7. Sepsis all forms

724 P36.0

8. Pneumonia 519 J18.9

9. Pediatric Community Acquired Pneumonia

423 J18.9

10. Septic Shock

403 A41.9


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ANNEX – E A.O. No. 2012-0012

Kindly accomplish the “Ten Leading Causes of Morbidity/Diseases Disaggregated as to Age and Sex” in the table below.

Spell out. Do not

AbbreviateM F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

1. Spontaneous

Delivery by Low Risk0 0 0 0 0 0 0 0 0 2012 0 3192 0 2304 0 1820 0 832 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 10166 10166 243

2. Delivery by

Ceasarean Section0 0 0 0 0 0 0 15 0 536 0 1503 0 1434 0 1478 0 989 0 325 0 16 0 0 0 0 0 0 0 0 0 0 0 6296 6296 242

3. Spontaneous

Delivery by High Risk0 0 0 0 0 0 0 78 0 831 0 358 0 244 0 323 0 871 0 762 0 37 0 0 0 0 0 0 0 0 0 0 0 3504 3504

4. Complete Abortion

(all types)0 0 0 0 0 0 0 1 0 143 0 298 0 284 0 239 0 171 0 101 0 10 0 0 0 0 0 0 0 0 0 0 0 1247 1247 236

5. Neonatal

Pneumonia539 688 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 539 688 1227 249

6. Potentially Septic 463 410 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 463 410 873 245

7. Sepsis (all forms) 389 335 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 389 335 724 250

8. Pneumonia 287 225 2 3 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 290 229 519 169

9. Pediatric

Community Acquired

Pneumonia

260 163 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 260 163 423 169

10. Septic Shock 235 163 1 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 236 167 403 017

65 - 69 70 & Over Subtotal

TOTALICD-10

CODE /

TABULA

R LIST

Age Distribution of Patients

35 - 39 40 - 44 45 - 49 55 - 5950 - 54 60 - 6415 - 19 20 -24 25 - 29 30 - 34

Cause of Morbidity

(Underlying)Under 1 1 - 4 5 - 9 10 -14


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ANNEX – E A.O. No. 2012-0012

11. Total Number of Deliveries

For each category of delivery listed below, please report the total number of deliveries.

Deliveries

Number ICD-10 Code

Total number of in-facility deliveries 20,344 Z38.0

Total number of live-birth vaginal deliveries (normal)

13,670 O80.0

Total number of live-birth C-section deliveries (Caesarians)

6,261 O82.0

Total number of other deliveries

Breech Extraction

Delivery by Forceps Extraction

292

86

O83.0

O81.0

12. Outpatient Visits, including Emergency Care, Testing and Other Services

For each category of visit of service listed below, please report the total number of patients receiving the care.

Outpatient visits

Number

Number of outpatient visits, new patient

35,223

Number of outpatient visits, re-visit

52,289

Number of outpatient visits, adult

67,146

Number of outpatient visits, pediatric

20,366

Number of adult general medicine outpatient visits

4,724

Number of specialty (non-surgical) outpatient visits

1,328

Number of surgical outpatient visits

143

Number of antenatal care visits

35,473

Number of postnatal care visits

4,112


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ANNEX – E A.O. No. 2012-0012

Emergency visits

Number

Total number of emergency department visits

9,129

Total number of emergency department visits, adult

7,948

Total number of emergency department visits, pediatric

1,181

Total number of patients transported FROM THIS FACILITY’S

EMERGENCY DEPARTMENT to another facility for inpatient care

5

Testing

Number

Total number of medical imaging tests (all types including x-rays, ultrasound,

CT scans, etc.)

26,660

Total number of laboratory and diagnostic tests (all types, excluding medical

imaging)

269,505

Other services and diseases seen

Number

Total number of outreach or home visits

10

Total number of immunization doses administered to children 0-59 months at

this facility or during outreach or home visits. Include immunizations

administered during child health weeks.

45,621

Total number of newly diagnosed cases of TB

( OPD cases )

13

Total number of confirmed cases of dengue

27

C. Deaths

For each category of death listed below, please report the total number of deaths.

Types of deaths

Number

Total deaths

886

Total number of inpatient deaths

Total deaths < 48 hours 363

Total deaths > 48 hours 523


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ANNEX – E A.O. No. 2012-0012

Total number of emergency room deaths

1

Total number of cases declared ‘dead on arrival’

1

Total number of stillbirths

395

Total number of neonatal deaths

791

Total number of maternal deaths

12

1. Gross Death Rate= 1.67%

Gross Death Rate = Total Deaths (including newborn for a given period)

Total Discharges and Deaths for the same period x 100

2. Net Death Rate= 1.00%

Net Death Rate = Total Death (including newborn for a given period) – death <48 hours for the period

Total Discharges (including deaths and newborn) – death<48 hours for the period x 100

3. Ten Leading Causes of Mortality/Deaths and Total Number of Mortality/Deaths.

Mortality/Deaths

Number ICD-10 Code

(Individual)

1. Septic Shock

403 A41.9

2. Respiratory Distress Syndrome

123 P22.0

3. Respiratory Failure

70 P28.5

4. Birth Asphyxia

49 P21.9

5. Disseminated Intravascular Coagulopathy

47 P60.0

6. Sepsis ( all forms )

19 P36.9

7. Persistent Pulmonary Hypertension

18 P29.2

8. Prematurity

15 P07.0

9. Multiple Congenital Anomaly

15 Q89.7

10.Anencephaly

14 Q00.0


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ANNEX – E A.O. No. 2012-0012

Kindly accomplish the “Ten Leading Causes of Mortality/Deaths Disaggregated as to Age and Sex” in the table below.

Cause of

Death (Underlying) Age Distribution of Patients

T O T A L

ICD-10 CODE/ TABULAR LIST Under 1 1 – 4 5 – 9 10 -14 15 –19 20 – 24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70 &

over Subtotal

Spell out. Do not abbreviate.

M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F M F

1.Septic Shock 235 163 1 0 0 0 0 0 0 0 0 2 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 236 167 403 3-009

2.Respiratory Distress Syndrome

76 47 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 76 47 123 3-042

3.Respiratory Failure 44 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 44 26 70 3-044

4.Birth Asphyxia 27 22 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27 22 49 3-041

5.Disseminated Intravascular Coagulopathy 24 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 23 47 3-047

24 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 23 47 3-047

6. Sepsis all forms 9 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 10 19 3-045

7. Persistent Pulmonary Hypertension

9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9 18 3-048

8.Prematurity 8 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 7 15 3-039

9.Multiple Congenital Anomaly

5 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 9 15 3-055

10..Anencephaly 5 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 9 14 3-051


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ANNEX – E A.O. No. 2012-0012

D. Healthcare Associated Infections (HAI)

HAI are infections that patients acquire as a result of healthcare interventions. For purposes of Licensing, the

four (4) major HAI would suffice.

For All Hospitals (Levels 1, 2, 3 General and Specialty)

INFECTION RATE = Number of Healthcare Associated Infections x 100

Number of Discharges

853 x 100

52,974

= 1.61 %

a. Device Related Infections

1. Ventilator Acquired Pneumonia (VAP) = Number of Patients with VAP x 1000

Total Number of Ventilator Days

147 x 1000

3,880

= 37.89 VAP/1,000 Ventilator days

2. Blood Stream Infection (BSI) = Number of Patients with BSI x 1000

Total Number of Central Line

622 x 1000

2,980

= 208.72 BSI/1,000 Central Lines

3. Urinary Tract Infection (UTI) = Number of Patients with UTI x 1000

Total Number of Catheter Days

9 x 1000

6,668

= 1.35 UTI/1,000 Catheter days

b. Non-Device Related Infections

Surgical Site Infections (SSI) = Number of Surgical Site Infections x 100

Total number of Procedures

49 x 1000

11,300

= 4.34 %


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ANNEX – E A.O. No. 2012-0012

E. Surgical Operations

1. Major Operation refers to surgical procedures requiring anesthesia / spinal anesthesia to be performed in an

operating theatre. (The definition of a major operation shall be based on the definitions of the different cutting

specialties ).

2. Minor Operation refers to surgical procedures requiring only local anesthesia /no OR needed, example suturing .

10 Leading Major Operations (

excluding Caesarian Sections )

Number

ICD-10 Code

1. Abdominal Hysterectomy 202 5-683

2. Salpingectomy 193 5-665

3. Salpingoophorectomy 80 5-653

4. Myomectomy 35 5-681

5. Oophorectomy 31 5-652

6. Cystectomy 21 5-575

7. Vaginal Hysterectomy 14 5-684

8. Laparotomy 14 5-541

9. Oophorocystectomy 4 5-651

10. Radical Hysterectomy 3 5-685

10 Leading Minor Operations

Number

ICD-10 Code

1. Laceration 5,006 O70.9

2. Episiotomy 4,698 5-738

3. Bilateral Tubal Ligation 4,328 Z30.2

4. Completion Curettage 915 5-690

5. Delivery by Breech Extraction 292 O80.1

6. Dilatation and Curettage 184 5-690

7. Delivery by Forceps Extraction 86 O81.0

8. Endometrial Curettage 78 5-690

9. Suction Curettage 57 5-690

10. Polypectomy 21 5-684


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ANNEX – E A.O. No. 2012-0012

2 STAFFING PATTERN (Total Staff Complement)

Profession/ Position/

Designation

Total staff working full time

(at least 40 hours/week)

Total staff working part time

(at least 20 hours/week)

Active

Rotating

or

Visiting/

Affiliate

(For

Private

Facilities)

Out-

sourced

Number of

permanent

staff

Number of

contractual

staff

Number of

volunteer

staff

Number of

permanent

staff

Number of

contractual

staff

Number of

volunteer

staff

A. Medical

1. Consultants (indicate One-

Peso consultant)

1.1. Internal Medicine

a. Generalist 1

b. Nephrologist 1

c. Surgery 1

1.2. Obstetrics/ Gynecology

(and subspecialty)

a.Reproductive

/Endocrinology/Infertility

2 1

b.Perinatology 1

c.Infectious Disease 1

d.Generalist 12

e.Ultrasound 1 2

f.Gynecologic Oncology 1 1

g.Trophoblastic Disease 1

h.Perinatology & Ultrasound 1

i.Maternal & Fetal Medicine 1

j.Perinatology/Maternal & Fetal

Medicine

1

1.3. Pediatrics

a.Generalist 4

b.Pediatric Intensive Care 1

c.Pedia Cardiology 1

d.Pediatric Infectious Disease 1

e.Nephrology 1

f.Pediatric Surgery 1

g.Developmental Pediatrics 1

h.Pediatric Gastroenterolog y&

Nutrition

1

i.Child Neurology 1

1.4 Surgery None None

1. 5 Anesthesiologist

a.Generalist 11 2

b.Pediatric Anesthesiology 1

1. 6 Radiologist

a.Generalist 1 1

b.Sonologist 1

1. 7 Pathologist

a.Generalist 2 3


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ANNEX – E A.O. No. 2012-0012

1. 8 Neonatologist

a.Neonatology 1 5

b.Post Graduate Fellows none none

c.Residents/Post Residents All residents and post residents are temporary

1.1 Internal Medicine

1.2 Obstetrical/Gynecology

1.3 Pediatrics

1.4 Surgery

B. Allied Medical

1. Nurses 174

2. Midwives 122

3. Nursing Aides 33

4. Nutritionist 8

5. Physical Therapist None

6. Pharmacists 23

7. Medical Technologist 22

8. Dentists 7

9. Midwifery School Pricipal 1

10. Chemists 2

11. Dental Aides 2

12. Laboratory Aides 8

C. Non-Medical

1. Social Workers 11

2. Medical Records Officer/

Hospital Health Information

Officer with formal training

in medical records

management

6

3. Laboratory Technicians 1

4. X-Ray Technicians 10

5. Administrative Officer 36

6. Accounting/ Finance Officer 3

7. General Support Staff

(maintenance, janitorial,

secretarial) – indicate if

outsourced

8. Medical Center Chief II 1

9. Chief,Medical Professional

Staff II

1

10. Engineers 2

11. Training Specialist 1

12. Health Education and

Promotion Officer

1

13. Statisticians 3

14. Computer Maintenance

technologist

2

15. Security Officer 1

16. Legal Assistants 1

17. Presidential Staff Assistant 1

18. Administrative Assistants 74

19. Hospital Housekeepers 3

20. Master Tailor 2

21. Training Assistants 2

22. Social Welfare Assistants 1

23. Administrative Aides 147

24. Laundry Workers 8

25. Cook 6

26. Security Guard 9

27. Seamstress 3

HOS-Stat Report Form

Revision:02

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ANNEX – E A.O. No. 2012-0012

3 EXPENSES

Report all money spent by the facility on each category.

Expenses

Amount in

Pesos

Amount spent on personnel salaries and wages

₱260,022,213.97

Amount spent on benefits for employees (benefits are in addition to wages/salaries.

Benefits include for example: social security contributions, health insurance)

36,257,406.60

Allowances provided to employees at this facility (Allowances are in addition to

wages/salaries. Allowances include for example: clothing allowance, PERA, vehicle

maintenance allowance and hazard pay.)

215,289,603.76

TOTAL amount spent on all personnel including wages, salaries, benefits and

allowances for last year (PS)

₱511,569,224.33

Total amount spent on medicines funded by the Revolving Fund

15,185,338.92

Total amount spent on medicines funded by the Government of the Philippines (from

any level of government, including the central, provincial and municipal

governments)

5,567,708.38

Total amount spent on medical supplies (i.e. syringe, gauze, etc.; exclude

pharmaceuticals)

45,462,032.63

Total amount spent on utilities

30,657,999.01

Total amount spent on non-medical services (For example: security, food service,

laundry, waste management)

31,267,116.24

TOTAL amount spent on maintenance and other operating expenditures

(MOOE)

₱128,140,195.18

Amount spent on infrastructure (i.e., new hospital wing, installation of ramps)

568,315.80

Amount spent on equipment (i.e. x-ray machine, CT scan) 7,123,656.16

TOTAL amount spent on capital outlay (CO) ₱ 7,691,291.96


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ANNEX – E A.O. No. 2012-0012

4 REVENUES

Please report the total revenue this facility collected last year. This includes all monetary resources acquired by this

facility from all sources, and for all purposes.

Revenues

Amount in

Pesos

Total amount of money received from the Department of Health None

Total amount of money received from the local government

None

Total amount of money received from donor agencies (for example JICA, USAID,

and others)

None

Total amount of money received from private organizations (donations from

businesses, NGOs, etc.)

None

Total amount of money received from Phil Health

137,380,956.15

Total amount of money received from direct patient/out-of-pocket charges/fees

53,082,722.33

Total amount of money received from reimbursement from private insurance/HMOs

None

Total amount of money received from other sources (PDAF, PCSO, etc.)

5,000,000.00

TOTAL Revenue

₱195,463,678.48

Report Prepared by : Emelita F. Sanchez

Designation/Section/Department : Statistician III Date: _______

Report Approved and Certified by : ____________________________ Date: _______

Chief of Hospital/Medical Director

_________________________________________________________________________________________________

PREPARED BY:

STANDARDS DEVELOPMENT DIVISION (SDD)

BUREAU OF HEALTH FACILITIES AND SERVICES (BHFS)

DEPARTMENT OF HEALTH (DOH)

APPROVED BY:

ATTY. NICOLAS B. LUTERO III, CESO III

ASSISTANT SECRETARY

DOH


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Documents

Department of Health BUREAU OF HEALTH FACILITIES AND … · Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES ANNEX – E A.O. No. 2012-0012 B. Quality Management Quality