ISO QMS INSTITUTIONALIZATION

Determined to attain an accreditation certifiable to ISO by July 2013, the BMC QMS Committee, upon authorization by Management, conducted from March 19 to 26, 2013 at the BMC Auditorium, an Orientation on ISO QMS Institutionalization for a total of twelve (12) sessions to accommodate all members of the BMC Staff.The BMC QMS Committee believes that equally important to Management Commitment as an Element of Success is an organization-wide participation, cooperation and support.

 

Repeatedly, for the morning and afternoon sessions, members of the BMC QMS painstakingly explained, discussed and expounded on the following topics:

*Overview of ISO QMS, Quality Policy, Quality Objectives, Status Report
    - Ms. Wilhelmina de Castro
    - Ms. Sherill Anne Nepomuceno
*5s (Work Area Organization)
    - Dr. Marifee Reyes
    - Ms. Daisy Andal
    - Ms. FelecitaRegalado
*Documentation
    - Dr. Sancho Tolentino
    - Ms. LinaPatoc
*Internal Quality Audit
    - Dr. RaymundoIbarrientos
    - Ms. Virginia Portuguez

 

Ms. De Castro and Ms. Nepomuceno communicated the QMS Major Activities – QMS Institutionalization, QMS Implementation and ISO 9001 Certification. BMC Road Map was shown to ensure that everyone understands his/her role so that BMC can get there. The QMS Structure was illustrated and described and how each Committee fits into the larger BMC ISO QMS Committee. Quality was redefined as a single management system, delighting the customer and everyone’sresponsibility.

 

Mention was made of the DOH Major Initiatives (Initiatives for Good Governance), i.e. Client Survey, Social Dialogue, Integrity Development Review, Performance Governance System Balanced Scorecard and Universal Health Care Thrusts and Strategies to effectively establish connection with BMC’s decision to start its quality journey, as well as their congruence with the BMC Philosophy, Mission and Vision.

 

To reinforce the Cluster Meetings had on establishment of Quality Objectives, Cascading of Objectives and Measures starting from the Hospital Quality Objectives to the Service/Division Objectives, down to the Unit/Section/Department Objectives, and finally, to Individual Objectives was discussed to underscore BMC’s objective that its people are its most valued assets.

 

The Quality Objectives are anchored on the BMC Quality Policy stated below:

 

QUALITY POLICY
We are committed to serve the Bicolanos
with the highest standard of health care
in compliance with statutory and regulatory requirements
as we aspire for excellence
and continual improvement
in all our services
to achieve customer satisfaction.

Resource Speakers on 5s emphasized on the benefits of 5s to understand 5s more, i.e. workplace becomes clean and organized, work becomes easier, results are visible to everyone, visible results trigger generation of more and new ideas, people are automatically disciplined, people become proud of well-organized workplace, resultant good company image generates more business, boosts employee morale, helps to quickly identify the root cause of a problem, and helps to determine the relationship between different root causes.

 

5s can be learned quickly and does not require statistical analysis to be used:

  • Sorting Out – get rid of what is not needed
  • Setting in Order – a place for everything and everything in its place
  • Sweeping/Shine - clean and maintain
  • Standardizing – make it as standard
  • Sustain – audit the system and improve it

 

The topic was closed with the key point that "Changing our workplace involves changing our attitudes".

Documentation is essentially clause 4 of the International Standard. Ms. Patoc encouraged an interactive discussion to translate ISO into friendlier terms. Accordingly, there should be no Non-Conformity (NC) in clause 4, otherwise the QMS collapses. The primary function of the Documentation Committee is Control of Records and Documents. Precisely, the activity (orientation) was conceived because the Documentation Committee has a dearth of the QMS requirements, i.e. Quality Manual, six (6) Quality Procedures, Quality Core Procedures, Quality Objectives Retention and Disposition Schedule in accordance with NAP Guidelines, SOIs/WI. The difference between a document and a record was given emphasis (the former tells what/when/who/where how to do (prescriptive), while the latter tells what has been done (descriptive). Distinction was made between internal documents (owned by BMC and with BMC as originator) and external documents (referenced to establish conformance with statutory and regulatory requirements, i.e. CSC Law and Rules, Republic Acts, COA and DBM Guidelines, PhilHealth Accreditation Standards, etc.).

 

At present, the Documentation Committee is establishing a Coding System anchored on the BMC Organizational Structure. In close coordination with the ISO Core Team, the Committee ensures that all documents undergo the required and established process for origination, review, approving, identification, revision and distribution.

 

For a better appreciation of the various documents and records being required from all hospital areas, distinction between and among the five (5) types of document copy was done:

  • Master Copy    -retained by the Documentation Control Office
  • Controlled Copy -distributed and kept updated for revision/s
  • Uncontrolled Copy -does not need to be updated
  • Reference Copy – used for revision
  • Obsolete Copy-revised and retrieved for proper filing and disposal

 

Ms. Patoc emphasized that once accredited, only those documents stamped Controlled or Uncontrolled could be used as official references. Any document without the stamp is not considered official.

 

Important points on Documentation were explained exhaustively, citing specific examples where necessary:

  • There is only one (1) identification number for every document;
  • Originals must be submitted to the Documentation Committee and stamped as Master Copy on all pages (and received, first page only);
  • The Documentation Committee determines the distribution of documents;
  • Documents are updated once every six (6) months;
  • Distributed copies are stamped Controlled on each page and stamped issued (first page only);
  • If there is any change, the originator must use the Document Change Notice form. For any revision, the Document Revision Record must be used;
  • The respective Unit/Department/Section/Service has the responsibility for the filing and storage of their respective records;
  • Documents must remain legible. Fax and thermal papers are not allowed;
  • Corrections must be done the legal way (Write a straight line on the entire word to be corrected, indicate print name and signature, and affix the date the correction was made);
  • The Documentation Control Office has no Master copy for external documents, but a Master List must be maintained;
  • Disposition must follow the NAP Guidelines. Records declared as obsolete could be recycled, shredded or sold.

 

The last topic was Internal Quality Audit (IQA). IQA is a systematic, independent and documented process for obtaining audit evidence and conducting it objectively to determine the extent to which the criteria are fulfilled. Simply put, it is doing what we have written. The DOH Audit Procedure was discussed to better understand the Audit Life Cycle (Planning, Conducting, Monitoring, and Reporting), as well as definitions of audit terms used. Audit Methodology adopts the PDCA (Plan, Do, Check, Act) approach. Minor NC’s were differentiated from major NC’s.

 

Resource Speakers closed the topic on IQA by sharing the best conclusion of an internal audit, as follows:
Technical preparedness of ISO QMS and everyone involved;
Professional Approach – right auditor-auditee relationship (mutual venture), and mutual courtesy.

 

Lina R. Patoc, MRM

ISO Documentation Committee