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Written by NCMH CQI Team

Category: News and Events

Published: 10 December 2015

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The Department of Health mandated all of hospitals under its umbrella to be ISO certified. In line with this, the National Center for Mental Health had taken steps to become ISO certified. The main purpose of certification is to establish a Quality Management System that will enhance customer satisfaction, help us to be more effective and efficient as an organization, and provide us a framework for continuous improvement in giving quality mental health services. As we made steps towards our vision to become a globally-accepted mental health institution, it was upon us to show the world that we provide quality services that adhere to international standards.

NCMH’s journey towards ISO certification began last February 2014 when the hospital’s top management created the Quality Management Team that led the preparation of the Center towards certification. The Medical Center Chief Dr. Bernardino A. Vicente was the Overall Adviser to ISO Preparation together with the Quality Management Representative Dr. Venus Serra-Arain, Chief Medical and Professional Staff II for Community Service spearheading the Quality Management Team. The team was divided into five major clusters namely: Workplace Organization, Internal Quality Audit, Document & Records Control, Training & Education, and the Secretariat.

The project was launched to the public on March 6, 2014 with the theme “Tara na, mag-ISO tayo” through a whole-day activity aimed at increasing awareness about the initiative among our hospital’s personnel. It was then followed by a series of seminars and trainings which were conducted by our ISO Consultant, Ms. Darlene Page-Elnar. These include ISO Awareness, Process-Based Documentation Training & Workshop and the Internal Quality Audit Training which led to the 1st Internal Quality Audit in our hospital last July 8, 2014. Fifty eight personnel were appointed Internal Auditors and were tasked with auditing different areas of the entire hospital. Dr. Victor C. Vinluan served as the Lead Auditor during this exercise.

As the preparation progressed, we’ve undergone several changes to our processes including the paperwork that support these processes. Part of these changes include the publication of newly formatted procedure and support document manuals, creation of hospital and non-hospital forms compendium which included the transition of logbooks into record sheets, implementation of the new signage system and the establishment of preventive maintenance and calibration of all hospital and non-hospital equipment.

Another important activity that was successfully implemented was the introduction of the “7 ‘S’ of Quality Workplace” conducted by Ms. Page-Elnar last November 2014. This was followed by the launch of the ICC’s baseline swabbing and the implementation of The Red Tag System. These set the stage for the 2nd Internal Quality Audit last April 2015 and the “Search for the Most Outstanding Pavilion, Ward and Office of the Center.” Pavilion 3, Pavilion 2 – Emergency Room, and Clinical Laboratory Section emerged as the winners in their respective category.

Asec Gerardo V. Bayugo, the head of the Quality Management Systems Office of the DOH, visited the NCMH last August 7, 2015 together with his team to assess the current status of our preparations towards ISO certification. Their findings were very favourable and they expressed their excitement at what they saw. They said that the hospital is well on its way to being certified.

Upon the invitation of the DOH to attend the Comprehensive Internal Quality Audit Training conducted by InfoAdvance, Inc., this led to the 3rd Process-based Internal Quality Audit to assess the preparedness of our hospital for the pre-assessment conducted by the external auditors. This evaluates our conformance to the requirements of the standards and the implementation of all the documented processes that we have.

TÛV Rheinland Philippines, who emerged as the winning ISO Certifying Body conducted a Pre-Assessment last November 3 and 4, 2015 that evaluated the centers preparedness towards ISO Certification. Results of which yielded a green light which signified that NCMH was ready to proceed to the next phase, the Stage I Onsite-Document Review and Stage II Comprehensive Audit. A total of fifteen man-days of extensive audit was conducted, and the National Center for Mental Health successfully passed with flying colors and was ISO 9001:2008 Certified last December 2, 2015.

The strong commitment of the top management served as the moving force of the Quality Management Team and the whole NCMH organization to be ISO certified.

The road which led the center towards ISO 9001:2008 Certification was a rough and rugged one, beset with trials and hardship faced by the center. The passion and dedication, eagerness for change, continuous improvement, and quality service led us to fully accomplish the goals we set forth. Going back to the tagline used during the ISO preparation launching “Tara na, Mag-ISO na tayo” we may now proudly say, “Ito na! ISO na tayo!”.

But the road does not end here, as we are only at the start of our new journey to sustain and continually improved our Quality Management System (QMS) for the upcoming surveillance audits, which will prove to be more challenging for our beloved center. Getting certified is one thing, but keeping the certification is another, that is why we must continue to work together and set a common goal, which is to continually improve for our client’s satisfaction.