ANNEX B

OFFICE PERFORMANCE COMMITMENT AND REVIEW (OPCR) MONITORING OF ACCOMPLISHMENT

Targets Actual Accomplishment Achieved?

Organizational Outcome / (per Division/Unit Accountable) (per Division/Unit Accountable) Yes/No
DOH Program Objectives Success Indicators (c) (d) (e)
(b)
(a)
1st 2nd 3rd 4th
1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
Quarter Quarter Quarter Quarter
Core Functions (link to strategy and office mandate)

(PrExC Output Indicator)

(OPCR Prescribed Indicator

or Additional Proposed
Indicator)
Support Functions

Strategic Functions

Prepared by (f): Date: Validated and Approved by (g): Date:

Mitos Gonzales
Planning Officer IV Head of Office
 ANNEX F

Document Code:
OFFICE PERFORMANCE COMMITMENT AND REVIEW Revision No.:
QUARTERLY MONITORING OF ACCOMPLISHMENT Effectivity:
FY 2021 : 3rd Quarter**

Name of Office*: DR. JOSE NATALIO RODRIGUEZ MEMORIAL HOSPITAL AND SANITARIUM

Accomplishment of the Quarter

Strategic Goals and Objectives Success Indicators and Target Quarterly Target (d) Accomplishment Rate Remarks
(a) (b) (c) Raw Data Actual (e) (f)
(if applicable) Accomplishment

Strategic Functions

At least 87% compliance to

requirements of specialty centers N: 176
Compliance to standards of Specialty Centers: by the end of 2021 (Human Requirements are based on the Resource Stratified Framework for
87% 100%
a. Dermatology Center (176 complied / 203 required) Resource, Services, Dermatology Centers
Infrastructure, Equipment, Fund
Source) D: 203

At least 68% compliance to

requirements of specialty centers N: 50
1. Capacitate the hospital in providing specialized by the end of 2021 (Human Requirements are based on the Resource Stratified Framework for
services thru establishment of specialty centers. b. Infectious Disease and Tropical Medicine (50 complied / 73 required) 68% 100%
Resource, Services, Infectious Diseases and Tropical Medicine
Infrastructure, Equipment, Fund D: 73
Source)

At least 93% compliance to

requirements of specialty centers N: 89
by the end of 2021 (Human Requirements are based on the Resource Stratified Framework for
c. Trauma Center (89 complied / 96 required) 93% 100%
Resource, Services, Trauma Center
Infrastructure, Equipment, Fund D: 96
Source)

2. Operationalize an interated comprehensive N: 1852

100% of COVID-19 referrals SDN and Referral System are concentrated on COVID 19 patient
essential services in the context of Service Functional exclusive COVID 19 Service Delivery Network and Referral System 100% 100%
were admitted and managed referrals from other facilities
Delivery Network (SDN) D: 1852

Core Functions
Indicator 1: % patients in basic accomodation with zero co-payment N: 2806

No. of patients in basic accommodation with zero co-payment / Total no. of patients in ≥98% 100.00% 102%
D: 2806
basic accommodation x 100

Indicator 2: % of returned to Hospital PhilHealth claims N: 155

No. of PhilHealth RTH / Total no. of PhilHealth claims processed and RTH + claims <4% 2.87% 128%
D: 5406
processed and paid by PhilHealth x 100

Indicator 3: % of ER patients with < 4 hours turnaround time N: 1506 ER currently serves employees for pre and post COVID
deployment medical consultation. ER services for the general
public were put on hold since the conversion of the hospital to an
≥97% 100.00% 103%
exclusive referral center last March 2020. As per institutional
No. of ER patients with <4 TAT / Total no. of patients who were received in the ER x policy, a 24-hour turn around time is required to provide enough
D: 1506 time for the release of swab result.
100

Indicator 4: % of patients with < 4 hours Discharge Process turnaround time N: 1516
No. of patients with <4 hours Discharge Process TAT / Total no. of patients ≥90% 98.57% 110%
D: 1538
discharged x 100
Indicator 5: % of Hospital Acquired Infection Rate N: 30

<1% 1.62% 38%

3. Institutionalize People-centered Quality Care-

Patient Safety in Health Facilities Page 2 of
 Total no. of inpatients who had hospital acquired infection after 48 hours upon <1% 1.62% 38%
admission for the year / Total no. of discharges and deaths occurring after 48 hours D: 1850
upon admission during the same year x 100
3. Institutionalize People-centered Quality Care-
Patient Safety in Health Facilities Indicator 6: % of patients with < 5 hours turnaround time for laboratory tests results N: 9584 Changes in the process flow of specimen gathering, testing and
release has changed the normal turn around time for most
≥90% 100.00% 111% laboratory services catered due to COVID 19. Scheduled extraction
No. of inpatient laboratory test result with <5 hours TAT / Total no. of inpatient every 4 hours, the addition of specimen bottles disinfection,
D: 9584 donning and doffing procedures have impacted laboratory TAT.
laboratory tests x 100

ISO Certification sustained + At ISO: Certification ISO: Pending posting

least 1 PGS initiative towards lapsed as of July 5, of new Invitation to
Indicator 7: Accreditation to international accrediting bodies N: Bid having Negotiated ISO: Continue coordination with Procurement/BAC regarding the
Stage 1 at the end of every 2021 ISO 9001:2015
quarter PGS: On-going Stage 1 Procurement as procurement process.
certification lapsed as
alternative mode.
of July 5, 2021 + On-
PGS: Organizational PGS: Facilitate remaining PGS Initiation Stage interventions (Pre-
going PGS Stage 1
Assessment were revalida and Revalida) as scheduled.
completed as
scheduled.
ISO + PGS Stage 1 ISO + PGS Stage 1 D: ISO + PGS Stage 1

Indicator 8: Report Card Survey (RCS) Scores (Randomly selected hospitals by

N: 791
National Report Card Survey)
(1) Compliance with ARTA provisions ≥90% 99.75% 111%
D: 793
(2) Overall Client Satisfaction

Indicator 9: 7 Research Outputs for the year N: 4

2 research outputs per quarter 200% 200%
Total no. of clinical and/or operational improvement research output funded by the
Budget Utilization D: 2
hospital and/orRate for FYto2021:
presented a local/international consortium and conference
Support Functions
Total obligations for FY 2021 / Total FY 2021 DBM a)approved CorporateUtilization
95% Obligation Operating At least 75% Obligation for the N: ₱ 1,333,337,830.54
78% 104%
Rate at the end of the year Budget (net50%
or at least of Personnel
by the endService)
of 1st semester 3rd quarter D: ₱ 1,701,046,113.76
4. To ensure efficient utilization of DOH funds b) 80% Disbursement Utilization Rate at the end of the year or at least 40% by the
N: ₱ 1,231,777,564.39
end of 1st semester At least 60% Disbursement for
92% 153%
Total disbursements for FY 2021 / Total obligations for FY 2021 the 3rd quarter D: ₱ 1,333,337,830.54

5. Establish program planning, monitoring and 100% submission for the 3rd N: 3
% of required hospital performance indicators and reports submitted on time (OPCR-
evaluation system to produce evidence-based Quarter: 3 Reports (OPCR- 100% 100%
Semi Annual, OPCR-QMOA, BED 2, BAR 1, PrExC)
strategies MOA, BAR 1, PrExC) D: 3

a) % of nonconformities (or similar) responded with Request for Action within the N: 2
100% 100% 100%
prescribed timeline D: 2

N: 6 The three (3) pending complaints were only received by PACU at

6. To ensure compliance with cross-cutting
requirements based on standard procedures and b) % of complaints closed 100% 67% 67% the latter part of September and hence, still submitted for resolution
timelines in accordance to ARTA and other D: 9 and on-going investigations.
relevant laws
N: 25
At least 35% of
c) % of COA Audit Recommendations fully implemented recommendations were 41% 117%
implemented by 3rd quarter D: 61

a.) % of filled non-medical positions 96% at the end of the year or at N: 270
least 75% by the end of 3rd 88.82% 118%
Quarter D: 304
7. To ensure deliveryof quality service through Total number of filled positions / Total number of positions (net of positions vacated
provision of adequate human resource based on and unfilled)
the approved standard staffing pattern
b.) % of filled Nurse, Medical Officer and Medical Specialist positions 96% at the end of the year or at N: 847
least 75% by the end of 3rd 90.01% 122%
Quarter D: 941
Total number of filled positions / Total number of positions (net of positions vacated
and unfilled)

Page 3 of
 N: 498 Based on the newly designed Office LDI tracker. Results as of
8. To increase capacity of DOH personnel in % of employees provided with Learning and Development Interventions based on At least 75% by end of 3rd October 27, 2021. Only 956 out of 1,121 or 85% of plantilla were
44% 59%
order to improve workplace perdormance Annual Training Plan quarter tracked and submitted.Total plantilla reported by HRMO as of
D: 1121 September 30, 2021.

N: 16 There are 16 mandatory utilities for Level 3 hospital based on

DOH-HFSRB Assessment Tool V2.
9. Ensure safety/security of patients, staff
Availability of mandatory utilities, water, electricity, communication lines, transport, 100% of the mandatory utilities
hospital/personnel property, and availability of 100% 100% With the release of the Green and Safe Health Facilities Manual 1st
maintenance of different equipment, security and other logistical support. complied
needed services Edition last September 29, 2021, a new Green and Safety
D: 16 Compliance target will be set by the DJNRMHS for 2022 which
will replace this success indicator.

Reported by (g): Date: Approved & Validated by (h): Date:

October 28, 2021 October 28, 2021

ALFONSO VICTORINO H. FAMARAN JR., MD, FPCS MYRNA C. CABOTAJE, MD, MPH, CESO III
Medical Center Chief II Undersecretary of Health, Field Implementation and Coordination Team

Page 4 of
100 1
99.9 1.1
99.8 1.2
99.7 1.3
99.6 1.4
99.5 1.5
99.4 1.6
99.3 1.7
99.2 1.8
99.1 1.9
99 2
98.9 2.1
98.8 2.2
98.7 2.3
98.6 2.4
98.5 2.5
98.4 2.6
98.3 2.7
98.2 2.8
98.1 2.9
98 3
97.9 3.1
97.8 3.2
97.7 3.3
97.6 3.4
97.5 3.5
97.4 3.6
97.3 3.7