ORIGINAL ARTICLE

Description of Core Performance Measures

and Indicators of Patient Safety Used by Select
Government and Private Hospitals in the Philippines
Diana R. Tamondong-Lachica, MD,1,2 Lynn Crisanta R. Panganiban, MD,1,3 Generoso D. Roberto, MD,1
Charissa Rosamond D. Calacday, RN, MAN1 and Agnes D. Mejia, MD1,2
1
Program for Healthcare Quality and Patient Safety, College of Medicine, University of the Philippines Manila
2
Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila
3
Department of Pharmacology and Toxicology, College of Medicine, University of the Philippines Manila

ABSTRACT

Background. In 2008, the Department of Health (DOH) issued Administrative Order 2008-0023 that called for an
“effective and efficient monitoring system that will link all patient safety initiatives”. However, there are still no explicit
and harmonized targets to measure effectiveness and to provide benchmarks that assess whether previous efforts
were helpful.

Objective. The study aimed to describe the status of patient safety performance measures and indicators on the
international patient safety goals (IPSGs) in select hospitals in the Philippines.

Methods. Descriptive, cross-sectional design was used to investigate currently used performance measures and
indicators. Data collection included administration of a Hospital Patient Safety Indicators Questionnaire (HPSIQ) that
summarized the currently used patient safety measures and indicators in the sampled Level 2 and level 3 hospitals and
triangulation by review of documents such as hospital databases, protocols on reporting, and manuals for information
gathering regarding patient safety. Performance measures were categorized using the Donabedian framework. Core
indicators were identified through review of standards that cut across the six IPSGs and evaluation of overarching
processes and concepts in patient safety.

Results. Forty-one level 2 and 3 hospitals participated in the study. Most performance indicators were process
measures (52%), while structure (31%) and outcome measures (17%) accounted for the rest. There is an obvious
lack of structural requirements for patient safety in the hospitals included in this study. Less than half the hospitals
surveyed implement risk assessment and management consistently. Reporting of events, near- misses, and patient
safety data are widely varied among hospitals. Data utilization for quality improvement is not fully established in many
of the hospitals. Patient engagement is not integrated in
service delivery and performance measurement but is
crucial in promoting patient safety.

Conclusion. Mechanisms to improve hospitals’ capacity

to monitor, anticipate, and reduce risk of patient harm
during the provision of healthcare should be provided.
Having a unified set of definitions and protocols for
measurement will facilitate reliable monitoring and
eISSN 2094-9278 (Online)
Published: January 26, 2024
improvement. Leadership and governance, both internal
https://doi.org/10.47895/amp.vi0.6931 (e.g., hospital administrators) and external (e.g., DOH)
that recognize a data-driven approach to policymaking
Corresponding author: Diana R. Tamondong-Lachica, MD and improvement of service delivery are crucial in
College of Medicine
University of the Philippines Manila
promoting patient safety.
547 Pedro Gil Street, Ermita, Manila 1000, Philippines
Email: drtamondonglachica@up.edu.ph Keywords: patient safety, performance indicators, quality
ORCiD: https://orcid.org/0000-0002-8921-9185 indicators, outcome and process assessment

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Core Performance Metrics in Patient Safety

BACKGROUND specified to measure success and to provide benchmarks

that qualify and quantify whether efforts are effective and
In 2008, the Philippine Department of Health (DOH) helpful. Determination of what performance measures and
directed more attention towards patient safety, through its indicators hospitals are currently using is likely a needed
Administrative Order 2008-0023 that aims “to ensure that first step in unifying and setting national targets.
patient safety is institutionalized as a fundamental principle
of the health care delivery system in improving health Objectives
outcomes.”1 The directive designated the National Patient
Safety Committee (NPSC) to establish a proactive reporting The study aimed to describe the status of patient safety
system for events that will foster learning from experience. performance measures and indicators on the international
The policy emphasized building a culture of patient safety patient safety goals (IPSGs) in select hospitals in the country.
and implementing patient safety programs in facilities The measures and indicators were also evaluated on how
following policies and standards developed by the NPSC frequently these are being monitored and reported by the
and the Philippine Health Insurance Corporation (PHIC) sampled hospitals.
Benchbook on Safe Practice and Environment. Promotion
of safe practice and environment, risk reduction strategies, METHODS
professional development, and patient empowerment are also
parts of the said document. Study Design
The PHIC developed core standards and criteria in Descriptive, cross-sectional design was used to inves-
quality health care such as those that relate to leadership tigate available performance measures and indicators for the
and management, medication management, surgical and period of January 2019 to March 2020.
anesthesia care, and infection control. These standards are
being used to assess performance of hospitals applying for Study Participants
Center for Excellence accreditation under the National A combination of proportionate random and purposive
Health Insurance Program. In its 2nd edition of the sampling was planned in selecting participant hospitals
PhilHealth Benchbook manual, the agency enhanced the in this study to capture a nationally representative picture
standards adopting concepts on patient safety, sentinel events, (Figure 1). Proportionate sampling was initially done at
risk management, international benchmarks of quality and the regional level for DOH-retained and local government
safety, among others.2 In the same manner, other regulatory unit (LGU) hospitals taking into consideration the level of
agencies such as the DOH, through its licensing and hospital classification but eventually, due to low participation
accreditation bureaus have a distinct set of standards as well. rates from sampled hospitals, the team decided to invite as
While the DOH Administrative Order called for an many of the eligible Level 2 and 3 hospitals in the study.
“effective and efficient monitoring system that will link all The Philippine General Hospital was purposely included,
patient safety initiatives,”1 and despite the current standards being the national university hospital (NUH), as well as three
set by health agencies, gaps still remain, particularly on the private hospitals with current or previous Joint Commission
overall assessment of the many interventions done and the International ( JCI) accreditation to represent those with
actual impact on the status of patient safety in the country. best practices in patient safety and provide a range and
There are no explicit and harmonized targets and indicators benchmarks for use of performance metrics.
­­

Total Number of Levels 2 and 3 Hospitals: 85 General + 11 Specialty = 96 Hospitals

6 IPSGs x 3 dimensions (structural, process, outcome) x 3 indicators/dimensions: 54 hospitals + 6 from purposive sampling
Total Number of Hospitals = 60

Proportionate sampling per region Purposive sampling

Number of DOH and LGU sample proportionate to Private hospitals with

existing numbers in the region (including specialty hospitals) JCI Accreditation

Luzon 50% n=25 Visayas 20% n=12 Mindanao 30% n=13 PGH (National
CAR, NCR, Regions 1-5 Regions 6-8 Regions 9-12, ARMM, Caraga University Hospital)

Figure 1. Sampling frame for study hospital participants.

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 Core Performance Metrics in Patient Safety

Table 1. Summary of the Core Standards in the Hospital Patient Safety Indicators Questionnaire
International Patient Safety Goal Key Concepts and Standards Guidelines and References
Core Patient safety committee (PSC) and its activities have adequate support The Joint Commission’s
National Patient Safety Goals
Hospital has adequate staffing pool with relevant training on patient safety (2015)

Specific risk assessment and management are utilized to identify World Health Organization
special/vulnerable populations like the elderly, pediatric, pregnant, and Patient Safety Solutions
psychiatric patients (2007)

Specific risk assessment and management are utilized to identify patients Philippine Health Insurance
at-risk for hospital- acquired conditions such as pressure ulcers, venous Corporation Hospital
thromboembolism, malnutrition, falls, and suicide Benchbook: Survey Manual
and Self-Assessment Book
PSC receives and processes reports related to patient safety and quality (2014)

Reports on patient safety program are used for improving care delivery DOH Health Facilities and
Services Regulatory Bureau
Outcome measures related to patient safety are monitored and reported Checklist

Medical records are secure, complete, and fully accessible to patients and
care participants

Rights and preferences of patients and care participants are upheld in care
processes and patient safety activities

Development and Administration of the HPSIQ concepts in patient safety. These were eventually categorized
Instrument as “core indicators.” A summary of the key standards under
The Hospital Patient Safety Indicators Questionnaire core indicators and references is outlined on Table 1.
(HPSIQ) was developed after a literature search of relevant
international and locally accepted patient safety standards Data Collection and Analysis
that included the JCI Accreditation Standards for Hospitals,3 Hospitals were asked to accomplish HPSIQ using data
and the PhilHealth Benchbook for Accredited Hospitals,2 from their centralized information management system or if
among others. Each standard was given corresponding this is not available, assigned hospital liaisons were instructed
performance metrics upon which the achievement of the said to distribute sections of the HPSIQ to the personnel/office
standard will be evaluated based also on literature review. The who can best provide the needed information then validate
initial draft of identified relevant measures and indicators and collate the data prior to submission to the research
for the data collection was presented to an expert panel team. Data from the HPSIQ were triangulated by having
consisting of members from the DOH Health Facilities respondents provide documentary evidence that include
Development Bureau and Health Policy Development and hospital databases, protocols on reporting, and manuals
Planning Bureau, PhilHealth, and an expert from a specialty for information gathering regarding patient safety and
private hospital for their insights and comments. The draft information on hospital characteristics and performance
HPSIQ was pilot tested in a public tertiary hospital that measures and indicators on the six IPSGs and later validated
was randomly selected from the pool of Level 2 and Level by members of the study team.
3 hospitals not included in the original sample. Feedback on The core indicators were identified through review of
the appropriateness of the language, content, and format of standards that cut across the six IPSGs and evaluation of the
the questions as well as processes to ensure confidentiality, overarching processes and concepts in patient safety. Using
data privacy, and efficiency during data collection were used the Donabedian Framework, all prospective indicators in the
for the final revision of the instruments. HPSIQ were categorized into either structure (S), process
(P) or outcome (O) measure. The structure measures pertain
Description of Patient Safety Hospital Survey to provider’s capacity, systems, and processes to provide high-
Instrument quality care, process measures indicate what a provider does
The HPSIQ is a self-assessment tool that was provided to maintain or improve health, either for healthy people or
to hospital administrators and personnel to identify their for those diagnosed with a health care condition, or outcome
existing performance measures related to the six IPSGs. measures reflect the impact of the health care service or
During the development of the questionnaire and review of intervention on the health status of patients.4 The types of
standards, the study team observed that some indicators cut measures offer different perspectives by which quality can
across the six IPSGs and evaluate overarching processes and be measured. Structure measures are often referred to as

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Core Performance Metrics in Patient Safety

“inputs” which assess the adequacy of resources to be able to 2 LGU hospitals, Level 3 DOH hospitals, etc.). Comparing
uphold the relevant standard. Process or “output” measures the hospitals in the sample to the distribution in the whole
signify if the structural elements are being integrated into country, there is a higher proportion of DOH (63%) and Level
consistent practices that ultimately result in improved 3 (51%) hospitals in the participating sample while LGU
outcome measures. Additional analyses included descriptive (16%) and Level 2 (24%) hospitals were less represented.
statistics using frequencies, percentages, mean, and ranges.
Donabedian Framework: Structure, Process and
Ethics Review and Approval Outcome Measures
The Philippine Council for Health Research and All prospective indicators in the HPSIQ were catego-
Development (PCHRD) Technical Advisory group provided rized into either structure (S), process or outcome (O)
the technical review and approval of the research protocol. measure. The types of measures offer different perspectives
It was then reviewed and approved by the University of the by which quality can be measured. Structure measures are
Philippines Manila Research Ethics Board and the Single often referred to as “inputs” which assess the adequacy of
Joint Research Ethics Board of the Philippine DOH. resources to be able to uphold the relevant standard. Process
or “output” measures signify if the structural elements are
RESULTS being integrated into consistent practices that ultimately
result in improved outcome measures. Of the 405 potential
Description of Sampled Hospital Participants indicators listed in the HPSIQ, 126 (31%) are structure
Table 2 provides a summary of the description of measures, 212 (52%) are process measures while 69 (17%) are
the hospitals who participated in this study. A total of 41 outcome measures. Specifically for core indicators, 31 (52%)
Level 2 and Level 3 hospitals were included in the study were structure measures, 18 (30%) were process measures,
with the majority (82.1%) being under the management and 11 (18%) were outcomes measures. At the outset, some
of the DOH and are Level 3. Majority (75%) of Level 2 IPSGs do not have outcome measures that can identify
hospitals are managed by the local government units. Only performance of the hospital in that aspect and these are
the private hospitals in the group have JCI accreditation, on patient identification and falls prevention.
while most public hospitals reported accreditation from other
bodies such as PhilHealth, Philippine Hospital Association, Core Indicators of Patient Safety
Performance Governance System (PGS) through Institute Core indicators are those that cover overarching
for Solidarity in Asia, International Organization for processes and concepts in patient safety which include (1)
Standardization (ISO), TÜV SÜD, and Accreditation resources for patient safety (e.g., budget for patient safety
Canada Internationale (ACI). committee, learning development interventions, and data/
Of the 41 hospital participants, there were 12 Level information management such electronic medical record,
2 hospitals composed of 6 LGU, 5 DOH, and 1 private information of management system); (2) risk assessment
hospital while there were 29 Level 3 hospitals that included and management to improve efficiency and equity; (3)
2 LGU, 24 DOH, 2 private, and 1 NUH. Analyses are reporting and learning systems in patient safety (e.g.,
presented according to Level, fiscal management, and by reporting of never events, near misses, AHRQ patient safety
specific hospital type (Level + fiscal management, e.g., Level indicators); and (4) patient/family-centeredness (e.g., patient

Table 2. Description of Hospital Participants according to Fiscal Management and Resources

All hospitals LGU hospitals DOH hospitals Private hospitals NUH
Description included n=8 n=29 n=3 n=1
N=41 % % % %
Level 2 29.3% 75 17.9 33.3 0
Level 3 70.7% 25 82.1 66.7 100
HFEP recipient 90.2% 87.5 100 n/a 100
JCI accreditation 7.3% 0 0 100 0
Other accreditation 95.1% 100 92.9 100 100
(Median, IQR) (Median, IQR) (Median, IQR) (Median, IQR) (Mean/total)
Average bed capacity 300, 300 174.5, 162.5 450, 250 338, 112.5 1334
Medical personnel 230, 259 86, 108 230, 225 1082, 415 926
Nursing personnel 364, 264 228, 151 364, 255 527, 204 1099
Ancillary personnel 159, 147 57, 49 174, 124 369, 389 917
Administrative personnel 215, 192 183, 31 215, 178 551, 160 1205
*IQR: interquartile range

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 Core Performance Metrics in Patient Safety

and care participants engagement, overall experience, and core indicators such as patient safety program, information
feedback) (Table 3). management system, EMR, and budget for patient safety
than DOH, LGU, and Level 2 ones. Also, we note the glaring
Resources for Patient Safety lack of budget on patient safety for public hospitals. Private
Almost all hospital participants report the presence of hospitals and the NUH also show more consistent use of
either a patient safety committee and/or officer; with only process measures such as training, use of patient safety reports
one hospital having none of these. However, in about 17% of for improvements, and risk assessment for hospital-acquired
hospitals, there is a committee or person looking over patient conditions. It seems Level 2 LGU hospitals need the most
safety, but no identifiable structured program. Having a support and guidance on core indicators for patient safety.
committee or person in-charge is noted only in 81% of Level
3 hospitals and only in 62% of Level 2 ones, while 25 of 29 Risk Assessment and Management
DOH hospitals and five of the eight LGU hospitals have Risk assessment to identify populations that can be vulne-
these. When asked if the patient safety committee regularly rable to in-hospital issues (e.g., elderly, pregnant, pediatric,
meets, only 29% said yes. Less than half of the hospitals also and psychiatric) is only being done by less than half of the
report monitoring the number of reports that are received hospitals. Tools to identify patients at risk for hospital-acquired
and attended to by the patient safety committee. Only 21% conditions (HACs) such as venous thromboembolism,
of public hospitals allot a specific budget in patient safety in pressure ulcers, malnutrition, falls, and suicide are only
the annual hospital budget and 15% maintain a patient safety about a quarter of the hospitals, being seldomly used in the
expenditure list, while all private hospitals do both. About Level 2 hospitals but are more consistently implemented in
54% indicate that their staff receive regular training on patient Level 3 and private institutions.
safety.
Of the different training modules on patient safety, those Reporting and Learning Systems in Patient Safety
on infection control are the most frequently offered (78% of Only 49% of the hospitals generate the said patient safety
hospitals), while those on general patient safety, medication reports, however, 80.5% of them claim that they use the same
safety, patient identification, falls prevention, effective reports for policies and improvement. This inconsistency
handovers, and surgical safety are less consistently offered by was observed among Level 2 hospitals and Level 3 DOH
the public hospitals. hospitals in whom the frequency of those who generate
Private hospitals, Level 3 hospitals, and the NUH patient safety reports are less than those who utilize these
have more available structure measures and resources on reports for further action (Table 4). Among public hospitals,

Table 3. Frequency Distribution on Existing Core Indicators of Patient Safety in Select Government and Private Hospitals in the
Philippines, 2019-2020
Level 2 Level 3 Private
Level 2 DOH Level 3 DOH NUH
LGU LGU hospitals
Description n=5 (%) n=24 (%) n=1 (%)
n=6 (%) n=2 (%) n=3 (%)
Resources for Patient Safety
Presence of Patient Safety (PS) Program 66.7 80 50 83.3 100 100
Presence of PS Committee 83.3 60 50 95.8 100 100
Presence of PS Officer/ Leader 83.3 100 100 95.8 100 100
Budget Allotted for PS 0 20 50 37.5 100 0
Availability of Electronic Medical Record 16.7 80 50 70.8 100 100
Presence of Information Management System 33.3 80 50 87.5 100 100
Conduct of Regular Training on PS 0 20 50 66.7 100 100
Risk Assessment and Management
Risk Assessment for Special Populations 66.7 40 100 30.2 100 0
Risk Assessment for Hospital-acquired Conditions 0 12 20 29.2 70 100
Reporting and Learning Systems
Generation of PS Reports 0 0 50 62.5 100 100
Use of PS Reports for improvement, policies 66.7 80 50 83.3 100 100
Use of PS reports on clinical program evaluation 50 40 50 58.3 100 0
Patient-centeredness
Patient involvement in creating PS activities, policies 50.0 60 50 79.0 100 100
Patient participation in PS activities 33.3 100 0 66.7 100 100
Patient feedback in PS activities 16.7 0 0 33.3 100 100
Records fully accessible to patients, care participants 83.3 100 50 95.8 100 100

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Core Performance Metrics in Patient Safety

generating patient safety reports are less consistently done Patient-centeredness and Engagement in Patient
compared to private hospitals, with none of the Level 2 Safety Initiatives
public hospitals doing so. When triangulated with documents Patient involvement in planning and implementing
review, data from nonconformity and corrective action patient safety activities and policies are reported by 73%
report (NCAR) forms are usually reported, processed, and of hospitals (Table 3), less consistently in the public and
submitted but these are not routinely integrated or considered Level 2 hospitals compared to the private and Level 3
in determining future strategies and policy directions as facilities. Further triangulation of this observation with the
evidenced by the lack of protocols or policies to summarize, hospital administration and frontliners show that patient
monitor, disseminate, and utilize said data. involvement in hospitals is limited to giving informed
Only about 32% and 36% of hospitals monitor “never consent as well as answering patient satisfaction surveys and
events” and near-misses, respectively. “Never events” are feedback forms. Making medical records fully accessible is
shocking medical errors that should never occur and consist an important first step in patient- centered care because it
of 29 events grouped into 7 categories: surgical, product or enables patients to correct medical information, add their
device, patient protection, care management, environmental, values and preferences, and empower them to take control
radiologic, and criminal according to the National Quality of their health. Majority of the hospitals surveyed report
Forum.5 These have been given some emphasis by many safety accessibility of patient health records.
advocates because these are considered unambiguous (clearly
identifiable and measurable), major adverse occurrences that DISCUSSION
result in death or significant impairment and are typically
preventable.6,7 A near-miss is an error or unplanned event This is one of the very few studies locally that describes
that has the potential to cause harm but fails to do so because the current performance metrics being used by hospitals to
of chance or because it is intercepted.8 Of the listed event assess patient safety and quality.10,11 It is part of a larger project
rates on Table 4, recording the rates of hospital-acquired that includes assessment of other aspects of performance
pneumonia (HAP) and ventilator-associated pneumonia measurement in patient safety (e.g., validity, reliability,
(VAP) are consistently done by more than half of the hospitals standardization, and patient-centeredness) and evaluation
per level and fiscal type. Falls, adverse drug events (ADEs), of the capacity and needs of hospitals to do performance
and medication errors are documented less often. monitoring which are beyond the scope of this report.
The AHRQ Patient Safety Indicators or PSIs (Table 5) The Donabedian framework defines healthcare service
are a set of indicators on safety- related adverse events in the delivery as a continuum composed of structures, processes,
hospitals following operations, procedures, and childbirth and outcomes, and asserts that quality of care (of which
that are validated and used widely. For purposes of this study, safety is a component) is the product when the structures
provider-level PSIs in the HPSIQ were used to allow for are translated into outcomes via the processes. In this early
individual hospital assessment and internal benchmarking, attempt to identify nationally implemented performance
and excluded the area-level indicators which are meant for metrics on patient safety, it is important to recognize that
geographic comparisons.9 Of the 17 AHRQ PSIs, only one these interconnected components of measurement are equally
indicator (transfusion reaction count) is monitored by at important – only when processes are of high technical quality
least half of the hospitals observed. and responsive to patient needs will health outcomes improve.

Table 4. Frequency Distribution of Event Reporting of Hospitals in Select Government and Private Hospitals in the Philippines by
Level and Fiscal Management, 2019-2020
Level 2 Level 3
Event Reporting LGU DOH Private LGU DOH Private NUH
n=6 (%) n=15 (%) n=1 (%) n=2 (%) n=24 (%) n=2 (%) n=1 (%)
Reporting of Never Events 16.7 0 100 0 41.7 50 100
Reporting of Near-Misses 16.7 0 100 50 41.7 100 0
Event rates
Hospital-acquired Pneumonia (HAP) 66.7 60 100 100 62.5 50 100
Ventilator-associated Pneumonia (VAP) 66.7 40 100 100 79.2 100 100
Surgical site infection 33.3 40 100 100 79.2 100 0
Catheter-related bloodstream infection 33.3 20 100 100 75.0 100 100
Catheter-related UTI 16.7 20 100 50 87.5 100 100
Falls occurring in the hospital 16.7 0 100 50 66.7 100 100
Adverse drug events 33.3 0 100 0 66.7 100 100
Medication error 66.7 60 100 100 62.5 100 100

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 Core Performance Metrics in Patient Safety

Table 5. Frequency Distribution of Reporting of AHRQ Patient Safety Indicators in Select Government and Private Hospitals in
the Philippines according to Level and Fiscal Management, 2019-2020
Level 2 Level 3
AHRQ Patient Safety Indicators LGU DOH Private LGU DOH Private NUH
n=6 (%) n=15 (%) n=1 (%) n=2 (%) n=24 (%) n=2 (%) n=1 (%)
Pressure ulcer rate 33.3 20 0 50 33.3 100 100
Death rate among surgical inpatients with serious treatable conditions 16.7 20 100 50 25.0 50 100
Retained surgical item or unretrieved device fragment count 16.7 0 100 50 33.3 50 100
Iatrogenic pneumothorax rate 16.7 0 0 50 4.2 0 0
Central venous catheter related bloodstream infection rate 33.3 0 100 100 50.0 50 100
Postoperative hip fracture rate 33.3 0 100 50 12.5 50 0
Perioperative hemorrhage or hematoma right 16.7 0 100 50 4.2 50 0
Postoperative metabolic derangement rate 16.7 0 100 100 4.2 50 0
Postoperative respiratory failure rate 16.7 0 100 100 8.3 50 0
Perioperative pulmonary embolism or DVT rate 16.7 0 100 100 8.3 50 0
Postoperative sepsis rate 33.3 0 100 50 25.0 50 0
Postoperative wound dehiscence rate 16.7 20 100 50 25.0 50 0
Accidental puncture or laceration rate 50.0 20 100 100 45.8 50 100
Transfusion reaction count 50.0 20 100 100 45.8 100 100
Birth trauma rate - injury to neonate 33.3 0 100 50 20.8 50 0
Obstetric trauma rate - vaginal delivery with instrument 16.7 0 100 100 20.8 50 0
Obstetric trauma rate - vaginal delivery without instrument 33.3 0 100 50 25.0 50 0

Such processes, in turn, will be possible only if facility and promote transparency and teamwork in care settings.13,14
structures provide an appropriate environment and have Several studies have shown the knowledge and skills
systems in place that allow for good processes. In determining gaps among our local healthcare providers and this is also
appropriate indicators for patient safety standards, it will be particularly true for patient safety.15,16 Apart from the overall
valuable to validate that structure and process outcomes are lack of training, there is varying emphasis in content being
linked to outcome measures either by evidence review or offered in the surveyed hospitals. This apparent emphasis on
by cycles of implementation by our local facilities. infection control practices is likely the result of the endorse-
There is an obvious lack of structural requirements for ment and strong implementation of its program by the
patient safety in the hospitals included in this study. While DOH. Many of the hospital participants have had infection
most hospitals have a patient safety committee or officer, control units or committees, long before they established their
fewer reported the presence of a structured program with clear patient safety programs or committees. General patient safety
objectives, defined roles for proponents, and appropriated concepts, particularly those on effective communication,
resources. The components of the said program would usually teamwork, and risk reduction, are not routinely included in
include event reporting and referral, basic safety orientation basic training but are expected to have tremendous impact
and training of personnel, and data gathering, analysis, and in preventing harmful events.17,18
monitoring across various units of the hospital, clinical and The results of this study reflect the underutilization of
non-clinical departments, and operating units. The seeming risk assessment tools to promote patient safety in this study.
lack of priority and focus on safety structures is likely not This represents the potential exposure of vulnerable patients
possible since many of the staff assigned under the patient to errors and harms as well as a missed opportunity to
safety committee are also assigned elsewhere in the hospital. make care processes more efficient, since these tools enable
This lack of resources specific for patient safety is likely providers to identify higher-risk individuals who may benefit
exacerbated in rural areas and geographically isolated and more from risk-reducing strategies rather than applying
disadvantaged areas with grossly deficient overall resource these same strategies for the rest of the inpatient population.
for health.12 Other inputs and tools for patient safety include While many facilities outside of the Philippines have
electronic health records and information management employed these more consistently, there are still barriers to
systems which improve documentation and staff support implementation such as lack of consistency and transparency,
(this may reduce medication errors and guideline adherence), lack of training, and inadequate guidance of subsequent risk
facilitate seamless workflow and transfer of information, management.16 Nevertheless, numerous risk assessment tools
allow collection and analyses of clinical and nonclinical data, are available that have been validated across different settings

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(e.g., entire hospital, operating room, etc.), different users There are very few patient engagement standards that
(e.g., provider-initiated and patient self-assessment), and are integrated into patient safety measurement in hospitals
different conditions (e.g., patient profiles like pregnant or as seen in the survey and even in literature. Ensuring medical
pediatric; or HACs). The challenge for hospitals is selecting records to be fully available and accessible to patients and
risk assessment tools that will provide them with useful their care participants which 92.7% of hospitals are doing.
information, without unnecessarily increasing workload While this finding should be regarded positively, the project
(including paperwork) among healthcare staff, and to have team believes that this should be probed further because
defined risk reduction strategies in place once high-risk medical records include not only clinical abstracts and
groups are identified. discharge summaries, but also patient charts and electronic
Reporting and learning systems generate data from health records which may not have been clear with the
monitoring processes, routine census, and summaries of root respondents. Many international organizations advocate for
cause analyses and should not only be done for adherence patient engagement not only to access their medical records,
to reporting standards by external regulators but should be but also to check their accuracy and to flag documentation
used to support continuous improvement.19 However, in errors. In a study on “open notes” or notes shared by patients
this study, consistent use of these reports by LGU hospitals and clinicians, 44% of participating patients reviewed their
can still be improved and more surveyed hospitals claim doctor’s notes, and about 8% used the feedback function to
that they utilize their patient safety reports for policies cite inaccuracies and report safety concerns such as medication
and improvement (80.5%) compared to those who report errors or misreported comorbidities.21 This innovation, while
generating the said reports (49%). A possible explanation proven to be helpful, represents a huge leap of change for
for the latter observation is that they use reports other than hospitals and clinics in the country.
those from the patient safety committee and patient safety There is a big gap in potential measures for patient-
measures for improvement; or there are more discreet or centeredness, and patient and family engagement that are
area-specific improvements done that may not have been appropriate, relevant, and feasible in the local setting. Many
subject to PS reports made at the hospital level. studies in the recent decade have shown that patient and
Incident reporting is the voluntary reporting of a patient family engagement is critical not only in individual healthcare
safety event that is usually accomplished by the staff that is/ decisions but also in healthcare services organizations,
are directly involved or those who were involved in the events health policy development, and in health research.22,23 It
leading up to the incident.19 This is a passive form of reporting, has been proven that effective patient engagement can lead
in comparison to active surveillance of patient safety events to better health outcomes, improves quality of care and
using direct observation, chart review, or triggers in electronic patient safety, and helps control health care costs. 24 “Patient
charting. Sentinel events (those resulting in death, permanent involvement” in this study was limited to giving informed
harm, or severe temporary harm), adverse events (those consent as well as answering patient satisfaction surveys and
resulting in harm or undesirable experience such as hospital- feedback forms. Hospital administrators should recognize
acquired conditions), never events, near-misses, and unsafe and aim for the further end of the continuum of patient
conditions are among the patient safety events that may be engagement that ranges from merely providing them with
reported through incident reporting. Under-reporting of needed information to a full partnership that acknowledges
patient safety incidents has been widely recognized as we see them as equal members of the treatment team or of quality
here in this report and can undermine an institution’s ability improvement activities.
to correct unsafe or inefficient work processes.20 The observed
higher reporting of HAP and VAP compared to falls, ADEs, Conclusion
and medication errors may be due to the following reasons:
first, HAP and VAP (as well as surgical site infections, Review of available evidence from local and international
catheter-related bloodstream infections, and catheter-related sources revealed that there are numerous performance
UTI) are medical diagnoses that are cursorily included by measures and indicators in patient safety but there are areas
physicians in patient charting making them easier to track; of overlap (hence the formation of “core indicators” in this
secondly, the latter set of indicators rely on voluntary/ study) and gaps (e.g., patient-centeredness). Also, structure,
incident reporting by personnel that are usually less likely process, and outcome measures are not explicitly linked
done; and lastly, infection prevention and control programs and in some IPSGs (e.g., patient identification and falls
are more established compared to other programs in patient prevention), there are no outcome measures that can identify
safety. While ensuring that reporting mechanisms are easy, performance of the hospital.
seamless, and reliable, learning systems are equally important Hospitals and their patient safety committees need
– these are designed to capture and understand from reports firmer support in terms of personnel, policies, and budget.
what patient safety concerns, risks, and/or occurrences are Mechanisms to improve their capacity to monitor, anticipate,
present to prompt action, revision, and improvement of and reduce risk of patient harm during the provision of
response and protocols. healthcare should be provided by the hospital leadership

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 Core Performance Metrics in Patient Safety

as well as the DOH. Risk assessment strategies to identify Acknowledgments

vulnerable populations and at-risk for hospital-acquired The authors would like to thank the following indivi-
conditions are not commonly practiced in this hospital cohort. duals for their invaluable contributions to this project and
Reporting and learning systems through a combination of report: the rest of the UPCM AHEAD Patient Safety
voluntary reporting and surveillance should be strengthened team namely Christine Aileen C. Benosa, Alvin Cloyd H.
for hospitals to undertake corrective action and quality Dakis, Samantha Yzobelle S. Bayhonan, Maria Celine Isabel
improvement initiatives. There are no explicit policies or Sombillo, Zara Mia S. Lagera, Bryan Albert Lim, Thomas
mechanisms to utilize, disseminate, and learn from data David P. Miguel, Kim Carmela Co, Mary Ann Ladia, Olivia T.
coming from nonconformity and corrective action reports Sison, Angel Bert L. Cosino, Lilian Gamutan, Paolo Niccolo
or patient safety reports. G. Santos, Sarah L. Obmaña, Mary Joy S. Taneo, Louie M.
Education in the improvement of healthcare and Alcazar, Dave Santuile (†); members of our consensus panel
patient safety is vital and should be dynamic, using new namely Maria Linda G. Buhat, Armand C. Crisostomo, Maria
and creative techniques. Training on safety should not Fatima Garcia-Lorenzo, Jaime A. Almora, Marc Anthony
only be comprehensive but integrate interprofessional Cepeda, Roderick Napulan; technical report reviewers
approaches to care, with emphasis on vital communication namely John Q. Wong, Oscar Picazo, and Dennis Batangan;
and teamwork. Further investigation on how to adequately Erickson Feliciano, colleagues from the DOH HFDB,
assess the involvement of patients in the hospital patient HPDPB, and PCHRD; and coordinators, administrators,
safety program should be undertaken. More importantly, and respondents from our hospital participants.
educating healthcare providers and managers on what patient-
centeredness is, how it can be integrated in care processes, and Statement of Authorship
how to measure its attainment, should be top-of-mind. DRTL and LCRP contributed in the conceptualization
Having a unified set of definitions and protocols of work, analysis of data, drafting and revising of manuscript,
for measurement will facilitate reliable monitoring and and final approval of the version to be published. GDR and
improvement. This will entail broader discussions among CRDC contributed in the acquisition and analysis of data,
stakeholders, with particular emphasis for facilities in and final approval of the version to be published. ADM
geographically isolated and disadvantaged areas (GIDA) contributed in the conceptualization of work, revising of
so that equitable policies are formulated and supporting manuscript, and final approval of the version to be published.
mechanisms are readily identified. Leadership and governance,
both internal (e.g., hospital administrators) and external (e.g., Author Disclosure
DOH) that recognize a data-driven approach to policy- All authors declared no conflicts of interest.
making and improvement of service delivery are crucial in
promoting patient safety. Funding Source
This study has several limitations. It covers hospitals only The study was funded by the Advancing Health through
since the literature on measures for primary care facilities Evidence Assisted-Decisions with Health Policy and Systems
are still explored, particularly for developing countries. Research (AHEAD-HPSR) program of the DOH and
Secondly, the focus of this study is measuring performance PCHRD.
in the achievement of the six IPSGs based on the JCI
Accreditation Standards for Hospitals 2011, which are some REFERENCES
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