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

• Quality Management/Quality Assurance Program: Organized set of activities designed to demonstrate on-going assessment of important aspects of patient care and services

• Jan 01, 2021 - Dec 31, 2021

1. Authorized Bed Capacity: 100 beds
   • Authorized bed: Approved number of beds issued by HFSRB/RO, the licensing offices of DOH
2. Implementing Beds: 150 beds
   • Implementing beds: Actual beds used (based on hospital management decision)
     
3. Bed Occupancy Rate (BOR) Based on Authorized Beds: 61.62% beds
   
   

   [Total Inpatient service days for the period]**	x 100
   [Total number of Authorized beds] x [Total days in the period (365 0r 366 for leap year) ]

• Bed Occupancy Rate: The percentage of inpatient beds occupied over a given period of time. It is a measure of the intensity of hospital resources utilized by in-patients.(given period of time is January 1 to December 31each year for the annual statistics)
• Inpatient Service days (Inpatient bed days): Unit of measure denoting the services received by one in-patient in one 24 hour period.
• Total Inpatient Service days or Inpatient Bed days =[(Inpatients remaining at midnight + Total admissions) - Total discharges/deaths) + (number of admissions and discharges on the same day)].

• Inpatient Care	Number
  Total number of inpatients	4,034
  Total Newborn (In facility deliveries)	187
  Total Discharges (Alive)	3,711
  Total patients admitted and discharged on the same day	19
  Total number of inpatient bed days (service days)	22,493
  Total number of inpatients transferred TO THIS FACILITY from another facility for inpatient care	458
  Total number of inpatients transferred FROM THIS FACILITY to another facility for inpatient care	45
  Total number of patients remaining in the hospital as of midnight last day of previous year	48

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

   Total length of stay of discharged patients (including Deaths) in the period =	5 - 6 Day(s)
   Total Discharges and Deaths for the same period

   • Average length of stay: Average number of days each inpatient stays in the hospital for each episode of care.
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.
   
   (Do not include deliveries)

   Cause of Morbidity/Illness/Injury	Number	ICD-10 Code
   1. Provisional assignment of new diseases of uncertain etiology or emergency use (COVID-19)	577	U00-U49
   2. Injury of unspecified body region	389	T08-T14
   3. Influenza and pneumonia	362	J10-J18
   4. Cerebrovascular diseases	156	I60-I69
   5. Renal failure	138	N17-N19
   6. Other diseases of the urinary system	79	N30-N39
   7. Other diseases of the digestive system	74	K90-K93
   8. Disorders of gallbladder, biliary tract and pancreas	70	K80-K87
   9. Hypertensive diseases	44	I10-I15
   10. Ischemic heart diseases	30	I20-I25

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

3. Total Number of Deliveries
   For each category of delivery listed below, please report the total number of deliveries.
   
   

   Deliveries	Number
   Total number of in-facility deliveries	194
   Total number of live-birth vaginal deliveries (normal)	115
   Total number of live-birth C-section deliveries (Caesarians)	79
   Total number of other deliveries	0

4. 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	4,475
   Number of outpatient visits, re-visit	5,767
   Number of outpatient visits, adult (Age 19 years old and above)	8,832
   Number of outpatient visits, pediatric ( Age 0 to 18 yrs old; before 19th birthday)	375
   Number of adult general medicine outpatient visits	3,538
   Number of specialty (non-surgical) outpatient visits	5,595
   Number of surgical outpatient visits	10,335
   Number of antenatal care visits	0
   Number of postnatal care visits	0

   
   

   Ten Leading Causes of OPD Consultation

   Ten Leading OPD Consultations	Number	ICD-10 Code
   1. Provisional assignment of new diseases of uncertain etiology or emergency use (COVID-19)	462	U00-U49
   2. Injury of unspecified body region	440	T08-T14
   3. Hypertensive diseases	164	I10-I15
   4. Other acute lower respiratory infections	150	J20-J22
   5. Intestinal infectious diseases	148	A00-A09
   6. Other viral diseases	122	B25-B34
   7. Diabetes mellitus	90	E09-E14
   8. Other diseases of the urinary system	75	N30-N39
   9. Influenza and pneumonia	73	J10-J18
   10. Tuberculosis	71	A15-A19

   
   

   Ten Leading Causes of ER Consultation

   Ten Leading ER Consultations	Number	ICD-10 Code
   1. Injury of unspecified body region	85	T08-T14
   2. Exposure to animate mechanical forces	34	W50-W64
   3. Diseases of esophagus, stomach and duodenum	26	K20-K31
   4. Other acute lower respiratory infections	26	J20-J22
   5. Other viral diseases	21	B25-B34
   6. Intestinal infectious diseases	14	A00-A09
   7. Other diseases of the urinary system	10	N30-N39
   8. Symptoms and signs involving cognition, perception, emotional state and behavior	7	R40-R46
   9. General symptoms and signs	4	R50-R69
   10. Hypertensive diseases	3	I10-I15

   
   

   TESTING

   Total number of medical imaging tests (all types including x-rays, ultrasound, CT scans, etc.)	Number
   X-Ray	11,663
   Ultrasound	5,030
   CT-Scan	3,809
   MRI	0
   Mammography	276
   Angiography	0
   Linear Accelerator	0
   Dental X-Ray	0
   Other	0
   Total number of laboratory and diagnostic tests (all types, excluding medical imaging)
   Urinalysis	8,879
   Fecalysis	1,563
   Hematology	21,217
   Clinical chemistry	76,137
   Immunology/Serology/HIV	37,845
   Microbiology (Smears/Culture & Sensitivity)	2,136
   Surgical Pathology	804
   Autopsy	0
   Cytology	1,244
   Blood Service Facilities
   Number of Blood units Transfused	2,313

   
   

   EMERGENCY VISITS

   Emergency visits	Number
   Total number of emergency department visits	185
   Total number of emergency department visits, adult	117
   Total number of emergency department visits, pediatric	68
   Total number of patients transported FROM THIS FACILITY’S EMERGENCY DEPARTMENT to another facility for inpatient care	48
   Total number of patients transported TO THIS FACILITY’S EMERGENCY DEPARTMENT from other health facilities i.e. RHU, Medical Clinic, Infirmary, other hospital)	0

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

  Types of deaths	Number
  Total deaths	403
  Total number of inpatient deaths	316
  Total deaths < 48 hours	72
  Total deaths ≥ 48 hours	244
  Total number of emergency room deaths	39
  Total number of cases declared 'dead on arrival'	48
  Total number of stillbirths	6
  Total number of neonatal deaths	10
  Total number of maternal deaths	0

1. Gross Death Rate 10.01%
   
   

   Gross Death Rate =	Total Deaths (including newborn for a given period)	x 100
   	Total Discharges and Deaths for the same period

   
   

   10.01% =	403	x 100 (User defined / EMR generated)
   	4,027

2. Net Death Rate 8.37%

   Net Death Rate =	Total Deaths (including newborn for a given period) - death < 48 hours for the period	x 100
   	Total Discharges (including deaths and newborn) - death < 48 hours for the period

   
   

   8.37% =	331	x 100 (User defined / EMR generated)
   	3,955

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

   
   (Do not include Cardio-respiratory arrest, put underlying cause instead)

   Mortality/Deaths	Number	ICD-10 Code
   1. Provisional assignment of new diseases of uncertain etiology or emergency use (COVID-19)	96	U00-U49
   2. Influenza and pneumonia	62	J10-J18
   3. Cerebrovascular diseases	23	I60-I69
   4. Other bacterial diseases	19	A30-A49
   5. Ischemic heart diseases	18	I20-I25
   6. Injury of unspecified body region	16	T08-T14
   7. Renal failure	4	N17-N19
   8. Other diseases of the digestive system	4	K90-K93
   9. Disorders related to length of gestation and fetal growth	4	P05-P08
   10. Viral infections of the central nervous system	2	A80-A89

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

(Do not include cardio-respiratory Arrest and maternal deaths)

• 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 (General and Specialty)

  INFECTION RATE =	Number of Healthcare Associated Infections	x 100
  	Number of Discharges

1. Device Related Infections

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

     (Not to be filled up by Level 1 with no ICU facilities)

   • 2. Blood Stream Infection (BSI) =	Number of Patients with BSI	x 1000
     	Total Number of Central Line (peripheral lines not included)

   • 3. Urinary Tract Infection (UTI) =	Number of Patients (with catheter) with UTI	x 1000
     	Total Number of Catheter Days

2. Non-Device Related Infections

   • Surgical Site Infections (SSI) =	Number of Surgical Site Infections(Clean Cases)	x 100
     	Total number of Clean Procedures done

• 	Percentage (%)
  INFECTION RATE	0.76
  Device Related Infections
  Ventilator Acquired Pneumonia (VAP)	119.05
  Blood Stream Infection (BSI)	44.28
  Urinary Tract Infection (UTI)	37.23
  Non-Device Related Infections
  Surgical Site Infections (SSI)	0.00

1. Major Operation refers to surgical procedures requiring anesthesia/ spinal anesthesia to be performed in an operating theatre. ( Refer to different cutting specialties.)
2. Minor Operation refers to surgical procedures requiring only local anesthesia/ no OR needed, example suturing.
   (Refer to different cutting specialties)
   
   

   10 Leading Major Operations (excluding Caesarian Sections)		Number
   1	CATARACT SURGERY	84
   2	Open treatment of tibial shaft fracture (w/ or w/o fibular fracture) w/ plate/screws, w/ or w/o cerclage	75
   3	47562-LAPAROSCOPIC CHOLECYSTECTOMY	71
   4	44950-APPENDECTOMY	53
   5	Exploratory laparotomy, exploratory celiotomy w/ or w/o biopsy(s)	48
   6	Craniectomy or craniotomy, exploratory; supratentorial	28
   7	Mastectomy, modified radical, including axillary lymph nodes, w/ or w/o pectoralis minor muscle, but excluding pectoralis major muscle	25
   8	Cholecystectomy;	24
   9	Repair inguinal hernia, sliding, any age	11
   10	Amputation, thigh, through femur, any level; re-amputaion	5

   
   
   

   10 Leading Minor Operations		Number
   1	Creation of arteriovenous fistula by other than direct arteriovenous anastomosis ; nonautogenous graft	181
   2	Insertion of cannula for hemodialysis, other purpose ; vein to vein	140
   3	Debridement of extensive eczematous or infected skin	61
   4	Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less	46
   5	Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm or less	38
   6	Dilation and curettage	28
   7	Percutaneous portal vein catheterization by any method	21
   8	Creation of arteriovenous fistula by other than direct arteriovenous anastomosis ; autogenous graft	13
   9	Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent	11
   10	Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, w/ or w/o fracture of ulnar styloid	7

• Profession/Position/Designation	Specialty Board Certified	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	Outsourced
  		Number of permanent full time staff	Number of contractual full time staff	Number of permanent part time staff	Number of contractual part time staff
  A. Medical
  1. Consultants	0	0	0	0	0	0	0
  1.1 Internal Medicine	0	0	0	0	0	6
  a. Generalist	0	0	0	0	0	0
  b. Cardiologist	0	0	0	0	0	6
  c. Endocrinologist	0	0	0	0	0	1
  d. Gastro-Enterologist	0	0	0	0	0	2
  e. Pulmonologist	0	0	0	0	0	4
  f. Nephrologist	0	0	0	0	0	6
  g. Neurologist	0	0	0	0	0	2
  1.2. Obstetrics/ Gynecology (and sub-specialty)	0	0	0	0	0	12
  1.3. Pediatrics (and sub-specialty)	0	0	0	0	0	10
  1.4. Surgery (and sub-specialty)	0	0	0	0	0	10
  1.5. Anesthesiologist	0	0	0	0	0	6
  1.6. Radiologist	0	0	0	0	0	5	0
  1.7. Pathologist	0	0	0	0	0	1	0
  2. Post-Graduate Fellows (Indicate specialty/subspecialty)	0	0	0	0	0	0	0
  3. Residents	8	0	0
  3.1. Internal Medicine	0	0	0
  3.2. Obstetricts-Gynecology	0	0	0
  3.3. Pediatrics	0	0	0
  3.4. Surgery	0	0	0
  B. Allied Medical
  1. Nurses		100	5
  2. Midwives		23	0
  3. Nursing Aides		19	0
  4. Nutritionist		1	0
  5. Physical Therapist		0	0
  6. Pharmacists		13	0
  7. Medical Technologist		26	5
  8. Laboratory Technician		1	0
  9. X-Ray Technologist/X-Ray Technician		13	0
  10. Medical Equipment Technician		4	0
  11. Social Worker		1	0
  12. Medical Records Officer/ Hospital Health Information Officer		1	0
  C. Non-Medical
  1. Chief Administrative Officer		1	0
  2. Accountant		2	0
  3. Budget officer		1	0
  4. Cashier		7	0
  5. Clerk		89	0
  6. Engineer		1	0
  7. Driver		4	0
  9. General Support Staff		0	0	0	0	0	0
  - Janitorial		0	0	0	0	0	0
  - Maintenance		9	0	0	0	0	0
  - Security		0	0	0	0	0	0
  Others, specify
  INSTITUTIONAL WORKER	0	28	0	0	0	0	0

• Report all money spent by the facility on each category.

  Expenses	Amount in Pesos
  Amount spent on personnel salaries and wages	86,327,628.93
  Amount spent on benefits for employees (benefits are in addition to wages/salaries. Benefits include for example: social security contributions, health insurance)	7,915,642.98
  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.)	23,784,661.31
  TOTAL amount spent on all personnel including wages, salaries, benefits and allowances for last year (PS)	118,027,933.22
  Total amount spent on medicines	105,577,971.78
  Total amount spent on medical supplies (i.e. syringe, gauze, etc.; exclude pharmaceuticals)	79,618,144.60
  Total amount spent on utilities	9,673,339.64
  Total amount spent on non-medical services (For example: security, food service, laundry, waste management)	119,343,343.78
  TOTAL amount spent on maintenance and other operating expenditures (MOOE)	314,212,799.80
  Amount spent on infrastructure (i.e., new hospital wing, installation of ramps)	36,650,996.58
  Amount spent on equipment (i.e. x-ray machine, CT scan)	16,096,479.40
  TOTAL amount spent on capital outlay (CO)	52,747,475.98
  GRAND TOTAL	484,988,209.00

• Please report the total revenue this facility collected last year. This includes all monetary resources acquired by this facility from all sources including donations.

  Revenues	Amount in Pesos
  Total amount of money received from the Department of Health	10,894,187.45
  Total amount of money received from the local government	3,552,793.19
  Total amount of money received from donor agencies (for example JICA, USAID, and others)	187,750.00
  Total amount of money received from private organizations (donations from businesses, NGOs, etc.)	0.00
  Total amount of money received from Phil Health	99,036,885.50
  Total amount of money received from direct patient/out-of-pocket charges/fees	330,474,588.10
  Total amount of money received from reimbursement from private insurance/HMOs	100,845,219.43
  Total amount of money received from other sources (PAGCOR, PCSO, etc.)	18,135,523.74
  GRAND TOTAL	563,126,947.41

  If donation is in kind, please put equivalent amount in peso

Report Prepared by: INEGO PAOLO M. PACA

Designation/Section/Department: Medical Records Clerk / Medical Records / Medical Records   Date: Mar. 31, 2022

Report Approved and Certified by : SANDRA ANGELICA FIEL CHIONG   Date: _______
Chief of Hospital/Medical Director