Summary of Regulatory Issuances (SuRI) Tracker

Introduction

Regulatory bodies’ advancement and improvement in policy development results to revisions of existing regulatory standards and requirements. Fast paced implementation of these policies affects the hospital’s policies and procedures, existing controls and infrastructure. Non-compliance(s) to regulatory standards may result to revocation of license to operate or a cease and-desist order to provide the related medical service.

Citations from regulatory bodies, particularly when publicized, may damage the hospital’s reputation and affect its relationship with the patients.

The Summary of Regulatory Issuances Tracker (SuRI) was developed to monitor the status of the action items required by the regulatory body based on new issuance and revisions to existing standards. Hospital License Department of Makati Medical Center developed this tracker to aid the officers in monitoring and cascading the regulatory requirements.

The SuRI tracker facilitates continuous improvement thru early planning, active identification and correction of gaps based on the new issuance, validation of the hospital’s compliance status and monitoring the status of its implementation.

 

Problem

When the Universal Healthcare Act in the Philippines was implemented during the COVID-19 surge, numerous policies were released. It was a challenge for the department to monitor the current issuances and ensure that required changes in the organization are implemented. This simple tool to monitor all applicable laws released by regulatory and certifying bodies improved the hospital’s readiness.

 

Aim

To ensure compliance to all newly released regulatory issuances. Cascade and prepare the hospital for the implementation of the new standards.

 

Method

1.  Hospital License Officers (HLO) monitors regularly the official website of the regulatory/certifying body and reads the newspaper to monitor newly released issuances. Issuances may be in the form of administrative orders, published presidential orders, regulatory/certifying body memorandum, Republic Acts and Joint Orders and may come from multiple agencies.

2.  Hospital License Department cascades new issuance(s) to concerned departments 24-72 hours upon publication in a newspaper of general circulation. For new issuances, HLO identifies the hospital’s compliance status based on new/ revised standards. HLO cascades the new issuances to concerned departments and communicates all applicable laws, regulations, and accreditation requirements to the Medical Director and the President & CEO.

3.  To ensure implementation of this strategy, the department developed a Hospital Policy and Procedure to emphasize the roles and responsibilities of the departments in the process of preparing the hospital comply with the new/ revised standards.

4.  In case of potential non-compliance or the issuance requires change(s) in the hospital process, HLO discusses action plans with concerned departments and to the Senior Quality Management Council. HLO disseminates approved action plans to comply with the new/revised issuance. Strategies to comply with the requirements are monitored and ensure its implementation before the effectivity date of the issuance.

 

 Results

-  Continuity of Business Operations

-  Zero citations from the Department of Health

-  100% required reports are submitted on time

-  Continuous Compliance

- Gawad Bayani Kalusugan Team Winner

-  First DOH-licensed Cancer Specialty Center in a General Hospital in the Philippines

-  Better forecasting of clinical services expansion

- Department of Health - Philippines Hospital Star Awardee

-  Ensure patient and employee safety

To date, new issuances that required changes in the organization are already closed.  110 out of 110 (100%) newly released regulatory issuances last 2022 are tagged as closed.  56 out of 56 (100%) newly released regulatory issuances last 2021 are tagged as closed.

 

Conclusion

Interdepartmental communication played a crucial role in (1) identifying strategies to comply with the requirements;
(2) ensuring compliance of the hospital to regulatory requirements; (3) synergizing implementation of the planned strategies;
(4) improving awareness and literacy on applicable laws in healthcare industry.

The objective to monitor newly released issuances and ensure that the hospital is prepared for the upcoming changes required by the regulatory bodies was met. To further improve the hospital’s compliance, action plans to address/resolve non-compliances are monitored. Hospital License Department have expanded its scope from evaluating departments’ compliance with standards from regulatory bodies thru internal quality survey to assisting these departments to comply and educating them with the new required standards.

 

Contact Information

Makati Medical Center

Hospital License Department

Address:  No. 2 Amorsolo Street, Legaspi Village, Makati City, Philippines 12229

Telephone No.: + 632 8888 8999

Email: license.policies@makatimed.net.ph