ANNEX A.O. No. 2012-0012 ANNUAL HOSPITAL STATISTICAL … · Department of Health BUREAU OF HEALTH...

Department of Health

BUREAU OF HEALTH FACILITIES AND SERVICES

ANNEX – E A.O. No. 2012-0012

ANNUAL HOSPITAL STATISTICAL REPORT

YEAR 2013

Name of Hospital: DR. JOSE FABELLA MEMORIAL HOSPITAL__ Street Address: _Lope de Vega, Sta. Cruz, Manila_

Municipality: __________________ Province : ______________ Region: _National Capital Region __

Contact No.: ___ 734-55-61 _______ Fax Number: ___ 734-71-46 ______________

Email Address: _____________________________________________________________________________

(PLEASE FILL OUT ALL ITEMS. PUT N/A IF NOT APPLICABLE.)

I. GENERAL INFORMATION

A. Classification

1. Service Capability

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

other services

General: Specialty: (Specify)

[ ] Level 1 Hospital [ ] Treats a particular disease (Specify):_______________

[ ] Level 2 Hospital [ ] Treats a particular organ (Specify):________________

[ ∕ ] Level 3 Hospital (Teaching/ Training) [ ] Treats a particular class of patients (Specify):________

[ ] Others (Specify):____________

Trauma Capability: [ ] Trauma Capable [ ] Trauma Receiving

2. Nature of Ownership

Government: Private:

[ ∕ ] National –DOH Retained/ Renationalized [ ] Single Proprietorship/Partnership/Corp.

[ ] Local (Specify): [ ] Religious

[ ] Province [ ] Civic Organization

[ ] City [ ] Foundation

[ ] District [ ] Others (Specify):________________

[ ] Municipality

[ ] DND/ DOJ

[ ] State Universities and Colleges (SUCs)

[ ] Others (Specify):_________________

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ANNEX – E A.O. No. 2012-0012

B. Quality Management

Quality Management/ Quality Assurance Program: Organized set of activities designed to demonstrate on-going

assessment of important aspects of patient care and services

[ ] ISO Certified (Specify ISO Certifying Body and

area(s) of the hospital with Certification) Validity Period ____________

[ ] International Accreditation Validity Period ____________

[ ] PhilHealth Accreditation Validity Period : December 31, 2014

[∕ ] Basic Participation

[ ] Advanced Participation

[ ] PCAHO Validity Period ____________

C. Bed Capacity/Occupancy

1. Authorized Bed Capacity: 700 beds

Authorized bed: Approved number of beds issued by BHFS, the licensing agency of DOH.

2. Implementing Beds: 479 beds

Implementing beds: Actual beds used (based on hospital management decision)

3. Bed Occupancy Rate (BOR) Based on Authorized Beds: ______%

(Total Inpatient service days for the period)**

(Total number of Authorized beds) x (Total days in the period) X 100

Bed Occupancy Rate: The percentage of inpatient beds occupied over a period of time. It is a measure of the

intensity of hospital resources utilized by in-patients. Inpatient Service days: Unit of measure denoting the services received by one in-patient in one 24 hour period.

**Inpatient Service days (Bed days) = [(Inpatients remaining at midnight + Total admissions) – Total

discharges/deaths) + (number of admissions and discharges on the same day)].

Bed Occupancy Rate ( BOR )

A. Based on Authorized Bed

Including Newborn = 125.78%

Excluding Newborn= 68.38%

B. Based on Implementing Bed Including Newborn = 184.11%

Excluding Newborn= 99.92%

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ANNEX – E A.O. No. 2012-0012

II. HOSPITAL OPERATIONS

A. Summary of Patients in the Hospital

For each category listed below, please report the total volume of services or procedures performed.

*Inpatient: A patient who stays in a health facility while under treatment.

*Bed day: Bed used for a continuous 24 hours by an inpatient.

Inpatient Care

Number

Total number of inpatients (admissions, including newborns)

48,853

Total Discharges (Alive) 47,253

Total patients admitted and discharged on the same day

55

Total number of inpatient bed days (service days)

321,889

Total number of inpatients transferred TO THIS FACILITY from another facility for inpatient care

2,388

Total number of inpatients transferred FROM THIS FACILITY to another

facility for inpatient care 31

Total number of patients remaining in the hospital as of midnight last day of previous year

730

B. Discharges

Kindly accomplish the “Type of Service and Total Discharges According to Specialty” in the table below.

Type

of

Service

No of

Pts

Total

Length

of

Stay/ Total

No. of

Days Stay

Type of Accomodation Condition on Discharge

Non- Philhealth

Philhealth

H

M

O

O

W

W

A

R

/

I

T H A U

Deaths

Total

Dis-

charges

Pay

Service

Charity

Total

Pay

Service

Total

< 48

hrs

> 48

hrs

Tot

al

Member/

Dependent

Indi-

gent

Obstetrics 22,195 131,049 367 18,602 18,969 604 115 2,402 3,121 0 105 0 2 31 28 0 4 4 8 22,195

Gynecology 771 4,147 48 369 417 108 9 198 315 0 39 0 1 4 2 0 0 3 3 771

Pediatrics 786 9,357 0 539 539 0 11 233 244 0 3

0

0 0 6 0 0 26 44 70 786

Surgery: 12 135 0 12 12 0 0 0 0 0 0 0 0 0 0 0 0 1 1 12

Pedia 0 135 0 12 12 0 0 0 0 0 0 0 0 0 0 0 0 1 1 12

Adult 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Others,

Specify

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 23,764 144,6888 415 19,522 19,937 712 135 2,833 3,680 0 147 0 3 41 30 0 30 52 82 23,764

Total

Newborn

6225 30,011 0 4,575 4,575 126 64 1,433 1,623 0 27 0 3 523 0 0 265 369 634 6,225

-Pathologic 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

-Non-Patho 17,980 147,190 0 13,275 13,275 0 212 4,445 4,657 0 48 0 0 0 0 0 0 0 0 17,980

* R/I – Recovered/Improved T- Transferred U – Unimproved H- Home Against Medical Advice A – Absconded D – Died (died upon admission)


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ANNEX – E A.O. No. 2012-0012

1. Average Length of Stay (ALOS) of Admitted Patients Total length of stay of discharged patients (including Deaths) in the period Total discharges and deaths in the period

Average length of stay: Average number of days each inpatient stays in the hospital for each episode of care.

Including Newborn = 5.81 days

Excluding Newborn =5.77 days

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.

Cause of Morbidity/Illness/Injury Number ICD-10 Code

(Individual)

1. Spontaneous Delivery by Low Risk

8,369 O80.0

2. Delivery by Cesarean Section

6,101 O82.0

3. Spontaneous Delivery by High Risk

4,098 O80.0

4. Complete Abortion ( all types )

1,166 O03.9

5. Neonatal Pneumonia

864 P24.9

6. Sepsis all forms

739 P36.0

7. Potentially Septic

683 P36.9

8. Pneumonia

368 J18.9

9. Pediatric Community Acquired Pneumonia

227 J18.9

10. Abdominal Uterine Bleeding

202 N93.9


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ANNEX – E A.O. No. 2012-0012

3. Total Number of Deliveries

For each category of delivery listed below, please report the total number of deliveries.

Deliveries

Number ICD-10 Code

Total number of in-facility deliveries 18,893 Z38.0

Total number of live-birth vaginal deliveries (normal)

12,467 O80.0

Total number of live-birth C-section deliveries (Caesarians)

6,101 O82.0

Total number of other deliveries

Delivery by Partial Breech Extraction

Delivery by Forceps Extraction

196

129

O83.0

O81.0

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

36,766

Number of outpatient visits, re-visit

51,561

Number of outpatient visits, adult

66,085

Number of outpatient visits, pediatric

22,242

Number of adult general medicine outpatient visits

3,411

Number of specialty (non-surgical) outpatient visits

3,858

Number of surgical outpatient visits

246

Number of antenatal care visits

36,742

Number of postnatal care visits

5,135


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ANNEX – E A.O. No. 2012-0012

Emergency visits

Number

Total number of emergency department visits

10,431

Total number of emergency department visits, adult

7,537

Total number of emergency department visits, pediatric

2,894

Total number of patients transported FROM THIS FACILITY’S

EMERGENCY DEPARTMENT to another facility for inpatient care

239

Testing

Number

Total number of medical imaging tests (all types including x-rays, ultrasound,

CT scans, etc.)

24,564

Total number of laboratory and diagnostic tests (all types, excluding medical

imaging)

233,138

Other services and diseases seen

Number

Total number of outreach or home visits

15

Total number of immunization doses administered to children 0-59 months at

this facility or during outreach or home visits. Include immunizations

administered during child health weeks.

42,774

Total number of newly diagnosed cases of TB

( OPD cases )

159

Total number of confirmed cases of dengue

50

C. Deaths

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

Types of deaths

Number

Total deaths

716

Total number of inpatient deaths

Total deaths < 48 hours 295

Total deaths > 48 hours 421


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ANNEX – E A.O. No. 2012-0012

Total number of emergency room deaths

1

Total number of cases declared ‘dead on arrival’

0

Total number of stillbirths

372

Total number of neonatal deaths

634

Total number of maternal deaths

8

1. Gross Death Rate= 1.49% Gross Death Rate = Total Deaths (including newborn for a given period) Total Discharges and Deaths for the same period x 100

2. Net Death Rate= 0.88% Net Death Rate = Total Death (including newborn for a given period) – death <48 hours for the period

Total Discharges (including deaths and newborn) – death<48 hours for the period x 100

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

Mortality/Deaths

Number ICD-10 Code

(Individual)

1. Respiratory Distress Syndrome

182 P22.0

2. Sepsis all forms

128 P36.0

3. Dissimenated Intravascular Coagulopathy

87 P60.0

4. Septic Shock

86 A41.9

5. Persistent Pulmonary Hypertension

36 P29.2

6. Birth Asphyxia

21 P21.9

7. Respiratory Failure

18 J96.9

8. Perinatal Asphyxia

17 P20.0

9. Multiple Congenital Anomaly

15 Q89.7

10. Anencephaly

13 Q00.0


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ANNEX – E A.O. No. 2012-0012



ANNEX – E A.O. No. 2012-0012

D. Healthcare Associated Infections (HAI)

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 (Levels 1, 2, 3 General and Specialty)

INFECTION RATE = Number of Healthcare Associated Infections x 100

Number of Discharges

808 x 100

47,969

= 1.68%

a. Device Related Infections

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

Total Number of Ventilator Days

173 x 1000

3,555

= 48.66 VAP/ 1,000 Ventilator Days

2. Blood Stream Infection (BSI) = Number of Patients with BSI x 1000

Total Number of Central Line

514 x 1000

2,764

= 185.96 BSI / 1,000 Central Line Days

3. Urinary Tract Infection (UTI) = Number of Patients with UTI x 1000

Total Number of Catheter Days

7 x 1000

6,461

= 1.08 UTI / 1,000 Catheter Days

b. Non-Device Related Infections

Surgical Site Infections (SSI) = Number of Surgical Site Infections x 100

Total number of Procedures

36 x 100

10,545

= 0.34

E. Surgical Operations

1. Major Operation refers to surgical procedures requiring anesthesia/ spinal anesthesia to be performed in an operating

theatre. (The definition of a major operation shall be based on the definitions of the different cutting specialties.)

2. Minor Operation refers to surgical procedures requiring only local anesthesia/ no OR needed, example suturing.

10 Leading Major Operations (excluding Caesarian

Sections)

Number ICD-10 Code

1. Salpingectomy 212 5-661

2. Abdominal Hysterectomy 209 5-683

3. Salpingooohorectomy 30 5-655

4. Vaginal Hysterectomy 23 5-684

5. Myomectomy 19 5-684

6. Cysterectomy 10 5-575

7. Adnexectomy 7 -

8. Radical Hysterectomy 6 5-685

9. Exploratory Laparotomy 7 5-541

10. Oophorectomy 5 5-652


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ANNEX – E A.O. No. 2012-0012

10 Leading Minor Operations

Number ICD-10 Code

1. Laceration 4,767 5-738

2. Episiotomy 4,078 5-738

3. Bilateral Tubal Ligation 2,545 Z30.2

4. Completion Curettage 1,166 5-690

5. Delivery by Breech Extraction 196 5-727

6. Delivery by Forceps Extraction 129 5-721

7. Dilatation and curettage 139 5-690

8. Endometrial Curettage 83 5-690

9. Suction Curettage 62 5-690

10.Fractional Curettage 11 5-690

2 STAFFING PATTERN (Total Staff Complement)

Profession/ Position/

Designation

Total staff working full time

(at least 40 hours/week)

Total staff working part time


Active

Rotating

or

Visiting/

Affiliate

(For

Private

Facilities)

Out-

sourced

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

A. Medical 1. Consultants (indicate

One-Peso consultant) 29 8 4*

1.1. Internal Medicine

a. Generalist 1

b. Nephrologist 1

c. Surgery 1 1.2. Obstetrics/Gynecology

( and subspecialty

a. Gynecologic-

oncology

1 1

b. Reproductive

Endocrinology &

Infertility

1 2

c. Perinatology and

Ultrasound

1 1

d. Infectious Disease 1

e. Ultrasound 1

f. Trophoblastic Disease 1

g. Maternal & Fetal

Medicine

1

1.3. Pediatrics ( and

subspecialty)


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ANNEX – E A.O. No. 2012-0012

Cont. of STAFFING PATTERN (Total Staff Complement)


Designation





Active Rotating

or Visiting/

Affiliate

(For Private

Facilities)

Out-

sourced

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

a . Neonatology 2 2

b. Pediatric Intensive Care

1

c. Pedia Cardiology 1

d. Pediatric Infectious

Disease

1

e. Pediatric

Nephrology

1

f. Pediatric Surgery 1

g. Developmental

Pediatrics

1

h. Pediatric

Gastroenterology &

Nutrition

1

i. Child Neurology 1

1.4 Anesthesiologist

a. Pediatric

Anesthesiology

1

2.Post Graduate Fellows

a, Fellowhip in

Neonatology

4

3.Residents

3.1 Obstetrics-

Gnecology

47

3.2 Pediatrics 12

3.3 Anesthesiology 5

B. Allied Medical

1. Nurses 292

2. Midwives 128

3. Nursing Aides 19

4. Nutritionist 8

5. Pharmacists 21

6. Medical

Technologist

14

7. Radilogic

Technologist

8


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ANNEX – E A.O. No. 2012-0012


Designation





Active Rotating

or Visiting/

Affiliate

(For Private

Facilities)

Out-

sourced

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

Number of

permanent

staff

Number of

contractual

staff

Number

of

volunteer

staff

8. Chemist 2

9. Medical Lab. Tech 5

10. Dentist 7

11. Dental aide 2

12. Laboratory Aide 9

C. Non-Medical

1. Social Workers 10 2. Administrative Officer 21

3. Attorney 1

4. Engineer 2

5. Accountant 2

6. Psychologist

7. Security Officer II 1

8. Legal Assistant 1 9. Presidential Staff Asst. 1

10. Statistician I 1 11. Administrative Asst. III 8 12. Administrative Asst. II 17

13. Draftsman II 1 14. Administrative Asst. I 1 15. Administrative Aide VI 42

16. Laundry Worker III 1 17. Administrative Aide V 6

18. CookII 5

19. Master Tailor I 2

20. Security Guard II 6

20.Administrative Aide IV 55

21.Administrative Aide II 54

22.Cook I 1

23. Laundry Worker II 2

24. Security Guard I 4

25. Tailor 1

26. Administrative Aide II 3

27.Seamstress 4

28. Laundry Worker I 2

29. Administrative Aide I 59


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ANNEX – E A.O. No. 2012-0012

IV.EXPENSES Report all money spent by the facility on each category.

Expenses

Amount in Pesos

Amount spent on personnel salaries and wages

P248,362,624.37

Amount spent on benefits for employees (benefits are in addition to wages/salaries. Benefits include for example: social security contributions, health insurance)

33,958,275.27

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.)

108,600,284.25

TOTAL amount spent on all personnel including wages, salaries, benefits and allowances for last year (PS)

P 390,921,183.89

Total amount spent on medicines funded by the Revolving Fund

20,924,318.21

Total amount spent on medicines funded by the Government of the Philippines (from any level of government, including the central, provincial and municipal governments)

424,003.68

Total amount spent on medical supplies (i.e. syringe, gauze, etc.; exclude pharmaceuticals)

31,999,597.94

Total amount spent on utilities

20,947,230.48

Total amount spent on non-medical services (For example: security, food service, laundry, waste management)

140,185,698.66

TOTAL amount spent on maintenance and other operating expenditures (MOOE)

P 214,480,848.97

Amount spent on infrastructure (i.e., new hospital wing, installation of ramps)

2,576,618.72

Amount spent on equipment (i.e. x-ray machine, CT scan) 48,876,929.23

TOTAL amount spent on capital outlay (CO) P 51,453,610.95

V.REVENUES Please report the total revenue this facility collected last year. This includes all monetary resources acquired by this facility from all sources, and for all purposes.

Revenues

Amount in Pesos

Total amount of money received from the Department of Health P 61,548,000.00

Total amount of money received from the local government None

Total amount of money received from donor agencies (for example JICA, USAID, and others) None

Total amount of money received from private organizations (donations from businesses, NGOs,

etc.)

None

Total amount of money received from Phil Health 68,382,112.25

Total amount of money received from direct patient/out-of-pocket charges/fees 66,052,266.06

Total amount of money received from reimbursement from private insurance/HMOs None

Total amount of money received from other sources (PDAF, PCSO, etc.) 3,580,950.00

TOTAL Revenue

P199,563.328.31


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ANNEX – E A.O. No. 2012-0012

Report Prepared by : Emelita F. Sanchez

Designation/Section/Department : Statistician I Date: _______

Report Approved and Certified by : RUBEN C.FLORES, M.D.,M.H.A._ Date: _______

Chief of Hospital/Medical Director

__________________________________________________________________________________________________________

PREPARED BY:

STANDARDS DEVELOPMENT DIVISION (SDD)

BUREAU OF HEALTH FACILITIES AND SERVICES (BHFS)

DEPARTMENT OF HEALTH (DOH)

APPROVED BY:

ATTY. NICOLAS B. LUTERO III, CESO III

ASSISTANT SECRETARY

DOH


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ANNEX A.O. No. 2012-0012 ANNUAL HOSPITAL STATISTICAL … · Department of Health BUREAU OF HEALTH...

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