Program: Master of Arts in Nursing

Major: Maternal and Child Nursing

Course: N 205 Nursing Administration
Professor: Dr. Federico V. Nagtalon
Student: Eunice Aimee R. Laxamana
Paper III: Think about your last clinical rotation experience. Identify one process that you
believe could be improved and describe how you would begin improving the process. Using the
FOCUS Methodology would be helpful.
Date: September 13, 2014

The day-to-day cycle at the City Health Office of Batac (CHO-Batac) starts with the nurses and
ends with the nurses. The CHO-Batacs processes have adapted the functional delegation scheme to
individually cater to the client/patients needs, especially at this point where they have a large pool of
nurses including Sagip Nars by the Provincial Government of Ilocos Norte (PGIN), Nurse Deployment
Program(NDP) by the Department of Health, and Volunteers approved by the City Government of Batac
(CGB). The nurses are delegated to tasks under Information, Admitting, Weight Monitoring,
Laboratory, Consultation and Pharmacy. Information Nurses are responsible in controlling the
number of patients that the City Health Officer (CHO) checks in the morning and in the afternoon by
providing patient numbers; in searching patient family folders; and in directing clients to the CHO-Batac
Departments Dentist, Sanitation, Cashier, Laboratory. Admitting Nurses performs primary assessment
of patients and jots down the patient chief complaints including its quality and duration. Weight
Monitoring Nurses are responsible in weighing pediatric and maternal clients for their admitting
information, and in weighing Pantawid Pamilyang Pilipino Program or 4Ps clients, in which their
weight is being recorded in logbooks. Laboratory Nurses assist in phlebotomy and in recording of
requests and results. Consultation Nurses assist the CHO in organizing folders of patients according to
their order at the information desk. Pharmacy Nurses assist in dispensing prescribed medications to
patients who came from the CHO consultation, and in organizing the available medications by inventory.
When the patient or client is directed to the dentist, the dental aide assists them and the dentist in the
dental clinic. When the client is directed to the Sanitation department, the Sanitation inspectors identify
the client according to their catchment areas and are properly assisted in acquiring a sanitary permit.
When the client is directed to the cashier, the cashier breaks down the payment and provides an official
receipt (OR) provided by the CGB. When the client is directed to the laboratory with a request, the nurse
or the medical technologist available will promptly collect blood sample and/or provide the appropriate
specimen collector with proper instruction; and then immediately process the collected specimen, in
which results are being jotted in the logbooks for references. Every Wednesday is Immunization Day,
and a function for Immunization Nurse is added, where the nurse is responsible in vaccinating Expanded
Program on Immunization (EPI) target clients. The midwives, on the other hand, without the Sagip Nars,
NDP and volunteers are responsible for the delegated tasks on top of maintaining records of
immunization, maternal cases, tuberculosis (TB) and multi-drug resistant TB (MDR-TB) Cases,
Consultation Census within their catchment area and community visits. Clients/Patients who need wound
dressing are attended by available the available nurses/midwives. This is the life at the CHO-Batac.
Deming, who is considered to be a quality management hero, introduced the plan-do-check-act
cycle which was later adapted to the acronym FOCUS-PDCA a methodology for continuous quality
improvement. FOCUS-PDCA stands for (F) Find a process to improve; (O) Organize a team that knows
the process; (C) Clarify current knowledge of the process; (U) Understand causes of process variation; (S)
Select the process improvement; (P) Plan the improvement and continue data collection; (D) Do the
improvement, data collection and analysis; (C) Check the results and lessons learned from the team effort;
(A) Act to hold the gain and continue to improve the process. (Ann Marinner-Tomey). Undertaking the
FOCUS-PDCA Methodology in all the processes an organization is a painstaking job for a
manager/leader. It needs careful analysis of all the processes. Quality assurance and quality improvement
goes hand-in-hand in developing organizations it never ceases and it constantly changes for the better.
Indeed, evaluating then planning and implementing again and again is a vicious cycle and it can get
tiresome uncomfortable. However, it needs to be done to continually cater to the organizations
constantly varying clientele.

Applying the FOCUS Methodology to CHO-Batac Process
Find a process to improve. This step of the method involves: a complete organization self-
assessment (determining if the organization meets the clinical standards in the provision of care); area for
improvement selection (completing an Identifying Improvement Worksheet (IIW)); data collection to
understand scope of problem and possible reasons for problem (reviewing records and reviewing findings
on IIW).
Does the CHO-Batac meet the clinical standard in the provision of care? According to the
Philippine Health Service Delivery Profile (PHSD Profile) in 2012, the Local Government Units (LGUs)
like the CHO-Batac, as part of the provider network for healthcare services, deliver health promotion,
disease prevention, primary, secondary, and long-term care. In the Summary of Health Services and
providers in the Philippines, 2012 under the PHSD Profile, the CHO-Batac is classified to be under the
Public Sector in Category A: Primary Care Facility and can be considered as a health center, local
government unit, community health team and are supposed to have the following services: under health
promotion health education, family planning, maternity care, prenatal care for mothers, child care,
nutrition and food safety, lifestyle-related or non-communicable diseases, communicable diseases,
environmental health and sanitation; under disease prevention childhood immunization, TB, Malaria,
Leprosy, Filariasis, Schistosomiasis, Rabies, Dengue Fever, and Severe Acute Respiratory Syndrome
(SARS), Human Immunovirus (HIV) and other Sexually Transmitted Infections (STI), environmental and
health sanitation, diabetes, hypertension, and cancer; under primary services - out-patient, dental and
laboratory services, disease programs like TB, Malaria and Dengue; under secondary services outpatient
care, acute and emergency care, and dental care; and under long-term care or rehabilitative services
long-term care for the elderly and disabled and programs for the disabled.
Although the PhilHealth Benchbook outlines all standars of quality processes and outcomesfor
hospitals, primary health care facilities and lower level hospitals are bypassed because of similar
perceptions of low quality.
Clearly, the CHO-Batac is providing the services it is supposed to offer. However, being a
primary health care facility, it is being looked down. Therefore, there must be some areas that need
improvement when it comes to the quality of delivery of the services being provided. The IIW briefly
assesses what the problem, challenge or opportunity is and the evidences that the problem, challenge or
opportunity needs fixing. In the case of the CHO-Batac, there is a national problem in which its
counterpart primary health care facilities are being looked down to. Down to the level of the CHO-Batac,
it is explicitly evident that some of its clientele are displeased or unsatisfied with its performance as it can
no longer function as a consultation clinic with readily available medicines when the CHO is not around.
Moreover, the CHO-Batac only has one physician and this further limits the number of clientele being
catered to. This problem gives the target clientele the idea that the CHO-Batac is worthless, especially
those that do not meet the cut-off for patients which defies easy access as pillar of primary health
care. In addition, this may reflect that the disease prevention services of the CHO-Batac are not effective
or good enough that more clients come by for treatment each day.
Organize to Improve the Process. This process involves creating a team with appropriate staff
for addressing the problem and determining a goal statement for improvement. An effective team is the
key to achieving improvement and its members should be based on knowledge of, and involvement in
process directly impacting patient care. There should be a champion who is expert about the topic, a
decision-maker who has the authority to promote or enhance the implementation of the improvement,
and day-to-day leaders who have expertise or special knowledge about the core process. (Primaris
Healthcare Business Solutions).
Considering that time and funds are easily provided, a meeting among qualified representatives of
the CHO Clientele, the head of the LGU that is the City Mayor, the head of CHO-Batac that is the
CHO, the head of the Provincial Head Office (PHO), and the Provincial Governor should take place and it
should be initiated by the Clientele Representative. The champions would be the PHO and CHO, the
decision makers would be the City Mayor and the Governor, and the Day-to-Day Leaders would be the
qualified Clientele Representatives. Ultimately, there will be barriers among the members and these could
be managed by having all the team members acknowledge that there is a need to be addressed the
problem: limited clientele catered to due to lack of consultation manpower; listen to viewpoints of the
members regarding the problem; agree to disagree with perceived as infeasible ideas; take responsibility
for reaching to a solution to the problem; and focus on resolving the conflict.
Teams have goals and it should be set as a clear statement of improvement and how it is to be
measured. It will serve as a means to focus and establish boundaries and define success. This is the goal:
By the end of 2016, the number of clientele served by the CHO-Batac will increase by 50% to 100%.
Clarify Current Knowledge of the Process. This step is defining the current process what is
being done. What is being done is usually evaluated by what policies and procedures there are for
procuring this process. Attaining the goal of having additional physicians means adding positions in the
LGU as prescribed in the Local Government Code. This means that it will involve the legislative and
executive bodies of the CGB and PGIN to create positions that are within the constraints of the LGU
funds.
Understand Sources of Process Variation. This is usually done with a Root-Cause Analysis
team and begins by focusing on three key questions: (1) What happened? ; (2) Why did it happen? ; And
(3) What are we going to do to prevent it from happening in the future? (Primaris Healthcare Business
Solutions)
Answering the questions: (1) The quality of care being provided is being jeopardized because the
Primary Health Care Provider cannot provide care to its clientele the community, as a whole,
particularly in consultations. (2) There is not enough consultation manpower, particularly physicians, to
attend to all the clientele needing primary health care. (3) Open an appropriate number of positions for
assisting physicians to compensate for the ideal doctor-patient ratio of 1:10,000.
Select the Process Improvement. This step of quality improvement is developing a change in
process by identifying an improvement based on the RCA. Eventually, change will always be needed to
improve the plan and the process and the team has to identify changes that need to occur based on RCA
results.
For instance that RCA analysis shows that there are to processes that may solve the problem: (1)
Add positions for physicians to cater to more number of clients; (2) Improve disease prevention services
to decrease number of clients per day. The team should identify what is to be changed through
establishing criteria that will help evaluate all the solutions like cost, potential benefits, potential problems
and ease of implementation; brainstorming on all solutions before rejecting any ideas by asking (1) can
we do this another way? (2) can it be done somewhere else and in another time? (3) can someone else do
it and (4) why do we do it the way we do now?; and evaluating the solutions arrived and arrive at a
consensus.
Certainly, improving disease prevention services through widespread health teachings that may
taper down and developing specific programs may cost less compared to hiring new physicians who will
be requiring a monthly salary until their contracts end or their retirement. Potential benefits of improving
disease prevention services promotes herd immunity and community empowerment while hiring new
physicians will address the problem of manpower shortage and the facility will be able to cater to more
number of clientele. Potential problems of improving disease prevention will be the training of available
manpower, and its duration while hiring new physicians will probably dole out the communitys desire to
keep themselves healthy as they perceive that there is always a physician to attend to them when they are
in need. As to ease of implementation, both processes need rigorous paper works improving disease
prevention will require requests for funding of trainings and community meetings which will lead to an
evaluation of feasibility of the program by the LGU which really takes time, while hiring new physicians
will require requests for the opening of new positions for physicians, the hiring process, the selection of
qualified applicants, orientation, and contracts which will also take time.
Weighing the pros and cons of both identified solutions, and for instance, improving disease
prevention was chosen over hiring new physicians, the PDCA may commence.
Starting the Change
Being the pioneer of this improvement, following the PDCA process is a viable idea. Plan-Do-
Check-Act: The FOCUS process is simply the planning part of the PDCA by developing a process
improvement plan. Executing the plan is Do-ing it and initiating it will involve requesting for a training
on effective health teaching for the selected available manpower. Once the manpower training is done, a
widespread health education involving disease prevention utilizing the Community Empowerment
Conceptual Model or Community Involvement in Health Conceptual Model (CIH-CM) by the World
Health Organization will take place. After the initial action, an evaluation (check) will be done with the
parameters of community health indicators in a particular disease. For instance, a health teaching on
dengue prevention was done in a particular township or barangay, evaluation parameters will involve the
mortality and morbidity rate of pneumonia cases in that particular barangay and a decrease in both at any
degree may imply success while a no change to an increase may imply failure. Failure of the plan will
require searching for other options like improving environmental sanitation parameters and others that
may arise in the process. Any change in the plan according to the evaluation must be implemented (act)
and then re-evaluated and the process goes on until such time that there is an improvement in the
parameters being set.
Conclusion
FOCUS-PDCA is an important continuing quality improvement tool and if properly
implemented, it may lead to a quality living by the community. It is but appropriate to make plans flexible
and to allow change for what is better. The CHO-Batac client threshold is in fact a limitation that needs to
be addressed. In the history of the CHO-Batac, there had been two physicians and the CHO, formerly the
Rural Health Unit (RHU), was less congested than at present and community visits were more often done.
As much as the CGB allows and has the means to do so, both processes improved disease prevention
and hiring a new physician, are highly recommended for the CHO-Batac.

References
Primaris Healthcare Business Solutions. 2008 Quality Improvement in FOCUS: Your Rapid Cycle
Improvement Guide to Achieving Results. Missouri
Tomey, Ann Marinner. 2004. Guide to Nursing Leadership and Management. St. Louis. Mosby

World Health Organization and Philippine Department of Health. 2012 Philippine Health Service
Delivery Profile. Philippines