Author name: Reniel Sanchez

“Mary Johnston Hospital (MJH) has really leveled up since our last visit!” This was the remark of Engr. Maria Axxess Retirva, one of the accreditors of the Philippine national government’s Department of Health (DOH). “It’s a pleasant surprise for me to know that MJH is the only hospital that is serious in its effort to its wards by providing a restroom for each patient and their guardians,” Engr. Retirva added. “Who knows what we will find our in our next visit!” This was after the DOH’s Health Facilities and Services Regulatory Bureau (HFSRB) paid a two-day visit to thoroughly inspect the United Methodist Church-affiliated mission hospital. Dr. Ma. Abigail G. Principe, Medical Specialist II, led the DOH team comprised of: Mr. Joven Arlu Pondevida, RN, Licensing Officer III; Engr. Retirva, Engineer II; and Mr. Seigfred Petines, RMT, Licensing Officer II. The two-day visit started on April 4, 2025. On the first day, the DOH-HFSRB conducted a meticulous review of various documents that included policies, procedures, and committee meeting minutes mandated for a Level 3 hospital. These included areas such as Credentialing and Privileging, Blood Transfusion, Healthcare Waste Management, Patient Safety, Infection Prevention and Control, Antimicrobial Stewardship, Pharmacologic and Therapeutic practices, Emergency and Disaster Preparedness, Continuous Quality Improvement, Grievance procedures, and Information and Communication Technology protocols. Additionally, they scrutinized patient charts across different departments, evaluated the electronic medical records system, assessed patient satisfaction levels, examined incident/sentinel event reporting, analyzed statistical reports, reviewed operational plans and training protocols, assessed disease surveillance measures, ensured compliance with occupational safety and health programs, and verified the certificate of compliance. In the afternoon, the team embarked on a comprehensive hospital tour, visiting key areas such as the Operating and Delivery Room, Emergency room, and Dispensary Unit. It also checked MJH’s compliance with land ambulance requirements. It also assessed laboratory and diagnostic services, including radiology and the heart station, as well as other ancillary medical services such as Dietary and Pulmonary care. Also, they evaluated nursing services, including critical care, nursing wards, hemodialysis, central supply, and sterilization facilities. The team members also inspected the newly renovated private and ward rooms. On the second day, the DOH-HFSRB continued its thorough examination of documents, covering a range of healthcare laws and regulations. This included scrutiny of existing programs and services supporting Newborn and Hearing Screening, Mother-Baby Friendly initiatives, family planning, immunization, tuberculosis, and HIV care. Additionally, they reviewed policies and procedures related to generic prescribing, health emergency and disaster preparedness, data privacy, allocation of charity beds, compliance with anti-deposit laws, registration of birth and death certificates, adherence to the Data Privacy Act, and enforcement of the Anti-Smoking Act. They also conducted on-site inspections to verify the practical implementation of these laws across various areas of the hospital. In the afternoon, the DOH-HFSRB shared their final feedback. It commended the “surprising” achievements of MJH as well as identified the challenges the hospital must address “within the next 30 days.” The DOH team pointed out the crucial areas of concern that need attention, including the non-availability of the Permit to Construct (PTC) for renovated rooms and facilities, aging hemodialysis machines, the need for a plan to establish a Sewage Treatment Plant, recommendations to improve the morgue and upgrade the Blood Station to a Blood Bank. All in all, the DOH visit was assessed by the MJH leadership and staff as an opportunity for the hospital to advance its journey toward improvement, and reaffirm its commitment to enhancing care and service initiatives for valued patients. They look at the visit as a crucial factor in MJH’s pursuit of International Organization for Standardization (ISO) accreditation, as the hospital endeavors to turn these challenges into avenues for healing, growth, and excellence.