Public Private Partnership (PPP) for the Organizational Strengthening of the Rizal Medical Center
Rizal Medical Center

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Philippines’ national health system was described to “remain in shambles” due to limited resources and insufficient financing apportioned for health facilities and modernizing public hospitals. Such challenges exist in the country due to an inappropriate health delivery system, inadequate regulatory mechanisms for health services, and poor financing, all contributing to the slow marked improvement of the country’s health indicators. The challenges of continuous quality health care delivery and long-term sustainable operations in public hospitals amidst limited resources abound. The Rizal Medical Center (RMC), a 300-bed tertiary, teaching and training hospital of the Philippines’ Department of Health, experienced problems in the efficient and effective delivery of health services. With its growing number of patients, there were noted patient complaints and concerns that the hospital needed to resolve. The absence of cost-effective and quantifiable strategies, policies, processes and systems brought about various issues and challenges. Hospital management was unable to address these matters due to limited access to human, technical and financial resources, aside from the employee’s attitude towards the patients and the lack of management skills to quickly respond to patients’ needs. Other problems include the lack of management’s resolve to fully implement and sustain change management efforts at all levels within the hospital; the need to motivate employees towards service and customer care excellence; and, the lack of a more professional way of handling complaints and conflict resolutions. Capacity building, skills development and the culture of continuous quality improvement among the hospital leadership and staff were major concerns as well. The inability of the hospital to address the issues and concerns mentioned above directly affected the larger community that it serves. This is composed of 26 cities/municipalities of Metro Manila and Rizal province, with an estimated population of about 10 million residents, and a clientele profile that includes those from the Class B, C, and D sectors. In response to the problems, the Makati Medical Center (MMC) Foundation was to share what the MMC hospital did best – the Makati Medical Center way of doing things : delivering high quality health services designed to ensure customer satisfaction, do things right, implement processes efficiently, and multiply limited resources sustainably. The MMC Foundation then took on the challenge of rejuvenating, reviving, and giving ailing public hospitals “a shot in the arm” with the goal of eventually declaring these public hospitals healthy and ready to provide world-class health services.

B. Strategic Approach

 2. What was the solution?
a. Rizal Medical Center (RMC), a national public hospital, established a partnership with the private sector, specifically the Makati Medical Center (MMC) Foundation, through its flagship program, “Public-Private Partnership (PPP) for the Organizational Strengthening of the Rizal Medical Center.” b. This flagship program assessed RMC’s organizational capacity, resources, competencies, challenges and opportunities, and revisited its vision, mission and service values. It was designed to develop strategic and sustainable operational plans for policy reforms, systems development and human resource development. c. Much needed support and resources were multiplied and generated to implement a strategic and sustainable change management program among the stakeholders, from national government, local government units (LGUs), local health boards of the district hospitals, civil society organizations, community health teams and private sector organizations.

 3. How did the initiative solve the problem and improve people’s lives?
A capacity-building flagship program entitled “Public-Private Partnership (PPP) for the Organizational Strengthening of the Rizal Medical Center” was introduced and implemented. The program’s aim is to provide support for RMC’s hospital leadership and its internal stakeholders, thereby enabling the self-sufficient implementation of customized strategic and sustainable plans, programs and projects. It was designed to address various internal organizational challenges of public hospitals through strategic intervention focused on organizational diagnosis, process improvement and resource generation and coaching/mentoring. It has been presented to the United Nations Economic Commission for Europe (UNECE) and is currently being developed as the International PPP Standard for the Organizational Strengthening of Public Hospitals. The flagship PPP program followed a four (4) – module implementation plan: Module 1: Organizational Assessment - analysis of organizational capacities, competencies and resources Module 2: Strategic Planning - enhanced statements of service vision, mission and service values and goals Module 3: Operational Planning - defined work plan with Key Success Indicators and resources for priority Service Improvement Areas including: Internal and External Communications/Procurement & Inventory Management, Human Resource, Finance, Customer Service, etc. Module 4: Case Study Documentation and Program Impact Evaluation – a print and video documentation of the partnership’s highlights, best practices and lessons learned, along with a detailed research study on the program’s positive effects and areas for improvement Results of the initiative: Based on the results of a Program Impact Assessment study conducted by an independent third-party organization, Rizal Medical Center (RMC) recorded a significantly and statistically improved performance after the PPP Program, specifically in the areas of: a. Emergency Room Efficiency as evidenced by the comparison of admission and discharge times from the ER Profiling Study conducted during and after the partnership, with discharge times recorded as 31% faster compared to before the PPP Program’s implementation. b. Process Standardization and Process Documentation as evidenced by the documents that confirm the written processes within RMC. It is also supported significantly by the awarding of ISO Certification 9001:2008 to RMC for fulfilling its requirements for process standardization and documentation. c. Organizational Communication, Collaboration and Culture as evidenced by the substantial measurable increase in perceived inter-departmental collaboration (+1.77 on a 5-point scale). It is further supported by the increased commitment to organizational norms (+1.36 on a 5-point scale) as measured by the behavioral change survey. d. Customer / Patient Satisfaction as evidenced by the comparison of Customer Satisfaction Surveys from before and after the partnership. Customer Satisfaction increased in 5 out of 10 departments, and remained at its highest in 3 more departments. Overall Customer Satisfaction increased from 85% to 95% over the course of the partnership. This was further supported by the observable behaviors of RMC employees in assisting customers and giving increased attention to patients’ needs. e. Task Ownership as evidenced by the numerous statements made by the TWG members during the Focus Group Discussions. It is validated by the measurable increase (+1.73) in perceived clarity of task ownership and inter-departmental communication (+1.77). f. Revenue Generation as evidenced by the report of RMC comparing its financial performance before and after the partnership. Revenue-generation in the RMC Pharmacy was more consistent after the partnership due to the improvement in inventory management and purchasing processes. g. Innovation and Continuous Improvement as evidenced by the creation of a new Quality Manual, systems automation, and the implementation of the serialized prescription pad. This is further validated by the measurable increase in collecting and using data for performance improvement (+1.59 on a 5-point scale).

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
It innovatively addresses UN SDGs 3 and 17 as a “People-first PPP.” Per UNECE, it “set out a clear statement that out of all the stakeholders, ‘people’ should be the priority and main beneficiary. Their focus should be on improving the quality of life of communities, particularly those that are fighting poverty and by creating local and sustainable jobs.” It is trailblazing as it advocates the “software” side of sustainable hospital management and operations, focused on capacity building for a public hospital’s human resources. This “soft PPP” supports and complements the technical and financial requirements, ensuring a sustainable strategy for public hospital management and operations. It goes beyond the usual components of PPP programs involving infrastructure support and procurement / contractual arrangements. Research and review of existing literature revealed PPPs being implemented in public hospitals, but mostly designed to provide and improve infrastructure and equipment. Up until the MMC Foundation’s flagship “PPP Program for the Organizational Strengthening of Public Hospitals” was institutionalized, there existed no blueprint for private and public hospitals to partner, thereby serving majority of marginalized Filipinos who otherwise cannot access the higher quality and more expensive basic health care and medical services provided by private hospitals.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The Makati Medical Center (MMC) Foundation initiated this partnership with Rizal Medical Center (RMC) as the implementing organization, and through which the program was administered. RMC, formerly Rizal Provincial Hospital, is a Department of Health-retained hospital, borne out of a need for the government to solve health problems and alleviate suffering of medically indigent patients and clientele particularly from the province of Rizal and its catchment areas, and the country in general. It started as a 25-bed-institution in 1941, and has grown to a 300-bed capacity teaching and training hospital. Through the years, RMC trained medical students and interns, nursing students at all levels, medical technologists, as well as post-graduate trainees in medical specialties, nursing and hospital administration. For 75 years of loyal and dedicated service since its inception, RMC continues to make its institutional presence felt by promoting sound and appropriate management guided by the following objectives: a. To provide a high quality of clientele / patient care to as many people as possible, economically and efficiently. b. To render emergency treatment and first aid in accidents and disasters. c. To assist in the preventive aspects of public health, such as case finding, immunization, pre-natal examinations, etc. d. To serve as a laboratory and workshop for doctors, nurses, medical technologists and all other health disciplines who are in training. e. To provide expanded and extended health services to other areas where there is a need. f. To facilitate staff development of all technical and non-technical hospital personnel at all levels through formal and informal programs of education, in-service training and continuing professional education. g. To enhance opportunities for research and studies. During the PPP program’s implementation, RMC catered to an annual total of 113,000 OPD (out-patient department) patients, 73,000 ER (emergency room) patients and 14,500 in-patients.
 6. How was the strategy implemented and what resources were mobilized?
A tri-partite Memorandum of Agreement (MOA) for a “Public-Private Partnership for the Organizational Strengthening of the Rizal Medical Center,” was signed on 19 June 2012 between : a. Makati Medical Center Foundation, a not-for-profit organization and Corporate Social Responsibility (CSR) arm of Makati Medical Center, b. Rizal Medical Center (RMC), a national teaching and training hospital of Department of Health; and c. Department of Health (DOH), an executive department of the Republic of the Philippines. MMC Foundation’s strategic directive was to assist public hospitals in developing a sustainable organizational and operational management plan, designed to help the hospital help itself. It provides for the organizational strengthening of public hospitals, through workshops and training interventions for hospital leadership, management and staff. Key result areas include development of a sustainable, long-term, strategic, organizational and operational plan for the partner public hospital. The framework was Kotter’s 8-Step Change Framework, identifying change champions within the organization and recognizing roles of internal and external stakeholders, involving them in various phases of program implementation. An RMC core team contributed to program assessment, planning, designing and implementation. The strategy was implemented in four (4) modules : a. Organizational Assessment - analysis of organizational capacities, competencies and resources b. Strategic Planning - enhanced statements of service vision, mission and service values and goals c. Operational Planning - defined work plan with Key Success Indicators and resources for priority Service Improvement Areas d. Case study Documentation and Project Impact Evaluation – recording of the partnership’s best practices, lessons learned and areas for improvement (1) Key developments and steps a. A temperature check on RMC’s health, before and after the PPP program, measuring specific organizational indicators as key parameters; b. A customized program impact evaluation conducted by an independent third-party evaluator that revealed whether the partnership fulfilled the goals and objectives it set out to accomplish; c. A documentation of the partnership, capturing best practices and lessons learned, along with identified areas for improvement towards developing a template for engaging future partner public hospital partners at the local, national, regional and global levels. (2) Main activities a. Assess RMC’s organizational capacity, resources, competencies, challenges and opportunities; b. Revisit its vision, mission and service values and develop strategic operational plans for policy reforms, systems development and human resource development; c. Generate support and resources for a change management program among the national government, local government units (LGUs), local health boards of the district hospitals, civil society organizations, community health teams and other stakeholders. (3) Monitoring and Evaluation Following the initial Impact evaluation conducted by a third party, and as part of the ISO accreditation in Quality Management System and Teaching / Training Hospital received by RMC on September 2013, RMC has consistently and regularly (bi-annual) conducted Internal Quality Audits and hospital-wide Management Reviews in order to tackle issues and concerns regarding conformance/non-conformance to standards we have set, root-cause analysis of unachieved targets and celebration of achieved targets. AJA external auditors also conduct bi-annual accreditation visits to monitor whether non-conformance and previous observations have been acted upon; and, whether new non-conformance and observations have arisen. These are reported to the hospital management for planning and policy review. (4) Project timeframe: Six (6) months, from 19 June 2012 to 30 December 2012. (5) Estimated Program Cost: PhP 1 Million, broken down as follows : 1. Organizational Assessment : PHP300,000.00 1. Includes research component, baseline data gathering, designing tools, surveys, interviews, FGDs, data analysis, documentation, reporting 2. Learning Sessions / Workshops / Mentoring / Coaching 400,000.00 3. Program-related costs and management 1. Communications, documentation, transportation, 150,000.00 manpower and logistical requirements 4. Program Impact Assessment 150,000.00

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
a. Program Proponent: Makati Medical Center (MMC) Foundation b. Implementing Partners: Rizal Medical Center (RMC) and First Pacific Leadership Academy (FPLA) c. Program Partners: Department of Health (DOH) and Makati Medical Center (MMC) Hospital d. Program Impact Evaluators : Mr. Luigi Mapa, Organizational Development Consultant

 8. What were the most successful outputs and why was the initiative effective?
a. The “Public-Private Partnership (PPP) for the Organizational Strengthening of Rizal Medical Center” is an innovative way to address the UN SDGs 3 and 17 as a “People-first PPP.” The partnership has been proven to be a working example of synergy between public and private institutions at its best. b. RMC’s ISO Certification 9001:2008 award was a clear and palpable achievement of the partnership. As a result of the training in process documentation, write-shop seminars and coaching / mentoring approach, RMC was adequately prepared and equipped to accomplish the basic requirements for process standardization and documentation. c. Continuous improvement, growth and development of its various programs and processes manifested at various levels during the course of their engagement with RMC. The PEPPP talks featured the best practices of MMC and the hospital tours demonstrated the situations on the ground, it became an inspiration to institutionalize innovative cultures of change and improvement in the hearts of the RMC leadership, management and staff: (i.) Improved turnaround time of disposition of ER patients due to the creation of Modified Point-of-Care Laboratory testing. (ii.) Recognition by the Philippine Civil Service Commission to meet the requirements in its pursuit of a Level II maturity in PRIME-HRM (Program to Institutionalize Meritocracy and Excellence in Human Resource Management). (iii.) Enhanced the hospital client encounter due to the regular Customer Service Champion Workshop. (iv.) Active promotion of Continuous Quality Improvement. (v.) Computerization of business transactions was continuously improved to increase income and to enhance efficiency (vi.) Increase in hospital income due to the Hospital Sponsored Membership (HSM), which resulted in a significant increase in PhilHealth member beneficiaries among admitted patients (from 44% in 2013 to 92% in 2016). (vii.) Emergency Medicine Clinical Rotation of MMC doctors in RMC helped in the augmentation of the training program. d. With MMC Foundation pursuing to replicate the success of this partnership, it subsequently partnered with other government medical institutions, utilizing the strategic template / model and having the RMC key mobilizers as subject matter experts, who are able to enhance their efforts to engage other health institutions. The positive ripple effects of this successful partnership provided opportunities for RMC to share the best practices and lessons learned with other public medical institutions at the local, national, regional and global levels. Indeed, this partnership serves as an inspiring example of the potential good inherent in well-prepared and executed People–First Public-Private Partnership.

 9. What were the main obstacles encountered and how were they overcome?
There were 2 main obstacles encountered during the implementation: a. Getting the entire staff of RMC convinced to engage themselves in this partnership was almost an insurmountable challenge. They perceived the hospital to be in good condition, and not needing any intervention. There were several speculations and doubts as to the intentions of MMC Foundation and its ultimate goal was mistakenly perceived as a possible privatization of RMC. However, as soon as the RMC leadership managed the situation and clearly communicated the proper messages down to the rank and file employees, widespread cooperation gradually took place. After the initial organizational assessment was cascaded, the staff of RMC began to appreciate, cooperate and comprehend the need for the partnership. b. The employees’ union took an aggressive stance by picketing during one of the visits of MMC Foundation. The confusion resulted from the perception that MMC Foundation was planning the privatization of RMC, where the job security of the employees were supposedly threatened. Upon assurance that their jobs were secure and the program’s scope and duration were limited to organizational strengthening, they were won over. Hence, active participation was demonstrated and outputs were facilitated.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
a. Sometime after the PPP initiative, RMC achieved its vision of being the preferred hospital of the community it served. Although RMC is a 300-bed capacity hospital, average daily census has increased to an average of 360 in-patients per day; while, OPD (out-patient department) consultations rose to 700 daily in contrast to 400/day previously. b. The reported annual Quantified Free services has increased from Php 57 million in 2013 to Php 97 million in 2016. c. Patient Satisfaction significantly improved from 85% (in 2013) of the clients giving RMC a good or better evaluation, to 94.8% in 2016. d. RMC has engaged in pilot projects by the Department of Health (DOH) and other government agencies in making Cancer Treatment free for eligible patients; increasing PhilHealth member benefits through a Hospital Sponsored Membership program; and, facilitating fund disbursement through an Electronic Modified Disbursement System.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Since the PPP initiative redounded to several institutionalized streamlining of processes, business transactions, and anti-red tape policies, integrity in management has greatly improved. With the highly functional and responsive Quality Assurance Office, all received complaints, inquiries and communication are handled appropriately and within a reasonable time period. The AJA bi-annual accreditation visits recorded this and reported to the top management. Accountability in public service is demonstrated by RMC through the Public Assistance and Complaints Unit (PACU), as well as through the Civil Service Commission’s Contact Center ng Bayan and the Office of the President. All of these are communicated in writing through official correspondence among government offices.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Prior to this initiative, women and girls were given equal attention in health care delivery services particularly in public hospitals in the Philippines. The initiative complements also with the government’s guidelines to improve the situation of the poorest and most vulnerable. In fact, a report of the Philippine Commission for Women (PCW) under a UNFPA Project was able to influence the Department of Health (DOH) to integrate gender in its interventions. In 2007, PCW assisted the DOH in the conduct of orientation on the Harmonized Gender and Development Guidelines (GAD) to program managers and technical staff of the different bureaus of the DOH. The capacities of different program managers and staff of DOH and DOH-retained hospitals on GAD planning and budgeting were enhanced in GAD Planning and Budgeting Workshop. Participants were able to assess where their offices stand in terms of gender mainstreaming and were able to brainstorm on how to address the numerous gender issues they face, both client- and institution-wise. At the local government unit, some initiatives were also formed including non-discriminatory health care delivery, gender sensitive and responsive health care services, and the integration of population development and gender indicators in formulating local development plans.

Contact Information

Institution Name:   Rizal Medical Center
Institution Type:   Public Agency  
Contact Person:   Dr. Relito Saquilayan
Title:   Medical Director  
Telephone/ Fax:   +63(0)9178996398
Institution's / Project's Website:  
E-mail:   relito_saquilayan@yahoo.com  
Address:   Pasig Blvd.
Postal Code:   1603
City:   Pasig
State/Province:   Metro Manila
Country:  

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