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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
ANNEX – E A.O. No. 2012-0012
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
ANNEX – E A.O. No. 2012-0012
Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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
(at least 20 hours/week)
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
ANNEX – E A.O. No. 2012-0012
Cont. of STAFFING PATTERN (Total Staff Complement)
Profession/ Position/
Designation
Total staff working full time
(at least 40 hours/week)
Total staff working part time
(at least 20 hours/week)
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
ANNEX – E A.O. No. 2012-0012
Profession/ Position/
Designation
Total staff working full time
(at least 40 hours/week)
Total staff working part time
(at least 20 hours/week)
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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Department of Health
BUREAU OF HEALTH FACILITIES AND SERVICES
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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