ISO CERTIFICATION 9001:2008 PROCESSES

AND REQUIREMENTS INTERVIEW

Subject: Lucena United Doctors Hospital and

Medical Center
We are very grateful to Dr. Nimfa D. Aparte (LUDHMC
chairman of the board), Dr. Jaimar R. Sapungan
(LUDHMC President), Dr. Juan Eugenio Fidel B.
Villanueva (Medical Director), Ma’am Heide B. De
Castro (HR Manager), and Ma’am Dianne D. Calzado
(Quality assurance officer) who took the time and effort
to approve our request and allow us to make an interview
with them regarding the specifications, requirements,
and processes of an ISO certification.
Lucena United Doctors Hospital and Medical Center is
Quezon’s first and only ISO 9001:2008 certified hospital
as it was formally declared as an ISO certified institution
on the 16th of May 2015 – a feat the Quality Assurance
Officer Dianne D. Calzado repeatedly said and “have to
brag unto us” during our interview which is
understandable considering the time, effort, and
sacrifice they did to achieve such feat.
A lot has changed since its inception in 1981, from being
at the heart of the city up to relocating to an 8,297
square meter property along the national highway in
Brgy. Isabang Lucena City and then, on December 1,
1996, LUDHMC moved patients in ambulances to their
new immaculately white hospital building with the
concerted effort of all doctors and other health
professionals..
They started delivering the best possible health care to
all their clientele keeping in mind the mission, vision,
and core values of Lucena United Doctors Hospital.
 MISSION
“We, at LUDHMC, are committed to enhance the lives entrusted to us
built upon high ethical standards and genuine sense of responsibility. We
provide and deliver dynamic and quality healthcare services to the
community in which we serve to produce healthy financial rewards for
investors as well as opportunities for growth and enrichment to our
employees and business partners. And in everything we do, we strive to
act with loyalty, utmost integrity, dedication, honesty, motivation and
competence.”
 VISION

“TO BE THE BIGGEST PROVIDER OF QUALITY

HEALTHCARE SERVICES IN QUEZON PROVINCE BY
2020.”
 CORE VALUES
L – Loyalty
U – Utmost Integrity
D – Dedication
H – Honesty
M – Motivation
C – Competence
.

The company had also set out quality guidelines, objectives

and policies to ensure that their healthcare service quality is
top notch in the province.
QUALITY OBJECTIVE

The objectives of the Quality Assurance Policy of the Lucena Doctors Hospital and Medical Center is
the preservation and enhancement of the high-quality health care provisions there pertaining
stakeholders’ trust for life. We intend to ensure that:

 Human Resources have the optimum knowledge, skills and the right attitude;
 Technology and Facilities are updated and properly maintained for accuracy,
safety and comfort of stakeholders;
 Services are delivered safely and efficiently;
 Systems are well defined, effective and evolving to add our stakeholders’
requirements; and
 Affordability shall not compromise quality
 These objectives are inspired by:

 Participatory healthcare management

 Patient Safety Principles
 Competence Development
 Fast Response
 Ethical Healthcare and Management Practices
 Management by Fact
 QUALITY POLICY
 Lucena United Doctors Hospital and Medical Center was established in 1981 to
provide comprehensive healthcare services to the people of Quezon and nearby
provinces and be a platform for advancement in the healthcare industry.
 In adherence to our Mission and Vision, we will provide the most appropriate,
comprehensive, cost-efficient healthcare services that exceed our stakeholders’
standards and expectations.
 We are committed to continuous improvement and have established a Quality
Management System which provides a framework for measuring and
improving our performance and to enhance customer satisfaction.
 Lucena United Doctors Hospital and Medical Center commits to ensure
compliance to all health safety and environmental regulatory and statutory
requirements of recognized national and international accrediting agencies.
QUALITY POLICY

 The Quality Policy shall be communicated to and made

understood by all stakeholders through orientation,
meetings, circulars and other appropriate means.
 The Quality Policy shall be reviewed periodically and as
necessary by management to adopt to current
requirements, standards and developments.
 After establishing the Company background of
LUDHMC, we are now able to proceed to the main
purpose of our interview , the requirements of ISO
accreditation, the process and preparation, and the
challenges of preparation.
 We have asked them a
series of questions and they
have abundantly shared
information with us
regarding the questions...
1. Does their quality policy include the framework for
setting quality objectives?

“Yes, because one of the major requirement for ISO

accreditation is, the institution should have a quality
policy together with the quality objectives. The ISO has
actually provided us a standard with it in them, so
basically policy and objective should be incorporated
within us. Besides, we have a separate organizational
structure from the hospital which communicates with
ISO for accreditation, this department is headed by our
medical director, but of course, his role there is different
from the hospital as he is the quality management
representative.”
2. The internal and external issues that are relevant to the
ISO accreditation of their organization.

“Internal issues within us is the acceptance of our

employees in regards to the starting of passing
requirements to be ISO certified, and the stakeholders
and employees adaptability. Actually, there are many
internal issues to be addressed but all comes back to
acceptance and adaptability. Now, in external issues
there are the problems sometimes with the cooperation
of out-patients, and if we’re talking about competition,
I’m sorry but we have to brag about this that we are the
very first ISO certified hospital in Quezon, now there are
many hospital following our steps and getting ISO
certified using us as a benchmark and that is the best
progress we’ve made and that is an advantage for us.”
3. Interested parties relevant to the organization and its QMS

“The whole organization is relevant, stakeholders, employees,

rank and file, security guards, janitors, etc. most especially
man power. This is not a one man show, our progress is the
work of everyone.”
4. Use of process approach and risk based thinking.

“This day, we are relying in our documented processes.

Most especially that we are aiming for the transition to
the latest version of ISO 9001:2015 which requires risk-
based thinking, risks are the effect of uncertainty,
therefore the hospital is preparing itself as all unit now
have a Risk Registry. So the risk is already identified
before it become an even bigger problem. Transition
from CPAR to CAR, so the company doesn’t need to
prevent any more problems because we are aiming for
total avoidance.”
5. How do they promote improvement?

“If they say that you are already ISO certified, we are
pressured to keep up with the expectation that comes
with this certification. However, there is no perfect
organization but we try our best to give our employees
benefits in monetary, and rest days especially when we
were just starting and employees’ workload had become
heavy. During audit, we also reward our employees with
free food, as thank you for their cooperation. Also, after
the accreditation we had a party and we gave out awards
to employees which recognizes their hard work.
Improvement should be continuous and monitoring is
now routinely because we are already stable and
established unlike before during the start that was a very
toxic time for us.”
6.The increase in quality output in relation to the increase of
price and if this point is true for their company.

“This is part of our quality objective, it is indicated that

price shouldn’t and does not affect the quality service.
Meaning, we have to give quality service in accordance to
our pricing, meaning we should meet customer
satisfaction. In fairness, statistically speaking our clients
are over-satisfied.”
7. Steps and preparation they are undertaking to achieve
the latest version of ISO certification, ISO 9001:2015.

7. Steps and preparation they are undertaking to achieve

the latest version of ISO certification, ISO 9001:2015.

“Actually we are preparing our employees, risk-based thinking and

processes, those are given, those are continuous and monitored so
it really isn’t a problem, however, we have a high turnover of
employees that is the problem of hospital here in the province.
Nurse, radio technologist, healthcare positions are lacking. Our
training officer is very stressed out about it, we are not just
preparing the documents, but we are preparing the competent of
our employees so we conduct continuous trainings and seminars.
Especially, during audit, the accreditors doesn’t ask the unit heads,
they ask the newest employee, if they are prepared and competent
enough.”
Some of the words here were already translated in
English as the interview was a mix of the English and
Tagalog language.

Our interview with Ma’am Heide B. De Castro and

Ma’am Dianne D. Calzado lasted for about an hour and
this report covered only the most important parts of that
one hour.
As you can learn from their answers, Lucena United Doctors
Hospital and Medical Center have communications between
departments that are free-flowing and the risk between units
and departments are already documented so that problems
are avoided.
Therefore, we conclude that Lucena United Doctors Hospital and
Medical Center is a highly efficient workplace and organization.
However, a workplace cannot be called efficient in the long run if it
is understaffed.
We recommend to Lucena United Doctors Hospital and Medical
Center a viable opinion in their lack of staff problem.
 Seeing that they need more loyal and effective staff, giving
out scholarships to underprivileged children that wants to
pursue a career in healthcare services, they could secure a
solution to their problem for the long-term, as someone you
help in their most vulnerable are the ones who are mostly
inclined to be faithful to you and serve you, especially if you
put a clause in their scholarship contracts that they are
required to work for you for a minimum number of years.
 This solution is similar to what the
government are doing for the Barrio
Doctors scholarship program
THANK YOU FOR LISTENING!

 Group Members:

 Patrick Duane Noche

 Ron Endriga
 Jovin Amo
 Tyrhone Reforma
 Marc Louie Amparo
 John Jerald Labitigan