WHILE hospitals are equipped to deal with emergency situations that involve multiple casualties, they were not prepared to deal with an invisible enemy known as the Covid-19 virus.
Imagine the concerns and the fears going through the heads of hospital administrators. Will frontliners get infected? What rooms can accommodate Covid-19 patients? Do we have enough medicines to treat them? Do we have enough PPEs for frontliners? How can we get non-Covid patients to come back to the hospital so that their illness will not worsen?
The BusinessMirror had the opportunity to interview the executives of nine private hospitals to get their views on how the pandemic has changed the way they run and manage the hospitals. One theme was common with all the nine hospitals—the challenges they face with PhilHealth and how they managed to keep afloat financially in spite of this.
Cardinal Santos
Medical Center
It all started in Cardinal Santos Medical Center (CSMC) last year when on March 6, 2020, the doctors at CSMC diagnosed the first local Covid-19 case. While he had no history of foreign travel, the 62-year-old was hypertensive and diabetic. He started coughing on February 25, 2020, went to CSMC on March 1 where he was admitted and diagnosed with severe pneumonia. The Department of Health (DOH) confirmed he was infected with Covid-19 on March 5.
On March 16, 2020, President Duterte announced the imposition of Enhanced Community Quarantine (ECQ) over Luzon, including the National Capital Region effective 12 am of March 17, 2020. This ECQ was to be extended on several occasions.
This first local Covid-19 case prompted CSMC to put in motion the safety protocols and the other services that they needed in order to address the expected influx of Covid-19 patients.
On managing physical resources
Dr. Zenaida M. Javier-Uy, CSMC Senior Vice President and Chief Medical Officer, said the direction from day one was for the hospital to increase its capacity to handle Covid cases.
“That was the direction that we took up and as we speak, we are building another wing in our hospital that will really handle our Covid cases,” Dr. Uy said. “It will be well-equipped to handle our Covid cases and there will even be Intensive Care Unit (ICU) cubicles for Covid cases. So increasing capacity is one we have addressed.”
According to Deidre Arnold Able A. Malapitan, AVP and Head of Facilities and Management and Safety Division, the facility is a duplication of the ER with a triage area, isolation rooms and beds.
“We are not treating our Covid patients in a temporary shelter but in a rigid structure that was built in 15 to 20 days,” Malapitan said. “We also converted two operating rooms (OR) into negative pressure ORs.”
Since the hospital did not have any dedicated ICU beds for Covid patients, Malapitan said they started building Covid ICUs last June and they are expected to be ready some time in October.
“It is a 28-bed Covid ICU, eight ICU beds and 20 isolation rooms. That is how Cardinal is preparing and continuously improving its response to Covid,” he added.
Another step that CSMC took to address the pandemic was to construct its own Molecular Laboratory which became operational sometime in September or October last year. Prior to that, Cardinal had been sending out its RT-PCR samples to the Research Institute for Tropical Medicine (RITM), the Lung Center and then to a private laboratory.
“One of the things that I will always be proud of is our strong collaboration with our local government. From day one, we were in close touch with the San Juan City local government and we collaborated on all efforts even on where to quarantine our healthcare workers,” she said.
More Covid-19 patients meant a growing demand for RT-PCR testing. Cardinal designated their parking area located in front of the Emergency Room as the swabbing station to provide enough ventilation.
“I think the doctors and the patients also appreciated the fact that they do not need to go inside the hospital or the Emergency Room just to get their swab. So we had swabbing schedules from Monday to Sunday,” related Dr. Monserrat S. Velasquez, Assistant Vice President and Head of Clinical and Specialty Services Division and Offsite and Ancillary Services.
Velasquez said they also faced challenges in sourcing Covid-19 medicines amid growing demand but a dwindling supply. The Pharmacy had to project how much the hospital actually needed to purchase for patients so that they would not have to stock up on them for a long period.
“We were actually well ahead of other hospitals, if I may say, in terms of making sure that we actually have all those medications,” she said. “And I think one of the advantages is that we worked closely with our infectious disease doctors. They are actually the ones recommending that this will be coming up soon and that we would be needing these medications in the next few months.”
A standard procedure for all Covid-19 patients is to undergo a CT scan and Cardinal devised a schedule where all clean cases, or non-Covid cases, are scheduled in the morning. Covid patients are scheduled in the evening until the early morning hours.
“The direction of the hospital is since we accommodate all these patients, we cannot admit all of these patients. We try as much as possible to treat them on an outpatient basis so that we can include doing ancillary diagnostics on an outpatient basis,” Velasquez said.
On financing and cash flow management
In terms of CSMC’s financial standing, Marivic S. Mabuti, Vice President and Chief Finance Officer, recalled that on the first month of the lockdown, CSMC’s revenues “really shrank, probably by 50 percent, and it was aggravated by the fear of people to come to the hospital.”
“Despite the significant drop in our census and revenues, we still decided at that time to retain everyone, all the employees and staff. As such, we had to bear the burden of having a huge fixed overhead cost versus the low revenues,” Mabuti said.
Every year, the hospital has a purchase plan and at that time, CSMC’s inventory levels were at an all-time high because “management was gearing for an increase and higher growth in 2020, coming up from the momentum of 2019.”
“So we were ready to take off. We had a huge inventory on hand and then suddenly the census of the hospital dropped. So we had to bring down inventory,” she explained.
In terms of capital expenditures, Mabuti said Cardinal already had several committed capex and projects underway. Due to the pandemic, some of the projects had to proceed while the necessary adjustments were made to either cancel or defer the other capital expenditures.
“All of those contributed to the erosion of our operating margins and the deterioration of our cash position. So what did we do? As they say, the worst thing that could happen is to do nothing during a crisis,” she said. “In our case, we turned our focus to cash, realizing that we need cash in order to survive during the crisis.”
Concrete steps were taken on the drivers of the hospital’s cash position and these include receivables, inventory, payables, purchases and capital investments. On the receivables side, Mabuti said the hospital reinforced daily collection from admitted patients. Online payment facilities were provided to patients, especially patients’ families who had a difficult time getting to the hospital because of transportation restrictions.
Adjustments also had to be made in CSMC’s operational expenses. Mabuti said management had to reallocate some of its budget to more important activities like, for one, the Covid support programs for employees, which included shuttle services and medical assistance.
“For our payables, we also worked with our vendors to restructure the payment terms as we tried to cope with the pressure of cash payments for Personal Protective Equipment (PPEs) and other Covid medicines and supplies,” she said. “Aside from taking these concrete actions on the drivers of our cash position, we also did a more frequent cash flow forecasting exercise. Instead of monthly, we made it weekly and even daily updates.”
After a year, Mabuti noted that the hospital is treating more non-Covid cases now compared to last year, when the hospital was treating solely Covid-19 patients. This patient mix has, according to Mabuti, “provided us with a good source of revenue for us to be able to cover the fixed expenses or the fixed overhead expenses of our hospital.”
“I would also say that we now have a better handle on the medicines and supplies, the stocking level, so we minimize the use of our working capital. On the receivables side, we remain diligent in collecting for our patients especially now that we are struggling with our ballooning receivables from PhilHealth.”
Raul C. Pagdanganan, CSMC President and CEO, added that the focus at the start of the pandemic was for the hospital to be liquid and come up with different scenarios.
“We call this scenario planning and what is important is whenever you have scenario planning, it is essentially what you call contingency provisioning because you really have to adjust in a pandemic situation with a magnitude such as Covid, you really have to prepare for what comes next, you really have to be agile,” he said.
In handling and protecting human resources
In any hospital, nurses usually are majority of employees and according to Leona Paula L. Macalintal, Director for Clinical Nursing Operations, two aspects influenced the way nursing services and resources were managed during the pandemic.
The first is in the way staff are allocated. Per Macalintal, in the nursing field, nurses tend to be assigned in one area and it is difficult to reassign them abruptly to special areas or other areas of practice they are not familiar with.
“But with the pandemic, we had the flexibility to move them around so that we could be able to accommodate both our Covid and non-Covid cases. We can also attribute this to the training programs that we have instituted to prepare them to also handle critically ill patients beset by Covid,” she said.
“So that’s the first thing. We were able to move them. Those assigned in the special areas can be assigned in general wards and vice versa. And even our nursing managers and educators are on board and are not limited to their administrative functions but can also perform clinical duties,” she added.
The second aspect gave Macalintal and the nursing team “a wider perspective in terms of how we can rationalize our nurse-to-patient ratios and the number of staff that we would need in each of the areas.”
“Prior to the pandemic, the nursing team was only focused on patient acuity and the other factors that we consider for nurse staffing. But because of our daily management meetings, and what is really happening around, even our nursing managers’ perspective of what to consider like the quarantine rate of healthcare workers, the total census of the hospital, the capacity we need to comply with have all to be considered in planning for the assignment of nurses in the different areas,” she explained.
Apart from the operational side, Macalintal said they also had to look out for the welfare of nurses and other employees. Maria Louzel L. Diaz-Tiozon, Vice President and Head of Human Resources Division, said the hospital decided to focus on the basics first. These basic needs include transportation, shelter and food. Management also booked 20 rooms in a hotel to accommodate employees needing quarantine.
It was also in March of last year when management decided to push through with its plan to increase nurses salaries by 40 percent. This was based on their earlier growth projections for the year.
“This resonated very well with our people. That was the story of 2020. It was about investing in the basic necessities, addressing the psychological needs of our people,” she said.
On services and upcoming plans
Even before the Covid-19 pandemic, CSMC had already introduced Cardinal on Wheels where the hospital brings its services to its patients. Dr. Marichu L. Catan, Vice President and Head of Business Planning and Development Division, noted an increase in demand for Cardinal on Wheels last year. Another service that generated a lot of interest were e-consults where patients could consult with their doctors online.
“We have extended the same e-consults platform to our corporate accounts. This is for primary care doctors. We will do 24/7 consultation of the employees with the primary care doctors so that we can address the needs of the employees. This is what you call the e-clinic management and we already have one client.”
Not all Covid-19 patients require hospitalization and to accommodate these patients. Dr. Catan said they came up with the Outpatient Covid Care, which enables the hospital to manage patients with mild Covid symptoms in the comfort of their homes.
“We did come up with some packages wherein laboratory procedures were done and the patient remained at home and they are monitored by a physician and a specialist for 14 days. The service was launched last March 24 and as of September 21, we already had 606 patients; 80 percent of this were fully recovered and 20 percent are still in the program. We only have 1 percent mortality,” she added.
Cecile Marie L. Escaño, Vice President and Head of Information Technology Division, said her team developed additional modules in CSMC Consult that would help deliver new products and services. This includes the interface with Med Express which allows patients to order their medicines and have them delivered to their homes.
Earlier this year, the hospital also migrated to a new hospital information system complete with an end-to-end electronic medical record system. While the system was initially to comply with the requirements of the Department of Health, Escaño said the system came in handy during the pandemic.
“The system allowed us to come up with our very timely and accurate data that would come up to our dashboards and would allow management to adjust and provide support wherever it is needed,” she said. “The HIS also comes with a doctor’s portal which allows doctors to access their patients’ EMR anytime, anywhere.”
Lessons learned
Perhaps the biggest lesson that CSMC learned during the pandemic is the importance of collaboration. Dr. Uy noted that from day one, they were in close touch with the San Juan LGU and “we collaborated on all efforts even on where to quarantine our healthcare workers.”
Macalintal noted that the pandemic also taught them that apart from the operational side, they also had to look after the welfare of their nurses and their employees. Tiozon echoed this: “The response we had was the crisis of Covid is a people down scenario.”
“The pandemic has been infecting people and people are also the ones responding at the hospital. So ever since, our actions were always guided by three principles. The first priority is down the line people are empowered to make decisions to protect the health of our employees and our people,” she explained.
The second is to ensure the continuity of hospital services especially during this time of a high demand for it. The third is to serve the greater community.
“One thing that I think we have learned is that there is no sense in solving this crisis individually, like Cardinal cannot just continue adding healthcare workers and adding rooms. That is not the way to do it. We need to collaborate with our government,” Tiozon said.
Asian Hospital
and Medical Center
When Asian Hospital and Medical Center was undergoing reaccreditation with the Joint Commission International (JCI), an organization that accredits and certifies healthcare organizations and programs across the globe, back in September 2019, Andres M. Licaros Jr., the hospital’s President and CEO, recalled that the reaccreditation team found Asian Hospital was not prepared to handle a globally infectious disease.
“The last infectious disease we encountered was the MERS-CoV but we did not have problems with that. JCI was saying that we were not ready because they saw some gaps like our numerous entrances and exits. So we were able to submit a plan and it was eventually approved,” Licaros recalled. “But little did we know that a few months later, come March 2020, Covid-19 would be upon us and all of it was new to us.”
While the Covid-19 pandemic caught everyone off-guard, Licaros said Asian was ready to deal with the virus on the clinical side and that it responded quite well.
“What changed was our attitude. We treated it more seriously. We were more careful because from day one, it was clear to us that we cannot protect others if we do not protect ourselves,” he said.
He added that the outcomes showed that Asian is more ready now to deal with the virus. The mortality rates have dropped and the hospital has been able to discharge patients over a shorter period of time.
While Asian can still manage to accept patients whose conditions are quite serious, Licaros said their chances of survival would depend on how soon they are brought to the hospital.
On managing physical resources
Licaros thinks they are very fortunate because Asian is designed like an American hospital with its own road network around the hospital. Hence, it was easy for the hospital to offer drive-through RT-PCR testing. It also has two towers, with Tower 1 catering to the clean or non-Covid cases and Tower 2 dedicated to Covid cases.
Since the ICU was already full and the Emergency Room had to accommodate critically ill patients who had to be intubated, Licaros created a new annex at the ER to accommodate an additional 18 beds.
He related that for the past two weeks, Asian was able to discharge three patients who were admitted in the ER. The first patient was intubated for 22 days and he was able to walk out of the ER with tears of joy. In fact, the other patients clapped for joy when he was discharged.
Another patient was sent home after being intubated for 19 days. The third patient was discharged on the day Licaros was interviewed by the BusinessMirror.
“This experience tells you that if you don’t give up, you do the right thing and you keep focusing and providing the appropriate care, it can be done only because we work together and we were confident that we would be able to do it,” he said. “And the outcomes are showing this.”
On financing and cashflow management
In terms of financial resources, Licaros said Asian Hospital is very fortunate that they did their work early so that the hospital would be debt-free. He recalled that when he inherited Asian in 2012, it had a P2-billion loan and he managed to pay it off in 2018.
“Since the hospital was debt-free, we had a very strong cash position which served us well because the cost of care escalated with Covid. You have to buy PPEs, you have to increase the level of protection, and alcohol consumption was at an all time high. In spite of that, we were able to sustain ourselves,” he said.
Even if the hospital experienced a drop in revenues and census, Asian was able to support its operations, which included protecting their healthcare workers and providing them with accommodation so that they would not bring the virus home.
“So the cost of operation for the hospital really escalated, which means your margins are reduced tremendously because of the high cost of goods and the decrease in revenues because people stayed away from the hospital,” Licaros explained.
After each surge, Licaros noted that the non-Covid cases would return to the hospital to seek medical attention. The hospital did surgeries and had to care for a number of heart attack and stroke patients.
“We are 10 months into the year and we have grown against last year. We are more profitable now but it is not back to the 2019 levels yet. We may just be approximating 2019,” he said. “So I expect 2022 is going to be a bounce-back year.”
In handling and protecting human resources
Despite the lower revenues and margins, Asian Hospital did not let go of any of its staff. However, by natural attrition, some employees resigned because their parents did not want them working in a hospital at that time. These were quickly replaced so that hospital services would not be compromised.
The staff’s health and security were Licaros’s top priority and he made sure that they were accommodated in the hospital as well.
“While business was affected, Asian Hospital remained committed to its people, As long as you want to work for Asian Hospital, you will keep your jobs,” Licaros said.
On services and upcoming plans
While Asian Hospital offers “virtually everything already,” Licaros said, “the difference now is that we are getting out from the model where we build and they come. We are going to bring the services close to home.”
Among the services Asian has already developed based on this model is Covid homecare, continuing chronic care for highly compromised patients and they even have personnel going to patients’ homes for blood extraction. Since it is difficult and more costly to cater to just a few of these requests, the plan is for Asian to bring their services closer to the communities that they serve.
“The plan is to put up diagnostic and treatment clinics that are going to be in our catchment areas of Batangas, Laguna, Cavite, where the communities are already growing and in place,” Licaros explained. “But the difference is this is not the regular satellite clinic. This will be linked to the hub, which is Asian, where all the specialists are on a digital platform.”
The patients can be diagnosed and treated at these treatment clinics while the more complex cases will be referred to Asian Hospital.
“Asian will really become a hospital without borders, without walls,” he said. “We can even bring the care home.”
Those who need to go to rehab can do so at home so that they will not be exposed to the virus and these same patients can be cared for remotely. However, Licaros admitted that this would be provided at a higher cost.
“But because people need it, there’s a substantial market and that’s the kind of market Asian caters to anyway,” he said. “But our vision is to provide this for everyone, through health insurance, through the National Health Insurance Program so that everyone can avail of this service.”
On lessons learned
For Licaros, the biggest lesson is what he did early on in Asian and that is to transform the culture of the organization into a strong culture of accountability.
“This means that we put ourselves to task that we are in this kind of work because we must serve the needs of our community, nothing more, nothing less. The risks to our lives and to our families do not matter because if we turn our back to our sense of duty, who else will do it?” he said.
“We want to stand by our promise that we are as good as we are because we are able to translate them into better outcomes at lower cost. And for that to happen, you have to have a strong culture of accountability, a commitment to quality outcomes, a commitment to bring down the cost of care because in truth, the single biggest barrier to access to quality of care, to safe patient care is cost,” Licaros added.
Licaros said he has been at the helm of Asian Hospital for the past 10 years and during those 10 years he wanted to achieve two goals—better outcomes at a lower cost of care and care anywhere, any time. This, he said, can only happen if the service is transformed solely into a digital platform.
“You can only do so if your focus is the patient. It has to be patient-centric as a service and therefore you have to be extremely obsessed with your customers,” he said.
“And these are the lessons that I learned. And I also learned how valuable our services were and that is why it is difficult for us to turn our backs to that kind of a need. And it is all anchored on trust, and trust is earned if you make your patients feel the way you make your employees feel,” he said. “That’s why it is important to prioritize our employees and our doctors. If you create a good working environment, they can deliver that warm, caring service to our patients.”
The Medical City
“THE pandemic has exposed the deficiencies and ineffectiveness of our health systems. It has stress-tested our individual and collective capacities to deal with unplanned and overwhelming exigencies. The only way we can make significant contributions to the solutions is to help one another and work together and to keep that optimism up and running. Those who are of no help or use shouldn’t be allowed to continue, those who can help should be tapped and supported.”
That was the assessment made by Dr. Eugene F. Ramos, President and CEO of The Medical City Enterprise, who added that the pandemic has not only affected TMC but the country’s entire healthcare system.
He recalled that even if TMC’s staff nurses and frontliners were trained for these kinds of situations, they were initially overwhelmed with the flood of Covid-19 patients. He had to make sure that his staff was safe and well protected.
“After a while, we slowly realized that we had to take care of the hospital ourselves and during the first months, you can really see, you can really sift through the different preparedness, individual preparedness of the staff, those who really stepped up and you can see the resilience and the readiness to fight,” Dr. Ramos said.
Increased capacity for Covid cases
He also raised concerns about the Department of Health’s order requiring private hospitals to increase their capacity for Covid patients from 20 percent to 30 percent, without knowing the situation in the hospital.
“You have to understand that it is not just about the number of beds that we don’t have. It’s not just about the resources and the supplies that we don’t have. It’s also about our nurses because they are gone,” Dr. Ramos said. “Even before the pandemic, we already had problems with nurses going abroad.”
He added that the “injustice” of it all is that the hospitals train the nurses who go into OR and Emergency Room nursing, and then they leave the Philippine hospitals to go for the United States, the Middle East and Europe because there is a need for them.
“When you step back and you take a look at the overall system, the broken health system is not just within the hospital or within the country. It is the world, the immigration and the departure of nurses from developing countries who develop the nurses to developed countries who don’t really invest in nursing and just get all the benefits,” he said.
“That by itself is inequity and that already shows that there is a problem in the health system. And you can’t blame the nurses if they need to go there because here they are overworked and underpaid. That is still part of the broken health system,” he added.
PhilHealth woes
In addition to dealing with the shortage of nurses, hospitals also have to contend with PhilHealth and its failure to pay the hospitals. Prior to the lockdowns, PhilHealth had declared that it would shoulder all Covid cases, perhaps not realizing that the number of cases would balloon to alarming levels. This forced PhilHealth to rethink its policies and it decided that it would just shoulder a maximum of about P750,000 for critical Covid patients.
“When the government lifts the lockdowns, there is going to be another spike and then they all go again to the hospitals. They prefer the private hospitals. They really do not want to go to public hospitals. And so the private hospitals have to bear the brunt of all of this. So this is where we are now,” Dr. Ramos said.
Natural attrition
Due to the challenges with PhilHealth, TMC had to cut down on some costs and to let go of 50 people who, by natural attrition, did not report back to work anymore largely because of the fear of getting the virus.
“Then the other thing is really to restructure loans in the banks and really make sure that our relationships with the banks are based on good faith and we had a good track record,” he said.
When it comes to dealing with Covid patients, Dr. Ramos said TMC has the good fortune of being a big hospital. It has two Emergency Rooms, one of which caters exclusively to Covid patients, two different entrances and different sets of elevators. When it comes to admitting patients, zoning is done through floors. The hospital has a floor for Covid patients and floors for non-Covid patients. There are also separate MRI and CT scan machines for the patients to use.
This also led the hospital to develop two systems in one hospital to ensure that there will be a separate team of healthcare workers attending to non-Covid patients as well.
“We have cash flow from our non-Covids and that’s precisely why we came up with these two systems to ensure that the non-Covids come because these are individuals—paying patients—kasi hindi sila Covid [because they are not with Covid].” In contrast, “Covid cases are PhilHealth receivables. That’s the cash flow and then we really tried to restructure, we did that,” he said.
New services
ON whether the pandemic had affected their planned services, Dr. Ramos said as much as possible, they did not want to play up Covid and they chose to concentrate on cardiovascular diseases, neurosciences, cancer, wellness, because “these are the diseases of the future, of modern developing countries because of lifestyle.”
He continued: “TMC has beefed itself up in terms of its virus laboratory, in terms of preparing for the viral diseases and we have also propped up our molecular laboratory. So, even beyond this Covid, we know for a fact that there will be another pandemic because things are changing, the climate change is happening.”
In addition to climate change, Dr. Ramos said people are also infringing on the habitats of animals and there are reports saying that the Covid-19 virus were started by bats.
“We have to look at it in terms of are we dealing with all the other reasons why this is happening. This is an ecosystem so this is related to the broken health system,” he said. “We are ready for that and we have already stressed test the people who are okay to deal with it.”
Lifestyle diseases
What, then, is to be expected in the coming years? Dr. Ramos expects people will be having problems with cancer. As they grow older, people will develop a lot of lifestyle diseases like hypertension, coronary artery disease and diabetes.
“The other thing that I think people should prepare for and… focus on is that people should assume more accountability over their own health and this is where wellness comes in. Wellness is going to be a big market,” he said.
When it comes to lessons learned during the pandemic, Dr. Ramos said if you feel that you are doing the right thing, you should do it.
“I realize that when you are out there, you really have to make the right decision and judgement call, and I think that is where leadership comes in. People are not used to making decisions and they wait for their bosses to decide. You will be amazed that during this stress testing, many of the bosses did not live up to expectations,” he said.
Bosses exposed
The bosses he was referring to were the bosses in government and since their ineptitude has been exposed, Dr. Ramos said he would be more than willing to work with them so that they can help run things better.
As for issues with PhilHealth, Dr. Ramos said he has been collaborating with other hospitals to work out a solution with them. He noted that PhilHealth chief Dante Gierran is a former director of the National Bureau of Investigation so his background is forensic, not health financing.
“So his attitude is to look for fraud. However, if they discover that only 5 percent of what is due the hospital is fraudulent, why should the other 95 percent suffer? We are talking to them and hopefully they realize that they need to help out,” he said.
The Medical City Clark
PANDEMIC or no pandemic, The Medical City (TMC) Clark will continue to move forward and introduce more services until it meets its goal of becoming the referral center of Central and Northern Luzon.
Dr. Almario G. Jabson, President and CEO of TMC Clark, added that while the hospital was better equipped to handle Covid-19 cases, it can never be ready because of the surges.
“If it is just a stable Covid population, it is okay. You are ready to deal with that. You can more or less address the Covid and the non-Covid cases. But when the surges come and our resources are finite, and you see people in the Emergency Room and in the tents already, no hospital can be ready for that,” he said.
Managing physical resources
The entire TMC network adopted a “One Hospital, Two Systems Strategy” where, according to Dr. Jabson, in one hospital, there are two systems in play. One system will be able to cater to Covid patients and the other non-Covid patients.
“The teams that are assigned to these patients are also separate. We have one team for Covid patients and another team for non-Covid patients,” he said.
Adopting this system also meant that TMC Clark had to invest a lot in facility improvement. Prior to the pandemic, the negative pressure patient rooms were scattered all over the hospital.
When the pandemic struck, Dr. Jabson said they retrofitted and converted 31 of their ward rooms into negative pressure rooms and made sure that they were all in one area. This area would then be assigned to Covid patients.
“This will not only be safe for the Covid cases but for our personnel as well. The safety of everyone is a paramount concern for whatever monetary cost that will entail,” he said.
On finance and cash flow management
Since it has been a challenge for all hospitals to collect from PhilHealth, Dr. Jabson said what can be done in terms of managing the finances is to just prioritize payments.
“You have to talk to your suppliers just to make sure that the cycle keeps spinning. If you collect a certain amount, allot this certain amount for your priority payments,” he said.
While PhilHealth has remitted some amount to the hospital, Dr. Jabson stressed that the hospital will continue to deliver quality care because “it is of the national interest to keep on serving.”
“We just have to learn to allocate our resources better and talk to our suppliers so that we can manage their expectations, he said.
On handling and protecting human resources
In addition to the facility conversion which retrofitted negative pressure rooms and adopted separate zones for Covid and non-Covid patients, another way that employees were protected throughout the pandemic was the institution of medical benefits for all employees two years earlier, Dr. Jabson said.
“This was a big help to them and since we now have our own Molecular Laboratory, they can be tested there on a regular basis,” he said. “During lockdown, we housed our staff in the hospital and we provided shuttle services.”
The hospital did not let go of any of their staff because this would be “adding to the burden of society.”
On services and future plans
TMC Clark introduced a number of new services to entice patients to go to the hospital and to not delay their health needs. Patients can opt to do online consultations. The hospital, Dr. Jabson said, has a pool of doctors who are specialists and are board-certified to talk to patients and to look after them while they are at home.
“Instead of going to TMC Clark for their laboratory procedures, we have TMC Clark on Wheels where we bring the laboratory to you,” he said. “We can provide you Pharmacy services and diagnostic procedures and X-ray and the results will be made available online.”
The hospital has also deployed two programs for contactless payments. Patients can now pay for their laboratories and other diagnostic procedures at the Outpatient Department through PayMaya. TMC Clark has also made arrangements with different banks and credit card companies and patients can actually pay for their services online.
“Despite Covid, we were able to offer new services like the Fibroscan, Nuclear Medicine Facility, research units, Animal Bite Center and so many more,” Dr. Jabson said. “The challenge now are the non-Covid patients who have put off their treatment for several months already.”
Figures indicate that more non-Covid patients visit the hospital now because they can no longer delay their medical needs.
“For the early part of October, 60 to 70 percent are non-Covid cases and 30 to 40 percent are Covid cases,” he said.
On lessons learned
Dr. Jabson says there is no stopping TMC Clark from its goal to become the referral center of Central and Northern Luzon.
“Regardless, whatever it is, whether the virus is present or not, the hospital keeps on improving itself. The hospital has to keep on moving,” he said.
Moving means introducing more non-Covid services, and Dr. Jabson is optimistic that TMC Clark will be opening its own Cancer Center some time next year.
“When you build a Cancer Center, there should be four elements—a chemotherapy infusion unit, Genomics and Molecular Laboratory, Nuclear Medicine and the Linear Accelerator. We are in the final stages of procuring the Linear Accelerator, one step closer to achieving our goal,” Dr. Jabson said.
Other plans include expanding the ICU and Critical Care Units and the capabilities of the Cardiovascular Center; opening a Stone Prostate and Treatment Center, and acquiring a more powerful MRI.
For The Medical City Ambulatory Clinic, the plan is to beef up its laboratory capability, its dialysis unit and vaccination program. It will soon launch its out-patient surgery services.
“We will end 2021 on a high note. Revenues have been up and in terms of gross revenue, Clark will be hitting P1 billion this year. That, however, will only be on paper because we have yet to collect from PhilHealth,” he said.
The Medical City South Luzon
“ONE stark difference between this year and the early months of the pandemic last year is the absence of the pervasive atmosphere of panic and the feeling of helplessness. We now know how to handle the infection in its various presentations and severities.”
That was the assessment made by Dr. Cesar Ramon G. Espiritu, President and CEO of The Medical City (TMC) South Luzon located in Santa Rosa, Laguna. He explained that while there will still be deaths caused by the virus, the major factors for survival are “how virulent the new variant has become and how early treatment is started.”
“This means, therefore, that patients have to seek treatment early,” he added.
On managing physical resources
When it comes to dealing with Covid-19 patients, Dr. Espiritu said TMC South Luzon was probably the first hospital in the country to build a totally separate facility behind the main hospital, which was named “Complex of Hope.”
“The original structure, which quickly expanded because of demand, had a main complex with three ICU beds and even private rooms. Beside it was an extended quarantine facility with 15 beds,” he said. “This was built in a record 17 working days during the lockdown and became operational in May 2020. Currently, the hospital’s capacity for Covid patients has grown to 46, of which 12 are ICU beds.”
The hospital also introduced a drive-through testing facility initially intended for RT-PCR tests. Later on, blood chemistry and X-ray were added to its services.
Dr. Espiritu noted that the surges “resulted in unmanageable ER consultations and a worsening bed availability situation,” and this gave birth to the Covid HomeCare Program.
“This allowed patients to teleconsult first with a physician or the ER hospitalist-on-duty to determine if they needed hospital care or if they could still be managed at home,” he said. “If the latter was still possible, the hospital would provide the necessary support like medication, monitoring devices, regular consultations, and even oxygen tanks, if needed.”
However, if the patient’s condition deteriorated, the patient would have priority for admission to the hospital.
On financing and cashflow management
Like all industries and businesses, Dr. Espiritu said healthcare and hospitals took a big hit financially. People stayed away because of fear and forced lockdowns. This also included those who chose to neglect their existing non-Covid health problems.
“For almost a year, even most of our doctors chose not to practice until they had a better grasp of the pandemic—its transmissibility, pathogenicity, prevention and management—and were confident that the precautions were in place for them to see patients safely,” he said. “This resulted in a huge drop in patient census to as low as a third of pre-Covid numbers.”
To control the financial crisis, it became important for the hospital to be responsive, innovative and agile, Espiritu said.
“Recognizing the challenges, analyzing situations, discovering solutions and implementing strategies ahead of the competition were the key factors that kept our organization afloat,” he said.
Thanks to these interventions, Dr. Espiritu said TMC South Luzon ended 2020 profitably with 2021 looking “to even be a stellar year.”
In handling and protecting human resources
In terms of protecting their healthcare workers, the very first thing they did was to provide them with the safest environment possible so they can continue delivering quality service to patients, Dr. Espiritu said.
“We had to modify our physical setup and processes within the workplace. This required having an adequate supply and proper use of PPEs, implementing safe practices, proper segregation of cases, crowd control and prevention protocols, among others,” he said.
Since Covid-19 transmission was airborne, Dr. Espiritu said a large chunk of their budget was spent on incorporating negative-positive pressure systems in the facility. With this system in place, the hospital was transformed into a safe zone.
Early on, the hospital had already accepted the fact that they would be unable to handle an influx in Covid-19 patients because of challenges in manpower and in the facility. As such, the hospital’s prime concern was to care for their frontliners physically and emotionally.
Regular health monitoring, psychological support, crisis management, performance recognition with a benefits and rewards program and social activities were some of the activities that the hospital provided for its employees.
To address the transportation problem, the hospital adopted a work-from-home schedule, provided shuttle services and accommodation by way of in-hospital quarters and by renting a staff house in a nearby community.
“These initiatives afforded obvious benefits. First is the convenience of eliminating the need to frequently commute. Second is the safety aspect by minimizing their exposure to commuters and people in their communities from where there was a higher risk of acquiring infection,” Dr. Espiritu said.
As a result of the hospital’s efforts, Healthcare Asia awarded TMC South Luzon with its “Employee Engagement Initiative of the Year” award for 2021. According to healthcareasiamagazine.com, the Healthcare Asia Awards aim to honor hospitals and clinics that have risen above the challenges and made a remarkable impact on their patients most especially amid the massive disruption caused by the Covid-19 pandemic.
“By providing the needed tools and opportunities for staff development, our organization nourishes a culture of engagement as well as an incentivized environment where everyone’s efforts are recognized and valued,” Dr. Espiritu said. “Exposed to such a positive workplace condition, employees develop a sense of pride, purpose and pleasure in what they do.”
On services and upcoming plans
The pandemic, Dr. Espiritu said, has definitely “shifted their priorities away from the traditional and conventional hospital-centered healthcare towards remote health, wellness and digitization with the convergence of technology and biology.”
Since patients were having second thoughts about going to the hospital, hospital services had to be geared towards remote health. This meant that the hospital would bring their services to their patients, wherever they might me.
“Telehealth became a priority and major endeavor. Our Medical Services Group, IT, Ancillary and Marketing departments quickly responded to the need and we were quick to get this started using the different platforms then available,” he said. “Our TeleHealth hub was created and it was a room that had multiple cubicles, each equipped with all the equipment and gadgets needed for teleconsultation. We are currently working on creating our own platform for better service coordination and data handling.”
In March 2021, TMC South Luzon rolled out its Mobile Clinic: a custom-built truck that offers X-ray, ECG, blood chemistries, Covid testing and eye consultations. To date, the Mobile Clinic regularly visits eight communities and one company on a monthly basis. Future plans include expanding coverage to additional residential and industrial areas.
To push wellness, Dr. Espiritu said the hospital aims to empower patients to prevent disease instead of seeking treatment. They will receive personalized health solutions that can be integrated into their daily routine. All this, he explained, will be enabled by data and algorithms provided within their healthcare system.
“There will be less emphasis on treatment and care, and more on prevention, diagnostics, and digital solutions such as mobile apps, smart monitoring devices and artificial intelligence enabled analytics tools,” he explained.
TMC South Luzon will also see the opening of the Kidney and Stone Center, Neurocritical Care and Stroke Clinic, Molecular Laboratory and Blood Bank in the last quarter of the year.
“These are in-hospital services by necessity. But through technology and further adaptation of AI, we will improve on the accessibility, efficiency and quality of service these units will provide,” Dr. Espiritu said.
On lessons learned
One of the lessons Dr. Espiritu learned in the pandemic was the importance of preparedness. While there had been warnings about the pandemic, they all fell on deaf ears. Hospitals were ill-equipped in their facilities, supplies, manpower and processes to deal with the health problems of such magnitude.
“Now that it has happened and knowing that there will be other pandemics to come, health institutions have already started adopting the needed countermeasures and they will continue to do so as new information comes out,” he said.
While the pandemic has disrupted our lives, Dr. Espiritu believes “it had accelerated a future which normally would have happened in five to 10 years from now.”
“In particular, here is the marriage of healthcare and technology. Individual monitoring devices, wearables, AI, robotics and other equipment that will allow us to care for more patients with limited manpower and extend our health reach outside the hospital setting is now a priority initiative and investment,” he said. “Our remote health program offering laboratories, diagnostics, rehabilitation, wound care, pharmacy services and teleconsultations are already fairly mature.”
While all these services were already available prior to the pandemic, Dr. Espiritu said “its growth was accelerated because of the demand from patients who were anxious to go to the hospitals.”
“We are committed to developing this, further convinced that, even after Covid-19, the demand will still be there as a preference for convenience,” he said.
Perpetual Help Medical Center Las Piñas
“WE are more prepared this year compared to last year in dealing with the pandemic. We have had our learnings and these have helped and guided us in our strategies, action plans, and decision-making efforts.”
So said Lt. Col. Richard Antonio M. Tamayo, President of Perpetual Help Medical Center Las Piñas, who added that the hospital had learned to cope with the pandemic which, in turn, has resulted in better management of resources, better supply chain management, among others, which have been helping businesses to survive and even thrive.
“The whole world was stunned and every human being was shell-shocked in 2020 with the sudden emergence of a global pandemic. Covid-19 brought daunting challenges with everyone in great fear of getting infected with the coronavirus,” Tamayo said.
People started to stay away from Perpetual and the other hospitals. Patients with chronic illnesses and even the doctors shied away from the hospitals. Nurses, allied medical staff and even the doctors were getting infected with the virus.
On managing physical resources
To accommodate the growing number of Covid-19 patients, Tamayo said they converted newly constructed patient rooms to be used as Covid-19 wards. An area in the hospital was renovated to serve as an Emergency Room Triage solely for confirmed, probable and suspected Covid-19 patients.
“We launched and offered services to deal with the pandemic situation such as the RT-PCR test and antigen test at the most competitive pricing levels,” he said. “We offered promotional discounts and packages to convince our patients not to delay their diagnostic tests and medical treatment.”
Tamayo recalled a time they had to shorten the operating hours of some of their centers because their staff had either been infected by the virus or were in quarantine while waiting for their RT-PCR test results.
“At some point, we had to adjust the working hours or work schedule of our employees to decongest and reduce the number of personnel to comply with the ruling of the Inter-Agency Task Force for the Management of Emerging Infectious Diseases, or IATF,” he said.
On financing, cashflow management and managing human resources
Implementing strict safety measures to prevent the spread of the virus meant additional costs as the hospital had to spend for regular and frequent disinfection, acquisition of PPEs and supplies for all medical staff, nurses and other frontliners. Construction and renovation had to be done in order to segregate the hospital into green, yellow and red zones.
As employees had no means of transportation, Perpetual had to provide shuttle services for their employees and board and lodging for many of their frontliners.
“At some point, we gave free meals and multivitamins to our medical workers and all other workers. Thanks to benevolent donors and sponsors, we received donations in kind, mostly food, drinks, face masks and face shields, PPEs, disinfecting supplies, vitamins, medicines, toiletries and many more. These helped us a lot in controlling our costs,” Tamayo said.
Supply chain management was also affected as some manufacturers and suppliers could not fulfill their orders because of the lockdown. Some suppliers demanded cash payments for their deliveries.
“A major challenge was the nonpayment or very minimal payment of claims by PhilHealth which affected our collection, and thus, our cash flow,” Tamayo added.
On services and future plans
While adjustments had to be made in Perpetual’s budget target and financial plan, management did not allow the pandemic to stop them from pursuing the expansion and enhancement of hospital facilities and acquisition of medical equipment with the latest or advanced technology.
“Thus, we were able to launch new services as we have stayed committed to providing quality and excellent healthcare services to our patients and the communities we serve,” Tamayo said.
To date, the management of Perpetual has completed construction of the new Clinic Building or the U-MAB (Unilane Medical Arts Building); the new state-of-the-art ICU complex, a connecting bridgeway to the Operating Room, expansion of the ER, creation of a separate area for the ER Triage and separate area for positive/confirmed, probable and suspected Covid-19 patients (Isolation and Critical Care Area), expansion and upgrading of the Heart and Vascular Institute complex, and the construction of the new multi-level parking facility, among others.
“We have also been accredited or identified by the Las Piñas City local government as one of the vaccination sites and have also been providing vaccine administration for the community and corporate clients,” Tamayo said.
On lessons learned
For Tamayo, the pandemic was a wake-up call for everyone, for all industries and businesses.
“For Perpetual Help Medical Center Las Piñas, it reminded us of the great value of our business continuity plan amid situations such as the pandemic. It also validated and reinforced our fundamental principle for corporate culture, our decisions, strategies, plans, actions, practices, processes, attitude, behavior,” he said.
He added that patient safety will always be the hospital’s top priority.
“Patient safety is achieved when we maintain and practice a culture of safety among our medical personnel, our healthcare workers, our Patient Care staff, all our frontliners and all of our employees,” Tamayo said.
VRP Medical Center
“We were all confronted with an unseen and unknown virus which no institution, no specialist, really nobody was prepared for.”
This was the statement that Veronica Regina P. Vergel De Dios-Garcia, the administrator of VRP Medical Center (VRPMC), made during a webinar organized by Philippines Graphic in February 2021 titled “Hospital Best Practices in Handling Covid-19 Patients.”
While VRPMC is now more prepared to deal with Covid-19, the hospital had to overcome many challenges in order to provide the best quality of care not only to its patients but to its healthcare workers as well.
“Well, actually almost everything in all aspects changed. We changed the way we managed the hospital compared to the pre-pandemic time so the focus is really different now because we have to ensure that everything we do is safe and compliant to infection control standards,” Garcia explained.
On managing physical resources
VRPMC is a 10-story building and in order to accommodate Covid-19 patients, Garcia said they had to implement zoning, where the 9th and 10th floors were Covid floors and the other floors are clean floors.
“We have floors that accommodate suspect patients, patients who are waiting for the results of their RT-PCR tests. Once their results are out, they will be transferred to where they should be admitted,” she said. “We also had to divide our ICU into clean and infectious areas.”
To accommodate the growing number of Covid-19 patients, VRPMC opened its second ER in September 2020 solely for Covid-19 patients. The new ER was constructed on the vacant long and narrow lot located beside the hospital. It has 16 beds including four critical beds, a green zone and a nurse station.
For patients who need to avail of outpatient services and do not want to enter the hospital premises, VRP also opened a curbside laboratory which offers ambulatory consultations and RT-PCR testing.
On financing and cashflow management
When it comes to hospital revenues and cash management, Garcia said the general perspective that hospitals are doing well and that business is good is not true.
“We need to continue operating with the same level of uncompromised quality but our census is really very low. That’s because patients are very evasive of hospitals and they will only go to the hospital if they really need it,” she said.
While she and her team are trying to minimize expenses and cut costs where possible, Garcia said they had to make sure that supplies and medicines, especially for Covid, are always available. She added that due to the situation, the hospital pharmacy now stocks more Covid medicines than the other medicines that they used to order.
“And then we are closely monitoring our collections, the cash flow because it is really a tough balancing act because our census has gone down to maybe just a third or a fourth of our average census pre-pandemic,” she added.
VRP is also enduring the delays of remittances from Philhealth. While they have already made representations with Philhealth as part of Mount Grace Hospitals, VRP has already signed an agreement that if Philhealth will not comply with some of their conditions, the hospital will pull out of Philhealth.
“We are not really a Covid hospital. In our network which is Mount Grace, the Covid hospital is really Fel De Mundo Medical Center. But there are times that we have more Covid patients than they do and because of that our exposure to Philhealth is really big,” Garcia said.
In handling and protecting human resources
While VRP did not lay off any of its employees, Garcia said that they have been maintaining a skeletal work force since the pandemic where their employees, especially those in the administration side, report to the office three days a week.
“Management is really supportive of the needs of our employees. We are very sensitive of their needs because like in our ER 2, we limit our admissions there. When the nurses say they can no longer handle additional patients, we stop admitting. We also do not want to compromise the health of our staff,” she said.
Compared to the previous surges, Garcia noted that the number of their healthcare workers being exposed to the virus had dropped in part due to the vaccines. She admitted though that there were still a handful of employees who refused to be vaccinated. As such, they had to be reassigned to other areas to lessen their exposure to Covid.
“We had to increase our hazard pay and we returned our retention programs for our nurses because of the situation. We were also able to get the Special Risk Allowance for our healthcare workers from the Department of Health,” she said.
On services and upcoming plans
The pandemic forced VRPMC to up their game in terms of programs and services for patients because, as Garcia noted, “people have become so evasive to the idea of coming to a hospital.
“We now we have telemedicine and a home service and home care option for mild Covid-19 cases. And then even with other transactions, like filling up a form or paying the bill, there always has to be a digital or online option. Really contactless,” Garcia said.
She said the pandemic forced the hospital to shelf some of their projects and investment plans. She pointed out that the lot where the new ER was built was meant for a planned 15-story medical tower. They were also in the process of relaunching their kidney transplant service which was deferred until next year.
“We were supposed to invest in a new Catheterization Laboratory (Cathlab) last year to cater to cardiovascular cases and it was pushed back in terms of timing. It is scheduled to be launched sometime later this year. Last year we purchased a new portable X-ray machine because we really needed it for the Covid patients. So there was a trade-off,” she said.
For the time being, Garcia said they are in the process of recovering some of the programs and services that were stopped because of the pandemic. One of those programs is the new Wellness and Aesthetics Center which has not really taken off.
“The doctors and staff are undergoing retraining to prepare for that. Our pediatrics group wanted to focus more on high-risk newborn services. Since more pediatric cases are being recorded, we felt it was time to look at it again,” she said.
On lessons learned
In addition to crisis management, Garcia said a good lesson she picked up during this pandemic was the value of teamwork.
“VRPMC is so blessed to have medico administrative leaders who are action oriented, proactive, dynamic and very supportive. We have leaders and a manager who listen to the needs of the staff, of the patients and of the doctors,” she said. “I work full time from home but I have division heads who report to work three times a week and we have an officer-in-charge every single day, even Sunday.”
Except during holidays, Garcia meets with her team at 4 pm daily to discuss the day-to-day hospital operations. She added that the division heads can contact her at any time of the day if they have an urgent concern.
“I would say another lesson learned would be preparedness although of course we were all caught off guard during the early months of the pandemic. Now, we try to think ahead, try to anticipate what the patients, doctors and staff need,” she said. “So we try to prepare with recovery plans, with back up plans so that we are prepared. I think these are the greatest lessons that I learned from this Covid pandemic. And it is important that you have people who are so devoted, so committed and so responsible.”