October 21

ISO 9001:2015
QUALITY MANAGEMENT SYSTEM
QUALITY
MANUAL
Provincial Government of Pangasinan
General Administrative and Support Services
QUALITY MANUAL 0.6
Document Code: PGP-QM-2017 Effectivity Date: May 2017 Revision: 0
0.6 Control of the Quality Manual
0.6.1 Authorization
This Quality Manual and its related documents are considered released or issued if the signature
of the Top Management appears in the AUTHORIZATION SHEET; otherwise it is unofficial and not
authorized for use and distribution.
0.6.2 Distribution
It is the responsibility of the Document Controller to maintain and retain documented

information. Copies of the manual is issued to officials and employees involved in the management,
support and/or actual operation of the QMS process. In case of personnel movement such as resignation,
retirement, termination and transfer to other offices, the Quality Manual remains with the office.
0.6.3 Confidentiality
The Quality Manual and its related documents are treated as confidential and should not be
removed from the premises without prior authorization from the Top Management.
Issuance of uncontrolled copies of the QMS documented information to individuals within or
outside the organization is not allowed, unless otherwise, approved by the Top Management. For
effective document control, only the Document Controller shall issue uncontrolled copies of the QMS
documented information, if deemed necessary and with prior authorization from the Top Management.
0.6.4 Amendment
Introduction of new procedures or services may require amendments to the existing Quality
Manual and related procedures. A reissue of this Quality Manual will be effective only when:
There is a change in the scope of certification;
There is a change in the management structure;
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QUALITY MANUAL 0.6
There is an improvement of the service process; and

Upon the instructions of the Top Management.
Requests or suggestions shall be made to the Chiefs of Offices using the Document Creation and
Change Form (DCCF) to ensure that such changes are reflected in the manual.
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QUALITY MANUAL 0.5
0.5 DISTRIBUTION LIST
Copy Number Issued To Functional Unit
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Controlled Copy
Master Copy
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QUALITY MANUAL 0.3
0.3 REVISION HISTORY
Document
Revision Description of Creation / Authored by Reviewed by Effectivity
No. Change Change Form Date
No.
0 Initial Release N/A Chiefs of Top May 2017
Offices Management
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QUALITY MANUAL 0.2
AUTHORIZATION SHEET
This is to certify that the contents of this Quality Manual have been duly reviewed and verified in
accordance with the standards of ISO 9001:2015 Quality Management Systems, and so approved for
distribution, use and implementation by the Provincial Government of Pangasinan.
________________________
AMADO I. ESPINO III
Top Management
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2. Normative Reference
The following documents, in whole or in part, are normally referenced in this document and are
indispensable for its application. For dated references, only the edition cited applies. For undated
references, the latest edition of the referenced document (including any amendments) applies.
1. ISO 9001:2015 Quality Management Systems - Requirements

2. Mandatory Procedures
2. l. Risk Management
2.2. Control of Documented Information
2.3. Control of Non-conforming Outputs
2.4. Feedback Management (Customer Satisfaction)
2.5. Analysis and Evaluation
2.6. Internal Audit
2.7. Management Review
2.8. Non-conformity and Corrective Action
2.9. Continual Improvement
3. Procedure Manuals
3.l Control of Non-conforming Output
3.2 Documented Information
3.3 Feedback Management
3.4 Improvement
3.5. Internal Quality Audit
3.6.Management Review
3.7 Non-conformity and Corrective Action
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3.8. Risk Management

4. Work Instructions
4. 1 Recruitment, Selection and Placement
4.2 Training and Employee Development
4.3. 7S of Good Housekeeping
4.4. Evaluation of Service Delivery
4.5. Referring Comments, Complaints, Suggestions
4.6. Strategic Performance Management System
4.7. Core Value/Core Competency Rating
4.8 Implementation of Program on Awards and Incentives for Service Excellence (PRAISE) in
the Provincial Government of Pangasinan
4.9. Health and Wellness Program
4. l0 Grievance Resolution Process
4.11 Complaint Resolution Process
4.12 Competency Assessment Internal Quality Auditors
Prepared by: Approved by:
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3. Terms and Definitions

3.1 Provincial Government of Pangasinan (PGP) the organization in charge of implementing
the QMS.
3.2 General Administrative and Support Services - ISO aligned activities. Core services that
provide technical and substantive support and overall administrative management support to the
operation of the organization.
3.3 Quality Management System - objectives and processes of the Provincial Government of
Pangasinan designed to focus on quality and client/patient satisfaction. The QMS consists of
written documents that address the ISO 9001:2015 standards. .
3.4 Quality Policy - includes objectives for quality management commitment to quality,
organizational goals and reference to customers expectations.
3.5 Quality Objectives - something sought, or aimed for, in relation to quality.
3.6 Top Management - responsible for ensuring that a quality system is established, implemented,
effective and maintained.
3.7 Audit Findings - results of the evaluation of the collected audit evidence against criteria.
3.8 Audit Scope - extent and boundaries of an audit generally includes a description of the physical
locations, organizational units, activities and processes, as well as the time period covered.
3.9 Audit Team - group of two (2) or more auditors assigned to audit a particular process or area
and supervised by a lead auditor.
3.10 Auditee - person or organization being audited
3.11 Auditor - person with competence to conduct the audit
3.12 Corrective Action - action taken to eliminate the root cause of an existing undesirable deviation
or non-conformity to prevent recurrence.
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3.13 Correction - action implemented to immediately correct non-conformity.

3.14 Conformance - an affirmative indication or Judgment that a product or service meets the
requirements of relevant specications, contract or regulation. Also, the state of meeting a
requirement.
3.15 Effectiveness - ability of the Quality Management System or process to achieve customer
requirements, quality objectives, performance targets and quality standards.
3.16 Efficiency - optimization of resources in a process. Operationally, it is the output accomplished
over a period of time, given the resources needed.
3.17 Internal Quality Audit (IQA) - a comprehensive, systematic and discipline continual
monitoring process that is initiated and managed by top management to determine whether
agreed-upon requirements are met.
3.18 Human Resource Management & Development Office (HRMDO) Audit - quarterly
monitoring and evaluation audit conducted by HRMDO program coordinators
3.19 Follow-up Audit - to verify the implementation and/or effectiveness of corrective action/s
implemented by auditors, a follow-up audit is conducted as scheduled in an IQA Plan.
3.20 Internal Quality Audit Plan (IQA Plan) - description of the activities and arrangements for an
audit prepared by the IQA Team Leader and to be confirmed by the Top Management.
3.21 Internal Quality Audit Program - the organizational structure, commitment and documented
methods used to plan and perform audits. -
3.22 Internal Quality Audit Team - group of auditors conducting an audit under the direction of the
internal Quality Audit Team Leader.
3.23 Internal Quality Audit Team Leader (IQAT Leader) - a member of the IQAT designated to
supervise the planning and performance of the audit, including the management of the IQAT. .
3.24 Lead Auditor - a member of an Audit Team of a process or area responsible for the teams
coordination, planning, audit assignments, observation classifications, presentations, and reports.
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3.25 Major Non-Conformity - a type of non-conformity that results from either of the following:
a. Non-conforming products which reached the customer, recurring or with adverse effect
on the achievement of targets;
b. Repeated failure (two consecutive audits) to achieve Key Performance Measure (KPM)
targets;
c. Repeated failure (two consecutive audits) to meet quality standard requirements which
drastically affects service delivery;
d. Non-compliance to a whole sub-clause or a combination of more than three (3) minor
non-conformities within a sub-clause of the ISO 9001:2015 standards.
3.26 Minor Non-Conformity a type of non-conformity that results from either of the following:
a. Discrepancy or lapse in discipline in the defined QMS;
b. Non-compliance to a certain aspect of a sub-clause of the ISO 9001:2015 standards
3.27 Non-conformity - a departure of a quality characteristic from its intended level or state that has a
severity sufficient to cause an associated product or service not to meet a specification
requirement; can be categorized as Major or Minor.
3.28 Objective Evidence - data, records and reports on performance against targets or quality -
standards which can be proven as accurate through inspection, observation, measurement, test,
monitoring tools or other means. Specifically, this refers to the KPM Scorecards, Quality Plan
Scorecards, KPM Monitoring Report, Quality Standards Monitoring Report, Control of Non-
Conforming Product Monitoring Reports, etc. It also includes records or reports on various
actions taken required to ensure effectiveness of the QMS like IQA Reports, CAR, CAR Status
Reports, Minutes of Management Review and other meetings, memoranda, etc.
3.29 Observation - this can either be a suggestion to improve the process or a weakness in the quality
management system noted by an auditor or an employee that may lead to non-conformity if not
corrected. It can also be an isolated non-fulfilment of a specific requirement that can be corrected
on the spot, e.g. typographical errors, missing words, one missing signature from a sample of
objective evidences, etc. which has no adverse impact on the effectiveness of the QMS.
3.30 Plan-Do-Check-Act (PDCA) Cycle - an interactive four-step problem solving process typically
used in business process to achieve breakthrough improvement.
3.31 Procedure - a document that specifies the method of producing a product or service, generally
involving a number of steps or operations.
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3.32 Process Owner - a particular employee of the PGP who performs specific process of the
organization
3.33 Root Cause - a fundamental deficiency that results in a non-conformance and must be corrected
to prevent recurrence of the same or similar non-conformances.
3.34 Root Cause Analysis (RCA) - a class of problem solving methods aimed at identifying the root
causes of problems or events.
3.35 Process Quality Audit - an analysis of elements of a process and appraisal of completeness,
correctness of conditions, and probable effectiveness.
3.36 Quality System Audit - a documented activity performed to verify, by examination and
evaluation of objective evidence, that applicable elements of the quality system are suitable and
have been developed, documented and effectively implemented in accordance with specified
requirements.
3.37 Corrective Action Request (CAR) - used to record and document correction and corrective
action upon audit for violations of policies, rules and regulations, other statutory laws and other
nonconforrnities in the QMS and ISO 9000:2008 requirements. It is also the tool to be used by
process owners to record the correction and corrective actions performed due to feedback from
customers, Internal Quality Audit and/or third party audit findings, employee suggestions or
observations, recurring problems, problems or deficiencies in the QMS, perceived risks or threats
to the QMS and the business and if performance gaps occur.
3.38 Internal Quality Audit Meeting - refers to the presentation of IQA findings right after the audit
based on the audit plan prepared and is called by the IQA team leader, or any meeting called by
the IQA team leader to discuss IQA-related topics.
3.39 Corrective Action - action taken to eliminate the root cause of an existing undesirable deviation
or non-conformity to prevent recurrence.
3.40 Correction - action implemented to immediately correct non-conformity
3.41 Management Review - refers to any meeting conducted by each support group or core process
with the Top Management and is properly documented with Minutes of Meeting. The summary
of office and hospital performance and accomplishments, effectiveness of actions taken to
address risks and opportunities, non-conformities and corrective actions and semi-annual audit
findings may be presented during the meeting, which is conducted semi-annually or whenever
deemed necessary to ensure the continuing suitability of the QMS, its adequacy and effectiveness
in satisfying the requirements of ISO 9001:2015 and its stated quality policy and objectives.
Likewise, the review shall be a venue to assess opportunities for improvement and the need for
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QUALITY MANUAL 3
changes to the QMS. The Documentation Team is responsible for preparing the minutes of the
meeting and distribution of notice of meetings.
3.42 Dept./Section Head - oversees the overall operations of the Department or Section and ensures
that the QMS is properly implemented and maintained.
3.43 Quality Management System Meeting - refers to the meeting called by the Human Resource
Management & Development Ofce (HRMDO) to present and discuss quarterly HRMDO audit
ndings, issues and concerns for continuous improvement. The QMS meeting may also be called
by any ISO team member or process owner anytime for changes or concerns vital to the
implementation of the QMS. Daily operations, structural development changes -and resource
requirements may be some of the agenda. The Documenting and Reporting Team is responsible
for preparing the agenda, minutes of the meeting and distribution of notice of meetings.
3.44 Internal Quality Audit Meeting - refers to the presentation of IQA findings right after the audit
based on the audit plan prepared and is called by the IQA Team Leader, or any meeting called by
the IQA Team Leader to discuss IQA- related topics. The IQA Team Leader is in charge of
preparing the agenda and any IQA team member shall take the minutes of the meeting. The
Documenting and Reporting Team is responsible for the distribution of notice of meetings.
3.45 Feedback Management - process where complaints, suggestions, compliments, perceptions,
opinions and needs of clients are addressed, noted, answered, considered and met.
3.46 Client Feedback - one of the tools used in the feedback mechanism which is accomplished by
clients after leaving the offices and hospitals and dropped in suggestions boxes located within the
Public Assistance Desk Area.
3.47 Client Satisfaction Survey - tool used in the feedback mechanism which is conducted
periodically to determine clients satisfaction levels in terms of definite parameters which
include: Quality of Service; Service Providers and Physical Working Conditions.
3.48 Service Delivery Survey - tool used to obtain client perception regarding the provision of
general and administrative support services to the ISO support group and to all offices and
hospitals under the Provincial Government of Pangasinan.
3.49 General Administrative and Support Services - ISO aligned activities/core processes that
provide technical and substantive support and overall administrative management support to the
operation of the organization.
3.50 Anti-Red Tape Act (ARTA) of 2007 - otherwise known as Republic Act 9485 declared the
policy of the state to promote integrity, accountability, proper management of public affairs and
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QUALITY MANUAL 3
public property as well as to establish effective practices aimed at the prevention of graft and
corruption in government.
3.51 Citizens Charter - service standards in accordance with the ARTA policy and as mandated for
local government units.
3.52 Public Assistance Desk - established in every office and hospital manned by a Public Assistance
Desk Officer (PADO) for purposes of attending to clients, their needs, queries, complaints, etc.
in a prompt and efficient manner.
3.53 Service Provider - composed of all employees who have personal contact with clients and
embody the core values, standards and policies of the Provincial Government of Pangasinan
3.54 Quality of Service - refers to the accuracy and timeliness of services provided, and availability
of required services (for offices), including food and availability of linen and medicines at the
hospital (for hospitals).
3.55 Physical Working Condition - office and hospital work areas and their surroundings including
facilities and equipment are clean, orderly, organized and working properly.
3.56. Internal Clients - refer to all provincial government employees
3.57. External Clients - refer to walk-in job applicants, researchers, employees from other agencies,
or anybody who is not a provincial government employee and in need of the services of the
provincial government (walk-in, eld and hospital patients)
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QUALITY MANUAL 4
4. Context of the Organization

4.1. Understanding the Organization and its Context
The organization shall identify internal and extemal issues that are relevant to the organizations
purpose and its strategic direction that may affect the delivery of planned results or achievement of
objectives. Internal Issues/Concerns are issues/ concerns arising from legal, technological, competitive
market, cultural, social and economic environments whether international, national, regional or local. On
the other hand, external issues Concerns are issues concerns related to values, culture, knowledge and
performance of the organization. Likewise, the organization shall identify risk factors that are part of the
processes being undertaken. Risk factors can be facilitated by considering the requirements such as
statutory/ legal requirements, organizational requirements, client/customer requirements and ISO
9001:2015 Quality Management System requirements and prepare risk registry using the Risk
Management Plan.
The organizations internal and external issues shall include factors or conditions that may affect
the achievement of the following Development Thrusts/ Strategic Goals:
1. Safe and peaceful neighborhood
2. Quality and affordable health care
3. Adequate and high quality education
4. Increased agricultural productivity
5. Better jobs and income opportunities
6. Youth and sports development
7. Tourism development and investment promotion
8. Affordable and cozy socialized housing and other social welfare services
9. Environmental protection and rehabilitation and disaster risk reduction management
l0. Infrastructure development and other special projects
Through regular planning sessions and meetings of Top Management and Support Groups, either
individually or collectively, the provincial government is able to determine/monitor its accomplishments
and developments as well as the issues (both internal and external.) that impede the achievement of the
strategic objectives as well as the Quality Management System.
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Figure 1. Organizational Structure of the ***********************
Put the flowchart of the

Deped ORG structure
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QUALITY MANUAL 4
Document Code: PGP-QM-2017 Effectivity Date: July 2017 Revision: 0
Figure 2. QMS Process Model of the *******************
Support and
Organization
Please put appropriate comments/boxes for

DEPED
Performance
Planning Leadership Evaluation
Improvement
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QUALITY MANUAL 4
4.2. Understanding the Needs and Expectations of Interested Parties

The QMS shall enable management to understand the needs and expectations of interested parties by
identifying these needs and expectations, translating the identified needs and expectations into requirements,
and communicating the requirements throughout the organization while focusing on process improvement to
meet and satisfy these needs. Top management shall determine the following:
1. Requirements specied by th.e interested parties;
2. Requirements not stated by the interested parties but necessary for specified service needs;
3. Statutory and regulatoiy requirements related to the service, and
4. Any additional requirements determined by the provincial government
Also, top management shall review these requirements/needs of the interested parties, and shall ensure that:
1. Concerns are addressed; -
2. The organization has the ability to meet defined requirements; and
3. Requirements are fulfilled with the aim of enhancing client satisfaction.
The Provincial Government of Pangasinan shall use a variety of methods to determine the needs and
expectations of interested parties which include clients and other government agencies as well as statutory
requirements through:
Planning Sessions
Meetings
Project Monitoring & Evaluation
Client Survey/Feedback
4.3. Determining the scope of the quality management system

The Provincial" Government of Pangasinan, in determining the scope of its quality management system,
shall consider the internal and external issues that may influence or affect the attainment of its strategic
direction, vision and mission. It shall also, identify the requirements of relevant interested parties, including the
specifications of products and continuation of services for the public.
Figure 2 shall be the organizations business process model in implementing the requirements of ISO
9001:2015 Quality Management System (QMS). The quality of the support groups services is defined in the
Quality Manual, Quality Procedures and Work Instructions or Standard Operating Procedures. The Quality
Manual describes the policy of Provincial Government of Pangasinan regarding all applicable aspects to ISO
9001:2015 standards, refers to the corresponding quality procedures, and also outlines the structure of the
documentation used in the quality system.
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QUALITY MANUAL 4
4.4. Quality management system and its process

4.4.1 The Provincial Govemment of Pangasinan shall. establish, implement, maintain and continually
improve a quality management system, including the processes needed and their interactions, in
accordance with the requirements of this International Standard.
The Provincial Government of Pangasinan shall determine the processes needed for the
management system and the application throughout the organization and shall:
1. Determine the inputs requiredand the outputs expected from these processes originating from
the planning process;
2. Determine the sequence and the interaction of these processes based on the business process
model;
3. Determine and apply the criteria and methods (including monitoring, measurements and
related performance indicators) needed to ensure the effective operation and control of these
processes as required by product specifications and continuing improvement actions;
4. Determine the resources needed for these processes and ensure their availability;
5. Assign the responsibilities and authorities for these processes V to ensure effective
implementation of service;
6. Address the risks and opportunities as determined in accordance with the requirements of 6.l.
that may affect the Provincial Government of Pangasinans attainment of its goals and
objectives;
7. Evaluate these processes and implement any changes needed to ensure that these processes
achieve their intended results to attain the satisfaction of clients;
8. Improve the processes and the quality management system as a demonstration of committed
service to the public.
4.4.2. To the extent necessary, the Provincial Government of Pangasinan shall:
1. Maintain documented information to support the operation of its processes in the form of
references, among others;
2. Retain documented information to ensure that the processes are being carried out as planned,
with necessary evidence.
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5 Leadership
5.1 Leadership and commitment
5.1.1 General
The Top Management is committed to sustain the effectiveness of the Quality Management System
(QMSS) by ensuring that the established quality policy and quality objectives are compatible with the content
and strategic direction of the province.
To guarantee the effective implementation of the quality management system and achieves its intended
results, top management shall:
1. Establish, maintain, and review its Vision, Mission, Core Values, Quality Policy and Quality
Objectives;
2. Provide relevant training on the QMS and related procedures;
3. Communicate and ensure that employees understand:
3. l the importance of meeting client, as well as, regulatory and statutory requirements;
3.2. the quality policy and quality objectives through postings and internal staff meetings,
among others; and
3.3. changes to procedures and documentation;
4. Ensure that the quality objectives are:
4. 1 established and reviewed for continuing suitability and adequacy, and
4.2. revised or changed when necessary;
5. Identify resource requirements and allocate resources to ensure an effective QMS including but not
limited to:
5.1 identication and allocation of the required human resources, training, equipment and
services.
5.2. allotment of resources to support the internal audit process;
6. Conduct management reviews; and
7. Oversee the continual improvement of the QMS.
Likewise, process approach and risk-based thinking shall be required to. the process owners to identify,
assess risks and measure the possible effects/impacts of such risks, and prepare action plans to address those
risks for the effective implementation of the quality management system in order to avoid client complaints and
other hazards (see Clause 6.1 Actions to address risks and opportunities).
To ensure that resources needed for the quality management system and in the implementation of
service processes are available, periodic Management Reviews shall be conducted in order to identify those
needs and inform top management.
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Relatively, the top management ensures that the Provincial-Government service processes meet the
client requirements adhering to ultimate client satisfaction.
Top management shall guarantee that the importance of the quality management system shall be
communicated to the entire organization as well as conforming to the quality management system requirements
through:'
Documented trainings
Posters/billboards/bulletin boards
Regular communication/memorandum
Staff meetings
Flag raising ceremony
Meetings of key personnel
Employee orientations
Departmental meetings
Email/intranet
Core team meetings
Support team meetings
Annual QMS planning
Television infomercials
Executive orders
Tarpaulins
Furthermore, part of ensuring the effective implementation of QMS is top management
directing/instructing employees/staff to perform their required functions in support to the achievement of the
strategic objectives of the organization.
In addition, achieving the intended results in the QMS shall be also assured based on the attainment of
the quality objectives and quality policy.
Top management shall ensure the suitability, adequacy and effectiveness of the organizations QMS
through constant continual improvement activities such as the conduct of management reviews, internal audits
and planning sessions.
Relatively, relevant management roles to demonstrate the leadership of personnel in their respective
areas of responsibility shall be supported by assigning them various duties and responsibilities in the
implementation of QMS.
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5.1.2 Customer focus

It is the policy of the Provincial Government of Pangasinan to implement and improve efficiency in the
delivery of government services to the public in order to satisfy and meet the requirements of its internal and
external clients in compliance with legal and statutory requirements. Clients include the general public as well
as employees of the Provincial Government being provided with general administrative and support services
certied to ISO 9001:2015 QMS.
Internal clients include offices and hospitals provided with general administrative and support services
certified to ISO 9001:2015 QMS.
External clients refer to walk-in, eld and hospital patients who have availed of the services of offices
and hospitals provided with general administrative and support services certied to ISO 900l:2015 QMS.
It is the responsibility of the Top Management to review the requirements related to the needs of the
client and ensure that:
client/patient and staff concems with regards to safety and other forms of risks are identied,
analyzed and addressed through risk-based thinking and risk management,
the organization has the ability to meet defined requirements such as those indicated in
Republic Act No. 9485, otherwise known as the Anti-Red Tape Act of 2007, and
client/patient requirements are dened and fullled with the aim of enhancing client
satisfaction.
Management uses various methods to determine client/patient requirements and satisfaction including,
but not limited to the following:
Customer survey and customer feedback
On-site inspection
Telephone, written and walk-in feedbacks
Program evaluation
Meetings
Annual Planning
The above-mentioned tools monitor and measure internal and external client requirements and
satisfaction that yield essential indicators regarding client perception and are considered vital to continual
improvement activities in offices and hospitals of the provincial government.
Likewise, the core services under the quality management system shall enable management to
successfully satisfy the present and prospective needs of customers by identifying these needs, translating those
needs and expectations into requirements, and communicating those requirements throughout the organization
while focusing on process improvement to determine, maintain and enhance customer satisfaction. Top
management determines:
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QUALITY MANUAL 5
requirements specied by the clients/patients including service delivery,

requirements not stated by the customer but necessary for specied service needs,
statutory and regulatory requirements related to the service, and
any additional requirements determined by the Provincial Government.
5.2 Policy
5.2.1 Establishing quality policy
The Quality Policy statement follows the framework of the Provincial Government of Pangasinan in order to
provide quality service to the public, and thus, meet citizens requirements and achieve client satisfaction. The
framework of the quality policy shall include the following:
l. Citizen focus
2. Leadership
3. Involvement of people
4. Process approach
5. Systems approach to management
6. Continual improvement
It prescribes the methods to accomplish this, which is done by continually improving processes and
services to ensure they consistently meet or even exceed the requirements. Moreover, the quality policy
statement provides the direction and framework for establishing key organizational level performance measures
and related improvement objectives.
The Quality Policy statement is controlled by its inclusion in this manual, and along with all policies
contained herein, is reviewed for continuing suitability during planning and management review meetings.
5.2.2 Communicating the quality policy

The Quality Policy shall be kept as documented information which shall be available at all times to
relevant interested parties that may want to go through it.
The Provincial Government communicates at all levels of the organization to promote awareness,
understanding and application of the quality policy through:
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Documented trainings
Posters/billboards/bulletin boards
Regular communication/memorandum
Staff meetings
Flag raising ceremony
Meetings of key personnel
Employee orientations
Departmental meetings
Email/intranet
Core team meetings
Support team meetings
Annual QMS planning
Television infomercials
Executive orders
Tarpaulins
5.3 Organizational roles, responsibilities and authorities

Top Management shall ensure that responsibilities and authorities are dened and communicated within
the organization. Likewise, the responsibilities of key personnel shall be dened and documented in the
succeeding pages of this Section to identify accountable personnel who shall be in charge of delivering the
necessary services and intended outputs. The delegation of responsibilities and authorities in the absence of
persons holding key positions shall be vested on the next lower rank, subject however, to the limit of its
authority. This is to ensure that top management and the QMS team shall report the performance of the QMS
and maintain its integrity when changes are planned and implemented.
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Figure 5: Organizational Structure of the Quality Management Team
HON. AMADO I. ESPINO III
PUT FLOWCHART HERE
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The specific roles and responsibilities of each member of the Quality Management Team are as follows:
Top Management
Establishes the general policy and defines authority, responsibility, accountability and inter-
relationship of all personnel.
Reviews and approves the QMS structure and quality policy.
Promotes risk-based thinking.
Reviews the effectiveness of the quality management system and monitors the
implementation of improvement action plans
Provides resources and supports the implementation of the agencys quality management
system.
Denes the responsibilities and authorities of each function in the organization.
Establishes the communication mechanisms.
Ensures that processes needed for the QMS are established, implemented and maintained in
accordance with ISO 9001:2015 standards.
Evaluates, monitors, evaluates, and coordinates that the QMS process delivers the intended
output.
Reviews and approves risk management plans of offices.
Carries out directions related to the operation of the QMS.
Maintains the integrity of QMS for the implementation of revisions/changes.
Promotes QMS awareness and customer requirements throughout the organization.
Reviews, checks and approves all documents pertaining to QMS.
Ensures that the Quality Policy and Quality Management System are implemented and
maintained.
Reviews the risk management plan.
Facilitates the Management Review and the improvement of the Quality Management
System.
Ensures that all personnel within the organization are developed into quality- conscious and
productive employees.
Ensures the effective planning, implementation, maintenance, and continual improvement of
the established QMS.
Documentation Team
Maintains the master copies of documented information and other support documents relative
to the implementation of the QMS.
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Issues and controls distribution of documented information and other retained documents
relative to the implementation of the QMS. .
Disposes obsolete documented information to prevent use or otherwise assured against
intended use.
Preserves obsolete documented information are retained for legal and/or knowledge
preservation.
Updates personnel-related documented information.
Updates maintained and retained documents.
Coordinates ISO related conferences and meetings.
Responsible for the lntemal Communication Process.
Prepares Minutes of Management Reviews and other ISO 900] :20 l 5 related
gatherings.
Ensures that current versions of relevant documents are available at point of use.
Implements process for the traceability of documents.
Coordinates enhancement of the procedure for control of documented information.
Coordinates with the Quality Management Team on all matters concerning Records
Management, specically on records generated from the QMS.
Planning and Risk Management Team
Collates and reviews the risk management plan of ofces and hospitals.
Conducts monitoring and evaluation of the effectiveness of action plans implemented.
Reports findings regarding monitoring and evaluation of the effectiveness of action
plans implemented under risk control to the QMR. Likewise, reports the same during
Management Reviews.
Maintains the risk registry and results of actions taken to control the identified risks.
lnternal Quality Audit Team
Ensures effectiveness and suitability of the established QMS through the conduct of internal Quality
Audit.
Develops procedures for lnternal Quality Audit, Control of Non-conforming Outputs and Corrective
Actions.
Ensures the effectiveness and timeliness of the actions taken.
Prepares the audit plan. Coordinates, and implements the agencys Audit Program.
Prepares the audit programme.
Monitors, measures and evaluates the conformity of the QMS to the organization and international
standard.
Defines the appropriate audit criteria and scope.
Selects auditors to ensure objectivity and impartiality of the audit process.
Identifies the necessary resources for managing the agencys Audit Program.
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Summarizes Internal Quality Audit results as input for Management Review.

Provides inputs during Management Review.
Monitors and maintains records of implementation of corrective actions for non-conformances
found/noted during audits conducted.
Determines the QMS, ISO 9001:2015 clause or sub-clause, statutory and regulatory laws, procedures,
guidelines and work instructions relevant to the process owners conformities, non-conformities and/or
opportunities for improvement.
Ensures that audit results are reported to relevant management.
Maintains documented information as evidence of the implementation of the audit programme and the
audit results.
Quality Improvement Team
Takes action, reviews and analyzes non-conformities, including anything that arises from customer
complaints; determines causes and implements any action needed.
Determines and selects opportunities for improvement and implements any necessary actions to meet
customer requirements and enhance customer satisfaction.
Improves products and services to meet requirements and address future needs and expectations.
Corrects, prevents or reduces undesired effects
Improves the suitability, adequacy and effectiveness of the QMS; and makes changes if necessary.
Updates risks and opportunities determined during planning.
Determines the necessary competence of personnel performing work that affects quality of service.
Monitors the trainings of personnel.
Provides training and other human resource development activities to satisfy competency requirements.
Provides trainings/seminars to the Quality Management System Team in enhancing their skills related to
their functions under the QMS.
Coordinates trainings needed for front liners.
Evaluates the level of competencies of the members of the Intemal Quality Audit.
Facilitates the preparation of each core services risk management plan.
Verifies the implementation of corrective actions and their effectiveness, together with the concerned
member of the Internal Quality Audit and the Internal Quality Audit Team Leader, when closing
Corrective Action Reports.
Considers the results of analysis and evaluation and the outputs from management review. to determine
if there are needs or opportunities that shall be addressed as part of continual improvement.
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6 Planning
6.1. Actions to address risks and opportunities
In planning the quality management system, the Provincial Government of Pangasinan shall consider the
identified internal and external issues and comply with the needs and expectations of interested parties and
determine the risks and opportunities that need to be addressed.
With this, the organization shall identify internal and external issues that are relevant to the
organizations purpose and its strategic direction that may affect the delivery of planned results or achievement
of objectives Internal Issues/ Concerns are issues/ concerns arising from legal, technological, competitive
market, cultural, social and economic environments whether international, national, regional or local. On the
other hand, extemal lssues/ Concerns are issues/concerns related to values, culture, knowledge and performance
of the organization. Likewise, the organization shall identify risk factors that are part of the processes being
undertaken. Risk factors can be facilitated by considering the requirements such as statutory/ legal
requirements, organizational requirements, client/customer requirements and ISO 9001:2015 Quality
Management System requirements and prepare risk registry using the Risk Management Plan.
Likewise, the organization shall determine the likelihood of occurrence of the identified risks and the
impact/ effect of the occurrence of the identified risks on the organizations processes and delivery of planned
results or achievement of objectives based on the data gathered. Rank the risk based on its degree in order to
facilitate prioritization of risks for decision - making and action planning. With this, the organization shall
prepare action plan for the identified risks. Action plan shall include prevention and mitigation approaches.
Prevention approaches are actions to be taken to avoid the occurrence of identified risks while Mitigation
approaches are actions to be taken to reduce or eliminate long-term effects of identified risks.
Furthermore, the organization shall track and review the identified risks if anything has changed; if the
likelihood of occurrence and impact of the occurrence has increased or decreased and monitor if there are any
new risks in the processes being undertaken. In this regard, the organization shall measure the effectiveness of
preventive and mitigation approaches implemented and document findings on its effectiveness. Lastly, update
the risk registry using the Risk Management Plan and communicate it to top management, all process owners
and division/ section heads.
6.2. Quality Objectives and planning to achieve them
The Provincial Government of Pangasinais strategic and operational plans shall be the results of a
regular planning process. This is the venue where the strategic thrusts of the agency shall be defined,
commitments shall be obtained, and resource requirements shall be determined. Objectives and targets shall be
set at appropriate levels but specific quality objectives shall be defined during the management review
meetings.
Prior to the conduct of corporate planning activities, the various operating units shall conduct pre-
planning activities to assess performance, gather information on requirements and expectations of interested
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parties and review and align future directions. The outputs of the planning process shall include, among others,
strategies for business and operational improvement, pursuit of the agencys mandates, product or service
innovation and for enhancing customer/client services and satisfaction.
The_Provincial Govemment of Pangasinan recognizes that planning provides a roadmap to achieve its
goals, quality objectives and Key Performance Metrics targets. Therefore, QMS planning shall be undertaken as
part of the management responsibility on an annual basis.
QMS planning shall be led by the Top Management who shall likewise ensure that the planning of the
QMS is carried out in order to meet the requirements of ISO 9001:2015 and the integrity of the QMS is
maintained when changes are planned or implemented. The Support group similar to other Process Owners and
the ISO Team shall prepare their QMS plan by identifying their functional objectives, key perfomiance metrics,
targets, monitoring tools and resources needed. They shall also prepare a Quality Plan to operate and control
process performance.
Likewise, the Top Management shall be responsible in allocating resources and creating a working
environment conducive to the attainment of the quality objectives. Together with the ISO Team, Top
Management shall ensure that the QMS Plans are cascaded to every member of the organization.
Through the Provincial Government of Pangasinans QMS planning process, it shall be the responsibility of the
Quality Management System Team, with the support of Top Management, to establish quality objectives for the
organization. Quality objectives provide a focus and drives continuous improvement through on-going review
and adjustment of the objectives as needed. The objectives determine the expected results and lead the
organization to apply its resources to achieve these results.
Top Management shall ensure that quality objectives, including those needed to meet client/patient
requirements, are consistent with the quality policy, established at relevant functions and levels in the
organization, and reviewed on a continuous basis to ensure the delivery of quality products and services.
Findings from management reviews, client satisfaction surveys, the feedback mechanism and other assessments
are considered in the development of the quality objectives.
To provide adequate and efficient lSO aligned support services
To adhere to the QMS standards and requirements i
To continuously improve its processes and sustain them
To enforce all statutory and regulatory laws with maximum compliance at all times
To enhance the competencies of employees through learning and development activities
To dene their role and establish an interface with the other Core teams to ensure objectives are
achieved
6.3. Planning of Changes
Top Management shall identify resource requirements and provide sufficient and appropriate resources
essential to the implementation of the QMS. Management shall ensure that the planning of the QMS is carried
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out in accordance with documented procedures that meet the requirements of ISO 9001 12015. The integrity of
the QMS shall be maintained when changes are planned and implemented. Change shall be conducted in a
controlled manner through quality planning which occurs during staff meetings, ISO core and support team
meetings and QMS meetings (Management Review).
Primary considerations for change during quality planning process may include:
Needs and expectations of clients/patients and interested parties
Quality of services
Performance of processes , and
Continual improvement of quality system
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7 Support
7.1. Resources
7.l.l General
The Provincial Government of Pangasinan determines and provides the resources needed to implement
and maintain the quality management system, continually improve its effectiveness, enhance client satisfaction
by meeting client requirements and ensure its sustainability.
Availability of resources is evaluated in terms of nances for infrastructure and manpower needs as well
as maintenance of the work environment where the quality management system is implemented.
The provincial government shall use public funds and resources effectively and conscientiously in
conformance with related statutory and regulatory requirements. This means that it shall satisfy the indicators in
its quality plans through its nancial, human and infrastructure resources identied in its annua] investment
program and budget plan. It shall consistently ensure availability of resources by evaluating and preventing
factors which may affect their efcient utilization.
Resource allocation shall be done with consideration of the capability and constraints on existing internal
resources, as well as needs which ensure that client demands and expectations are met or exceeded.
Resource allocation and the process of planning & utilization and results of its monitoring and evaluation
shall be discussed and assessed during management reviews.
The Department Heads are likewise responsible in determining the appropriateness of resource requirements
and providing adequate resources for their ofce. Resources are provided so that the organization will be able
to:
Implement and maintain the QMS and continually improve its efciency and effectiveness, and
Enhance client satisfaction by meeting their requirements.
The determination of resources is considered during the annual planning and budgeting phases and is
continued throughout the year, as needed, to ensure that appropriate resources are available to implement and
maintain the QMS outsourced services, to continually improve its effectiveness and enhance customer
satisfaction by meeting or exceeding customer requirements.
Within the realm of their responsibility and funding sources, Department Heads are responsible for determining
the appropriate resource requirements and the provision of adequate resources. They are also responsible for
continual improvement in effectively identifying and satisfying customer requirements. Resource allocation and
needs are also considered during the management review process. In addition to this, a review of resources
occurs when new products or services are being developed. Risks which may affect the quality of resources or
encumber the efficient provision of products & services brought about by related issues on resources are
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assessed by the offices and hospitals through annual planning & target setting as part of the functions of their
Performance Management Teams.
7.1.2 People
The Provincial Government of Pangasinan, through its Human Resource Management & Development
Office, shall determine and provide competent persomiel necessary for the effective implementation of its
quality management system and for the operation and control of its processes in accordance with the policies,
rules and regulations of the Civil Service Commission and the Department of Budget Management. It shall
develop and follow a systematic procedure of Recruitment, Selection and Placement free from external and
internal risks. The assessment of personnel requirement or manpower complement is discussed during
management reviews and provincial budget meetings.
7.1.3 Infrastructure
The Provincial Government of Pangasinan determines, provides and maintains the infrastructure needed
to achieve conformity to product, service and client requirements. Infrastructure includes:
Office and hospital buildings and other associated facilities which establish a quality work-life for all
employees in order to work more effectively and efficiently, promote teamwork through sharing of
project leaming, inter-center collaborations, technologies sharing, et. al and is conducive for working
and learning by dening workstations, and formulating and observing quality workplace standards. The
maintenance of offices and hospital buildings and other associated facilities is managed by the
Provincial Engineering Office (for major repairs) and General Services Office (for minor repairs).
Service vehicles which serve as transportation human and non-human resources and ensure that service
delivery is timely and efficient. The maintenance management & monitoring of service vehicles is done
by the Provincial Engineering Office
Equipment, hardware and software that are necessary to support the requirements of organizational
systems and process. All offices under the support team conduct planning and ascertain maintenance of
all its civil, electrical, air-conditioning, mechanical and biomedical equipment and ensure that the
delivery of general administrative and support services are not hampered and compromised. The
maintenance of equipment, hardware & software shall be done respectively by the General Services
Ofce for utilities, electrical equipment, air-condition, hospital equipment and related structures while
the Management Information Services Office manages computer repair and maintenances and systems
analysis & development.
Information & communication technology shall be used in various organizational systems and
processes. Development of systems to improve quality of work, process conformity, service delivery and
records management shall be done. The Management Information Services offices shall be in-charge of
systems analysis, development, monitoring and evaluation and shall work with offices and hospitals in
integrating information & communication technology in their core processes.
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The maintenance of infrastructure is embedded in the standards & requirements of the 7S of Good
Housekeeping and relevant statutory and regulatory requirements monitored by the Human Resource
Management & Development Office. Offices and hospitals within the administration and supervision of the
provincial government and process owners shall prepare their Preventive Maintenance Plans which includes
actions that will minimize or avoid potential risks in the quality of infrastructures.
7.1.4 Environment for the Operation of Processes

The Provincial Govemment of Pangasinan provides a clean, safe and well-lit working environment. It
manages the work environment needed to achieve conformity to product and service requirements. It
implements preventive maintenance of facilities and utilities, environmental control strategies which include
solid waste management in compliance to the Solid Waste Management Act or RA. 9033, housekeeping
schedule or 7S of Good Housekeeping Day as a requirement of the 7S of Good Housekeeping Program,
formation of emergency response team & building and facility inspection which implements the Occupational
Safetv and Health standards of 1989.
Human and physical factors are considered to the extent that they directly impact on the quality of
products and services rendered by the provincial government and the ofces and hospitals under its
administration and supervision.
The implementation and continuous evaluation of the 7S of Good Housekeeping Program by the
HRMDO in all facilities of offices and hospitals of the provincial government ensures that the quality of the
work environment and public service is sustained. The term work environment" relates to those conditions
under which work is performed including physical, environmental and other factors. This is accomplished
through employee training, a continuous improvement planning process and management reviews. The
Department Heads shall ensure that the work environment has a positive inuence on motivation, satisfaction
and performance of employees to enhance their effectiveness.
The HRMDO has designed a Morale Survey Form to measure the satisfaction levels of employees based
on the following parameters: Work; Work Environment, Organization; Peers/Co-workers; Supervisors and
Employee Services. This is conducted and administered by the HRMDO to employees of offices and hospitals
every semester. Morale Survey results are analyzed and interpreted. Significant data are presented in a bi-annual
Morale Survey Report and submitted to concerned Department Heads for review prior to submission to the
QMR.
It is necessary to determine the motivation and satisfaction levels of employees because it is of the
essence that to realize ultimate client satisfaction and eventual engagement, employee satisfaction and
engagement must first be achieved.
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The Provincial Government of Pangasinan has likewise ensured that employee welfare and wellness is
addressed through the implementation of programs like the Employees Health and Wellness Program and the
Program on Awards and Incentives for Service Excellence (PRAISE). These programs aim to promote
employees health and wellbeing and reward excellent performance.
7.1.5 Monitoring and Measuring Resources

The Provincial Government of Pangasinan implements a comprehensive monitoring and measurement
system of its physical, human and nancial resources.
Physical resources include all infrastructure resources indicated in 7.1.3. Monitoring and measurement
of physical resources follows the 7S of Good Housekeeping standards, Regular and unannounced inspections
are done by the 7S Patrol Team composed of focal persons from different provincial government ofces and
hospitals and the Human Resource Management & Development Office Client satisfaction surveys also include
items in line with the perception of clients with the physical working environment and quality of service of
offices and hospitals.
Human resources are all employees of the Provincial Government of Pangasinan under the leadership of
the Local Government Chief Executive through the supervision and management of the Human Resource
Management & Development Office. Skills test and competency assessment are done through various HRMDO
tools. The Recruitment, Selection and Placement unit implements examination or testing for applicants for entry
for work to the Provincial Government of Pangasinan to increase the validity of its selection process.
Organizational & Individual Learning & Development Needs are assessed annually by the Learning &
Development unit to determine learning gaps and recommend programs and activities which will increase the
level of competency of employees to ensure quality of their work. Performance Management System is also
implemented by the Provincial Govemment of Pangasinan to regularly monitor and evaluate the
accomplishments of employees based on targets agreed by them and their supervisors through the Individual
Performance & Commitment Report (lPCR).
Office Performance & Commitment Report (OPCR) and Division Performance Commitment Report
(DPCR) are also used to measure the actual performance as against planned targets of offices and hospitals of
the provincial government, Onsite validation is conducted quarterly by the Provincial Performance Management
Team to ensure that all targets in the quality plans of offices and hospitals and the Operational Plan of the
Provincial Government are met or exceeded. Internal audit is conducted at least twice a year to monitor the
compliance of offices and hospitals with relevant product, process, service and organizational requirements.
HR examination tools are subject to review, modication or revision to maintain the integrity and
reliability of examination results.
Financial resources are covered in the Annual Investment Program, Budget Plan and other fund sources
of the provincial government. Quarterly monitoring of annual investment programs and accomplishments are
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monitored by the Provincial Planning & Development Office and the Internal Audit Unit through paper
evaluation and onsite inspection.
Regular calibration of all monitoring and measurement tools is done to ensure the reliability and the
validity of results.
Results of the monitoring and measurement of resources are reviewed and discussed during continuous
improvement meetings of Provincial Performance Management Teams and every management reviews.
7.1.6 Organizational Knowledge

The Provincial Government of Pangasinan determines the knowledge necessary for the operation of its
processes and to achieve conformity Of products and services. These include knowledge and information
obtained from:
a. Internal sources, such as existing studies, survey results, and in-house training, among others; and
b. External sources such as local and foreign scholarships, seminars, conferences, and information
gathered from clients, experts or external providers.
When addressing changing needs and trends, the Provincial Government considers its baseline
knowledge and determines how to acquire or access necessary additional knowledge.
7.2 Competence
The Provincial Govemment of Pangasinan defines the qualifications of staff, and ensures that they are
appropriately and adequately trained and aware of their role in the delivery of services affecting product/service
quality. Qualications as dened in job descriptions are based on education, experience and/or training. The
Human Resource Management and Development Office is responsible in providing baseline information and
data on the qualication standards required by a job/position. The Department/Section heads are expected to be
familiar with the qualifications and competencies needed for various tasks and are responsible in assessing and
ensuring that their personnel given these tasks are qualified and competent to undertake them.
Employees performing work affecting product and service quality are competent on the basis of
appropriate education, training, skills and experience. A Learning and Development Plan is established annually
to ensure enhancement of the skills, knowledge and competence of the employees. These trainings and learning
development plans maximize the potentials of the employees to perform their duties. Training of the personnel
include mandatory supervisory development courses, in-house seminars, required trainings for technical and
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administrative staff provided by other agencies, professional development seminars, and local and foreign
scholarship grants.
A post competency assessment is conducted to employees six months after having attended a training.
A Learning and Development Team is composed in each office and hospital under the provincial
government to determine the level of competency of the employees. The team is responsible for identifying
learning interventions in case of competency gaps or competency improvement needs. Results are indicated in
the annual Individual Learning Development Plan of every employee which is prepared by the Learning
and~Development Team of each office/hospital.
The Department Head:

Determines the necessary competency needs for personnel performing work affecting product and/or
service quality.
Ensures that tasks affecting product, process and system quality shall be performed by personnel who
are qualified and competent to perform these tasks.
Plans professional development programs during personnel evaluations.
Ensures that its personnel are aware of the relevance and importance of their activities and how they
contribute to the achievement of the quality objectives.
Maintains appropriate records of education, training, skills and experience.
The Human Resources Department:

Conducts competency matching
Identifies employees competencies and required competencies
Matches employees competencies (Core, Functional, Leadership) to their functions
Plans trainings based on the results of the competency matching
Implements training programs to equip employees with competencies needed in performing their
functions
Monitors training effectiveness
Evaluates employee perfonnance though a Performance Management System (Accomplishment and
Behavioral)
Orients and trains new employees
Assesses competency level of employees
Identies learning interventions for competency gaps
Prepares annual Individual Learning Development Plan
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Competency assessment arises from statutory changes, new knowledge in the area of expertise, process or
equipment changes, and/or the development of new products and services. Task specific training is provided
through its internal or outsourced trainings. The HRMDO, however measures only core and leadership
competencies and is responsible in conducting internal trainings. Offices and hospitals are responsible in
developing functional competencies of employees. The HRMDO monitors the level of functional competencies
through the result of their quarterly performance evaluation. Outside trainings are not included in the Work
instructions of the HRMDO because the collection/updating of training certicates for inclusion in the 201 file
are done in the succeeding year. The Top Management is responsible for establishing/approving ISO quality
training and orientation sessions. These sessions provide employees with an understanding of the contents of the
ISO 9001:2008 standards and the application of the QMS policies and procedures. Personnel attendance and the
results of the quality training and orientation sessions are documented and maintained in accordance with
Procedures in Control of Records.
7.3 Awareness
Training and subsequent communication ensure that the employees are aware of:
a. The Quality Policy;
b. Quality Objectives;
c. Their contribution to the effectiveness of the QMS, including the benets of improved performance;
and
d. The implications of not conforming with the QMS requirements.
e. vision & mission of the provincial government
f. strategic direction and development thrusts
g. core values of provincial employees
h. programs and services of the administrative and support services
To ensure that the QMS is communicated to its employees, the management conducts Orientation and
Values Development Seminar on AQMS including the Five Mandatory Procedures.
Orientation report and checklist is also submitted by new employees to monitor their awareness on
organizational policies, rules and requirements. This step is necessary to ensure that offices and hospitals
discuss their quality plans and objectives with the employees and make them realize their role and participation
in accomplishing the goals and objectives of their organization as well as their mandate.
7.4 Communication
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The Top Management ensures that internal communication takes place regarding the effectiveness of the
QMS and its processes. A quarterly internal meeting is the method of communicating the QMS. Internal
communication methods include the:
a. Meetings of key personnel
b. Employee orientation
c. Departmental meetings
d. Email/intranet
e. Core team meetings
f. f. Support team meetings
g. g. Annual QMS planning
h. . Bulletin boards
i. Television lnfomercials
j. Executive Orders
k. Tarpaulins
l. Use of corrective action processes to report nonconformities or suggestions for improvement;
m. Use of the results of analysis of data;
n. Meetings (periodic. scheduled and/or unscheduled) to discuss aspects of the QMS;
o. Use of the results of the internal quality audit process;
p. Memoranda to employees.
7.5 Documented Information
7.5.1 General Requirements
The International Standard species the need to maintain or retain documented information in order to
give structure, clarity and evidence of the system being maintained.
Documented information can be in any format as long as it provides appropriate evidence to
demonstrated compliance. It can be in any format decided by the organization.
Maintain
a) Scope of the Quality Management System (4.3)
b) Quality Management System and Its Processes (4.4.2 a)
c) Quality Policy (5.2.2 a)
d) Quality Objectives (6.2.1)
e) Operation planning and control (8.l e)
Retain:
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a) Quality management system and its processes (4.4.2 b)

b) Monitoring and measuring resources (7. 1.5.l)
c) Measurement traceability (7.1.5.2 a)
d) Control of documented information (7.5. 3)
e) Operation planning and control (8.l e)
f) Review of the requirements for products and services (8.2.3.2)
g) Design and Development Planning (8.3.2 j)
i) Design and development inputs (8.3.3)
j) Design and development controls (8.3.4)
k) Design and development outputs (8.3.5)
l) Design and development changes (8.3.6)
m) Control of externally provided processes, products and services (8.4.l)
n) Identication and traceability (8.5.2)
o) Property belonging to customers or external providers (8.5.3)
p) Control of changes (8.5.6)
q) Control of nonconforming outputs (8.7.2)
r) Monitoring, measurement, analysis and evaluation (9.1.l)
s) Internal Audit (9.2.2)
t) Management review outputs (9.3.3)
u) Nonconformity and corrective action (10.2.2)
The Provincial Government of Pangasinans Quality Management System (QMS) is designed to assure
consistency in meeting the customers needs and expectations through the actual pertonnance of the
documented processes, procedures, work instructions and support policies, systems and procedures.
The QMS of Provincial Government of Pangasinan is described in the following documents:
Level I: Quality Manual: The highest level of Quality Management System documentation, it embodies the
quality policy, organizational structure, resource management and process diagrams for services provided as
well as specic policies for business processes, quality control, review and improvement. Policy statements are
guides by which the organization carries out its mandates within the scope ofits various functions and activities
Quality Manual:
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The Quality Manual aims to: (a) To assure quality utilizing clearly stated policies, such as the Quality
Policy, mission, vision and core values; (b) To dene the processes employed to achieve and continuously
maintain quality standards through the business process map, process diagrams and process descriptions; (c) To
serve as a reference in the implementation and maintenance of Provincial Governments Quality Management
System; and (d) To guide all employees in the performance of their functions.
Level 2: Procedure Manual or the Standard Operational Instructions Manual: It serves as an operational
guide on the activities the agency does and the manner by which it achieves stated policies. lt provides
guidelines on how to communicate or deploy and perform these various activities. The Manual includes
operational instructions that describe the detailed series of steps in performing routine activities.
Level 3: Support Documentation or Quality Records: These include records providing evidence of
conformity with established procedures and operational instructions as well as the agencys QMS. Support
documents or quality records include plans, standard operating procedures (SOP), guidelines and work
instructions (WI), which describe the detailed series of steps in determining routine activity It also includes key
performance metrics, quality plans, records and scorecards.
7.5.2 Creating and Updating
The Provincial Government of Pangasinan has established and maintained a documented procedure that
denes the life cycle of a document from creation to disposition and the controls undertaken to preserve its
integrity. lt specifies the uniform coding system common to all member offices. All documents are reviewed
and approved for adequacy by authorized personnel prior to use (special paper) (electronic data, back-up
copies) (changes : DCCF) It lays down activities in the creation, identication, approval, distribution,
modication, storage and disposal of documents within the Quality Management System (QMS).
7.5.3 Control of Documented Information
7.5.3.l The Quality Manual and its related documents are considered released or issued if the signature
of the Quality Management Representative/Top Management appears in the AUTHORIZATION SHEET;
otherwise it is unofficial and not authorized for use and distribution.
It is the responsibility of the Document Controller to distribute the manuals to concerned employees and
officials. Copies of the manuals are issued to ofcials and employees involved in management, support and/or
actual operation of the QM S process.
The Quality Manual and its related documents are treated as condential and should not be removed
from the premises without prior authorization from the Deputy Quality Management Representatives.
Issuance of uncontrolled copies of the QMS documents to individuals within or outside the organization
is not allowed, unless otherwise, approved by the Deputy Quality Management Representatives. For effective
document control, only the Document Controller shall issue uncontrolled copies of the QMS documents, if
deemed necessary and with prior authorization from the DQMR.
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(masterlist of maintained documented information, masterlist of retained documented information, masterlist of

external documented information, distribution list, document creation and change form, tracking slip, special
paper)
7.5.3.2 Control of Documents
All documents and records related to the effective functioning of the established quality management
system are controlled. The Control of Documents Procedure governs the creation, revision. identification,
approval, distribution, storage and disposition of documents. The Masterlist of Controlled Documents and
Masterlist of External Documents states all documents used in relation to the QMS. These documents include
but are not limited to the following:
Quality Manual;
Procedures, Work Instructions and Guidelines/SOP;
Extemal Documents;
Quality Plans; and
Quality Records.
Internal Quality Audits are conducted to assess the effectiveness of the Quality Management Systems
documentations.
All controlled documents, internal and external in nature included in the Quality Management System, are
coded. Process owners are responsible for informing the Document Controller for updates on external forms and
documents used as references in the Quality Management System. The support group has adopted a uniform
coding system common to all member ofces. All documents are reviewed and approved for adequacy by
authorized personnel prior to use. A master list identifying the current revision status of documents is being
maintained. This will prevent the use of incorrect, invalid or obsolete documents. Only the pertinent issues of
appropriate documents are available at locations where operations essential to the effective functioning of the
quality management system are performed. Also, incorrect, invalid or obsolete documents are promptly
removed from all points of issue or use to prevent unintentional use. Obsolete documents that are retained are
suitably identied. All external documents received by the agency bearing codes shall be indicated in the
Master list of External Controlled Documents designed for the purpose.
The HRMDO Deputy Quality Management Representative shall verify if the created/revised document had
been posted/updated in the Masterlist of Controlled Documents thru a Tracking Slip.
A documented information shall be retained should there be any changes in the documents involved in the
Quality Management System after its initial approval and issue. These changes shall be subject to the document
creation and change procedure. All document changes are reviewed and approved by designated members of the
PGPs Quality Management System Team unless otherwise specically delegated. For changes in the Quality
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Manual, the Quality Management Representative and/or any Deputy Quality Management Representative may
initiate the change to be approved by the Top Management.
Control of Records
The Provincial Government of Pangasinan has established and maintained documented procedures for
identication, collection, storage, protection, retrieval, retention and disposition of quality records including
records generated from external documents/forms.
Records for quality related activities are maintained to demonstrate conformance to specified
requirements and for the effective operation of the Quality Management System. Every office belonging to the
support group maintain quality records relevant to the general administrative and support services they provide.
A Masterlist of Records is maintained for all quality records. The responsibilities for generating these
records are described in the Key Performance Matrices procedures of the Quality Management System
including the designated personnel responsible for the maintenance of the records to ensure that these:
Contain all necessary information
Are legible
Are stored and retained in such a way that they are readily retrievable; and
Are stored in facilities that provide a suitable environment to prevent damage, deterioration and/or loss.
The Master List also species the retention period and appropriate disposal of each quality record depending
on regulatory requirements and management needs. The minimum retention period is normally (2) years. After
the retention period, these are transferred to Archives for another year, although there are records that may be
held signicantly longer.
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8 Operation
8.1 Operational Planning and Control
It is the policy of the Provincial Government of Pangasinan to ensure the quality provision of general
administrative and support services through the implementation of a systematic and organized process, within a
specic time frame to satisfy clients. Operational planning and control shall be consistent with the requirements
of the QMS and core processes.
a. In operational planning and control, the support team shall determine the quality objectives and
requirements of the product/service.
b. Establish criteria for:
l. Processes based on quality and efficiency which shows the time frame and procedures to be
followed
2. Verication, validation, monitoring, measurement, inspection and calibration activities
specic to the product/service and the criteria for product/service acceptance shall be retained.
c. Provide resources specic to the product/service as indicated in the Annual Investment Plan and
Annual Procurement Plan.
d. Establish documented information needed to provide evidence that operational planning and control
meet the internal and external requirements. Non-conforming products/services shall be identified,
segregated, reported, analyzed and corrective action implemented (based on Procedure Manual under
Control of Non-conforming Outputs).
e. Determine documented information that will be maintained and retained to ensure that processes have
been carried out based on functional quality objectives and conformity to product and service
requirements.
Workow and work processes shall be communicated to the public through the provincial website.
infomercials, billboards, signages, flyers and meetings. Likewise, all process owners shall be required to be
involved in service and process improvement. The need for new products and services may arise based on
customer, national, or statutory requirement.
8.2 Requirements for Products and Services
8.2.1 Customer Communication
The Provincial Government of Pangasinan shall establish, determine and implement effective
arrangements through appropriate customer communication regarding information on services provided,
handing inquiries, contracts or orders, including changes and deployment utilizing a variety of channels such as,
but not limited to the following:
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a. Memorandum
b Meetings
c. Communication Plan
e. Citizens charter
f. Email
g. Website
Likewise, the organization shall pay particular attention to feedback management, which include client
compliments and complaints, Client Satisfaction Survey, Morale Survey and Service Delivery Checklist to
gather internal/external client feedback (complaints, compliments, suggestions) and determine their degree of
satisfaction in meeting the requirements for products and services.
In addition, procedures shall be posted to inform clients on how their requirements are processed.
Contingency actions in case of risks shall be dened by the respective process owners.
The support group shall exercise care with customer property while under its control or is being used. It
shall identify, verify, protect and safeguard customer property such as intellectual rights, survey, data,
specifications, manuals, and software provided for use. If any customer property is lost, damaged or otherwise
found to be unsuitable for use, this shall be reported to the customer and retain the corresponding records.
8.2.2 Determining the Requirements for Products and Services
a. Requirements for products and services may include:
Statutory and regulatory requirements related to the service/product including .processes by the
regulatory offices,
Requirements specied by clients including requirements for delivery and post-delivery activities.
Requirements not stated by the customer, but necessary for specified use or known and intended use.
Any additional requirements determined by the organization including best practices.
Provision of simplied instructions with allotted time for processing requirements (Citizens
Charter) posted at conspicuous places in all offices and hospitals.
b. The organization can meet the claims for the products and services it offers based on legal and
statutory requirements.
The above-mentioned requirements shall be fulfilled by the provincial government in implementing its
QMS.
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8.2.3 Review of the Requirements for Product and Services

The Provincial Government of Pangasinan shall review the requirements related to the product/service
based on guidelines established prior to contracting with a client and ensures that:
a. It has the ability to meet requirements for product and services to be offered to customers.
b. They are clearly and easily understood and preferably explained in a language the public understands.
c. Processes are posted through the Citizens Charter and are well disseminated and adequately
communicated.
d. Implementing guidelines under the procurement process shall be followed to include legal and
statutory requirements.
e. Contract or order requirements (specications) differing from those previously expressed are
reviewed.
8.2.3.2 Documented information of products or service requirements shall be retained regarding:
a. results of the review of the requirements for products and services,

b. changes in requirements,
c. new requirements on products or services.
8.2.4 Changes to Requirements for Products and Services

Changes or amendments to requirements for products and services shall be communicated to the
organization and end-users by process owners through meetings and memoranda.
8.3 Design and Development of Products and Services
8.3.1 General
The Provincial Government of Pangasinan Support Group shall design and develop its own system,
processes, monitoring and measurement tools, continuous improvement activities and scorecard such as, but not
limited to:
a. Computerized systems development
b. Monitoring and measurement tools of organizational development programs and quality
management system
c. Manuals, work instructions/procedures of process owners
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d. Learning and Development activities for continuous improvement of competencies of process

owners
e. Performance Management to include performance scorecard
8.3.2 Design and Development Planning

The process owners shall plan and control the following, such as, but not limited to the:
design and development of systems,
processes,
monitoring and measurement tools,
continuous improvement activities and
scorecards to be used by different offices and hospitals.
During the design and development planning. top management and the process owner shall determine:
a. the responsibilities and authorities for design and development,
b. the design and development stages, and
c. the review, verication and validation that are appropriate to each system, process, or monitoring and
measuring tool.
The process owner shall manage the inputs needed for the system, processes, monitoring and
measurement tools, continuous improvement activities and scorecard being developed to ensure effective
communication and clear assignment of responsibility. Documented information shall be retained to
demonstrate that design and development requirements are met.
8.3.3 Design and Development Inputs
Inputs relating to functional and performance requirements shall be determined by the top management
of the following design and development of products and services, namely: l) system, 2) processes, 3)
monitoring and measurement tools, 4) continuous improvement activities and 5) scorecards that were developed
to be used for the QMS in compliance with legal and statutory requirements. The inputs shall be reviewed for
adequacy. Requirements shall be complete, adequate, and accurate.
Risks shall be identied, as part of design and development input.
The process owner shall also retain documented information on previous design and development
activities.
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8.3.4 Design and Development Control

In case changes shall be installed in the system, processes, monitoring and measurement tools.
continuous improvement activities and scorecards and other designs that were developed, the changes shall be
reviewed, veried and approved by the top management.
Design and development updates and activities shall be identied and documented information
maintained and retained.
8.3.5 Design and Development Outputs

The outputs of design and development shall be suitable for verication against the design and
development input and shall be approved for release. A user's manual, work instruction or guideline shall be
included as output for the system, and process or monitoring and measuring tool developed.
The process owner shall retain documented information on design and development outputs.
8.3.6 Design and Development Changes

At suitable stages, systematic and periodic reviews of design and development shall be performed by
process owners to identify any problem and propose necessary action.
Participants in such reviews shall include process owners and the requesting party. Records of the results
of the reviews and necessary actions shall be maintained through the approved ISO minutes of meeting form.
Documented information regarding changes, result of reviews, authorization of changes and actions
taken to prevent adverse impacts shall be retained.
8.4 Control of Externally Provided Processes, Products and Services
8.4.1 General
The Provincial Government of Pangasinan shall establish procedures and processes embodied in the
Work Instructions and Quality Procedures on Procurement and Supply Management to ensure that purchased
products conform to specied requirements. These are general administrative and support services from the
General Services Office and shall be undertaken in the following manner:
The General Services Office (GSO) shall purchase the products indicated in the Purchase Requests
submitted by offices and hospitals from duly accredited suppliers in accordance with acceptable and
existing procurement rules and regulations
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The supplies requested shall be delivered upon their availability on a weekly basis to hospitals or as
needed for hospitals/offices.
An Acceptance and Joint Inspection procedure shall be established to ensure that products delivered
are in conformity with specified requirements through a quality assurance and control process.
The Bids and Awards Committee (BAC) shall evaluate and select suppliers based on their ability to
supply products or services in accordance with the organizations requirements and written regulations, Criteria
for selection, evaluation and re-evaluation of suppliers shall be established per purchasing specifications and
procedures based on the needs of users, the quality objectives, and the suppliers qualification procedure. The
performance of suppliers of drugs, medicines, medical supplies and equipment shall be reviewed by the GSO
while the Provincial Engineering Office (PEO) shall check the quality of spare parts if it conforms with the
approved specification/s. Records of the results of review and all necessary actions arising from the evaluation
shall be retained.
8.4.2 Type and Extent of Control

The top management shall ensure that externally provided processes, products and services do not
adversely affect its capability to consistently deliver conforming products and services to its customers
External providers shall strictly adhere to the requirements/criteria set by the organization.
The organization shall set parameters for external providers to follow in order to consistently meet
customer and applicable statutory requirements. Likewise, top management shall determine the verication, or
other activities, necessary to ensure that the externally provided processes, products and services meet
requirements.
8.4.3 Information for External Providers
Purchases shall be made only from suppliers who have been properly accredited by the BAC. Purchase
orders shall be reviewed by the General Services Office to ensure that all pertinent specications and
information relative to the item to be purchased are accurate and complete.
The provincial -government shall communicate the following to its external providers regarding:
a. product requirements and the required processes to follow or abide
b. the approval of;
l. products and services
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2. methods, processes and equipment

3. the release of products and services
c. the training or competence required
d. the external providers interfaces or dealings with the organization
e. control and monitoring of the external providers performance
f. verication or validation activities that the organization, or its customer, intends to perform at the
external providers premises to ensure that products or services meet the requirements
Purchasing information shall be posted on the PHILGEPS to include the Provincial (ioverninent bids
and proposal information, community and supplier information, all documented information as well as bid
award summaries.
8.5 Production and Service Provision

8.5.1 Control of Production and Service Provision
The Provincial Govemment of Pangasinan through the general and administrative support group shall
carry out all its services in a planned manner and under controlled conditions by conforming to the requirements
set by the organization itself and to legal and statutory requirements. Controlled conditions shall include, as
applicable:
a. the availability of documented information that denes:
l. the characteristics of the products to be produced or product requirements, the services to be
provided, or the activities to be performed
2. the results to be achieved
b. the availability and use of suitable monitoring and measuring resources. such as equipment and
survey
c. the implementation of monitoring and measuring activities including regular preventive maintenance
and onsite audits to verify that products and services meet requirements
d. the use of suitable infrastructure and work environment is adequate for the operation of processes
e. the appointment./identication of competent persons, including required qualification
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f. the validation, and schedule of revalidation, of the ability to achieve targets

g. the implementation of actions to prevent human error
h. the implementation of release, delivery and post-delivery activities
8.5.2 Identication and Traceability
The status of general administrative and support services provided shall be identied with respect to
monitoring and measurement requirements throughout the product/service realization process.
Where traceability is a requirement, the support group shall control the identication of the
product/service provided and maintain documented information relative thereto.
8.5.3 Property Belonging to Customers or External Providers

The support group shall exercise care with customer or external providers while under its control or is
being used. lt shall identity, verify, protect and safeguard customer and/or external providers whose services are
being used by keeping retained information confidential. If any customer or external providers property is lost,
damaged or otherwise found to be unsuitable for use, top management shall report this to the customer and
maintain the corresponding records.
8.5.4 Preservation
The process owner shall ensure that all products purchased for delivery to all offices and hospitals are
maintained in conformity with requirements. As applicable, preservation of products which shall include
identication, handling, packaging, storage and protection shall be managed by process owners. Preservation
shall also apply to the constituent parts of the product.
8.5.5 Post-delivery Activities

Requirements for post-delivery activities associated with products and services shall be met The extent
of activities required shall be determined after consideration of the following:
Statutory and regulatory requirements
Nature, use and intended lifetime of products and services
Customer requirements and feedback
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8.5.6 Control of Changes

Changes for production and service provision shall be reviewed by top management during Management
Review meetings and controlled to the extent necessary to ensure conformity with requirements based on
organizational and statutory and legal requirements.
Documented information shall be retained describing the results of review of changes, identifying persons
authorizing the change and necessary actions arising from the review.
8.6 Release of Products and Services
Planned arrangements through internal audits and onsite monitoring and inspections, at appropriate
intervals, shall be implemented to verify that product and service requirements have been met.
Release to customer shall not proceed until the planned arrangement/process has been satisfactorily
completed, unless otherwise approved by top management, and, as applicable, by the customer.
Documented information regarding release of products and services shall be retained by process owners,
including:
Evidence of conformity with accepted criteria/requirements
Traceability to person/s authorizing the release
8.7 Control of Non-conforming Outputs
Non-conforming outputs are identied and controlled to prevent the unintended use or delivery (see
Procedure Manual on Control of Non-conforming Outputs).
Corrected non-conforming outputs are veried for their conformity to requirements.
Documented information are retained in order to describe non-conformities, actions taken, any
concessions obtained and identify the authority deciding the action taken to address the non-conformity.
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9. Performance Evaluation
9.1 Monitoring, Measurement, Analysis and Evaluation
As a mechanism to measure the perfomiance of the established Quality Management System, the
Provincial Government of Pangasinan shall monitor and measure the following requirements needed to achieve
the quality policy of the organization:
a) Functional Quality Objectives
b) Results of Internal Quality Audit
c) Results of Management Review
d) Statutory/ Legal Requirements necessary to produce outputs and deliver services
e) Client/ Customer Requirements
The agency shall monitor the implementation of the system through the semi - annual conduct of
Internal Quality Audit. Likewise, to monitor the product/service outputs and outcomes in terms of meeting the
client customer requirements and expectations, weekly, monthly and quarterly gathering of client/customer
feedback and perception shall be conducted.
Subsequently, results of Internal Quality Audit (Non-conforming products or services and other
problems in the Quality Management System) shall be identified, recorded, evaluated and addressed through
correction and corrective action and shall be discussed during the semi-annual conduct of Management Review.
With this, correction and corrective action shall be assessed in order to determine its status and effectiveness of
implementation.
Client/customer perception as to whether the organization has been meeting its requirements shall be
regularly monitored through a survey using Client/ Customer Satisfaction Survey and/or Service Delivery
Inspection Checklist as the tools for gathering data/information on clienu customer feedback and perception.
Client/ customer complaints and feedbacks shall be recorded, analyzed, interpreted and promptly and
effectively acted upon.
With this, the agency shall follow the schedule below to monitor and evaluate the performance and
effectiveness of the quality management system and shall retain appropriate documented information as
evidence of the results.
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SCHEDULE QUALITY MONITORING AND EVALUATION INTERNAL CORRECTIVE AND MANAGEMENT REVIEW AND
PER MONTH MGT. QUALITY PREVENTIVE ACTION REVIEW IMPROVEMENT
SYSTEM AUDIT REPORT
PLANNING
SURVEY REPORT
INSPECTION
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
9.1.2. Customer Satisfaction

There are two kinds of customers/clients whose feedback are being gathered and interpreted. They are
the internal and external customers/clients.
Internal customers/clients refer to users of output produced by an internal supplier from another process.
These are composed of provincial government employees. On the other hand, external customers/clients may
refer to walk-in job applicants, researchers, employees from other agencies, or anybody who is not a provincial
government employee and in need of the services of the provincial government.
The Human Resource Management and Development Office has designed Feedback Management
(Client Feedback and Client Satisfaction Survey) tools to identify external client feedback and their levels of
satisfaction based on these parameters: Service providers, Quality of service and Physical working condition.
The HRMDO has also established and maintained a documented procedure for the effective recording and
analysis of client perception as well as a documented procedure for the effective handling of customer-related
information to monitor client complaints/feedbacks (See Procedure Manual on Client Satisfaction and
Feedback Management).
Client satisfaction and feedback data shall be collected/gathered by HRMDO Program Coordinators on a
weekly, monthly and quarterly basis in all offices and hospitals under the provincial government.
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On the other hand, the Employee Morale Survey and Service Delivery Inspection Checklist are tools
used to obtain feedback from internal clients or provincial government employees themselves which are
conducted every six months or semi-annually. The Employee Morale Survey seeks to measure employee
satisfaction on the following parameters: Organization, Working Climate./Environment, Personal/ Professional
Development. Leadership and Employee Welfare (See Implementing Guidelines on the Conduct of Employees
Morale Survey). The Service Delivery Checklist aims to obtain employee perception on the services of the
offices and hospitals under the administrative and support services, social services and hospital services. Each
of the offices and hospitals under the administrative and support services, social services and hospital services
shall be responsible in gathering its own internal client feedback. Each process owner shall present survey
results during exit staff meetings to address non-conformities and to formulate corrective actions using the CAR
form.
Audit shall be conducted through on-site inspection using two survey questionnaires, the Client
Feedback Form and the Client Satisfaction Survey. Client feedback regarding complaints are recorded in the
Corrective Action Request (CAR) form which shall be presented during the exit conference to the
Administrative Officer, Chief of Hospital and representatives/process owners from the respective section/unit
where the negative feedback has been identified.
Survey results shall be summarized and documented through reports and shall be presented during
Quarterly Monitoring and Evaluation Meetings with representatives from both offices and hospitals
Client satisfaction shall be a part of the agenda during Management Review Meetings. Findings shall be
summarized, and reports relative to the same shall be prepared and presented to top management for appropriate
action. Top management shall ensure that data regarding product/service and process conformance, supplier
performance, and customer satisfaction are always documented/recorded. Inputs shall be validated and analyzed
using appropriate data analysis techniques and the final output form part of management reviews. Although
results are summarized quarterly, such data shall also be discussed semi-annually during Management Reviews.
The regular on-site monitoring done by the HRMDO Program Coordinators serves as a basis to keep
track of organizational performance through over-all client satisfaction. Likewise, client satisfaction data is a
vital tool in the continuous improvement of the quality management svstem.
9.1.3. Analysis and Evaluation

The Provincial Government of Pangasinan shall analyze and evaluate appropriate data and information
arising from monitoring and measurement. With this, the result of analysis shall be used to evaluate the
following:
a) Conformity of products and services (see Clause 10.2)
b) Degree of customer satisfaction (see Clause 9. 1 .2)
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c) Performance and effectiveness of the Quality Management_System (see Clause 4.4)

d) Planning has been implemented effectively (see Clause 6.2)
e) Effectiveness of actions taken to address risks and opportunities (see Clause 6.1)
f) Performance of External Providers (see Clause 8.4)
g) Need for improvements to the Quality Management System (see Clause 10.3)
With this, the Provincial Government of Pangasinan shall use applicable statistical techniques and
measurement tools to establish, control and verify process capability and characteristics. Data on conformity to
organizational, statutory/legal, client/customer, and product and process requirements as well as performance of
external providers shall be evaluated, analyzed and interpreted on a regular basis (monthly, quarterly, and semi
annually and annually).
The agency shall use data gathering methods to determine the performance and effectiveness of the
Quality Management System processes including, but not limited to:
a) Conduct of Surveys
b) Onsite Monitoring and Validation
c) Semi - Annual Internal Quality Audit
d) Quality Management System Planning
e) Management Review
t) Continuous Improvement
These methods are necessary to ascertain that organizational, statutory/legal, client/customer, and
product and process requirements as well as performance of external providers meet the planned results.
To facilitate the presentation of analysis and evaluation of processes, a Monitoring and ljvaluation
Summary Report shall be prepared by the process owners to present the quarterly accomplishment of
objectivesl planned results based on the established Functional Quality Objectives of each of the processes. The
report shall contain key result areas which are areas or categories of results that are essential to effective
performance in the organization. Objective and key performance indicators which are measurable factors within
a given key result area to identify the kind of measurable outputs desired in each of the key result area shall also
be included. Targets, accomplishments and gaps shall also be presented in each of the key performance
indicators.
Performance Gaps and Non - Conformity shall also be measured. With this, when performance gaps
occurred and/or or when results of the activities are not achieved which means occurrence of Non - Conformity,
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the agency (process owners and/or Internal Quality Auditors) shall obtain reasons for the occurrence of gaps
and/ or non - conformity through the conduct of Root Cause Analysis (See Procedure Manual on Root Cause
Analysis). Likewise, they shall prepare a Corrective Action Request (CAR) to document the conducted
correction and corrective action in addressing the unmet targets (See Procedure Manual on Non-Conformity and
Corrective Action).
The effectiveness of the corrective action shall be veried through follow- up review and verification. If
corrective action is found to have evidence of effectiveness upon review and verification, Corrective Action
Request (CAR) shall be closed. If otherwise, which means no evidence of effectiveness has been found upon
review and verification, Corrective Action Request (CAR) shall not be closed.
Consequently, if necessary, the agency shall conduct Risk Assessment and update risks and
opportunities determined during planning through the use of Risk Registry (See Procedure Manual on Risk
Assessment/Analysis).
Overall, data and information resulting from analysis of data through numerical, graphical and trend
analysis methods shall be used to measure and monitor the suitability and effectiveness of the Quality
Management System, specically on the provision of general administrative and support services, social
services and hospital services. Likewise, these data and information shall be analyzed, interpreted and presented
during Management Review meeting for continual improvements.
9.2. Internal Audit
The Provincial Government of Pangasinan shall conduct semi - annual Intemal Quality Audit every May
and November of the calendar year. The Internal Quality Audit shall be conducted by the Internal Quality Audit
Team composed of Internal Quality Audit Team Leader and Auditors, The Quality Management Representative
selects and appoints the members of the Internal Quality Audit Team composed from among the staff members
of offices and hospitals belonging to the administrative and support, social and hospital services. Selection is
based on the following competencies and qualifications:
l . College graduate;
2. Knowledgeable on ISO 9001:2008 standard, QMS and governing statutory and regulatory
requirements;
3. Familiar with the provincial structure, programs and service processes;
4. Exhibits good analytical skills;
5. Had undergone internal audit training for 16 hours from an ISO accredited certifying institution;
6. Has experience in any audit process;
7. Knowledgeable in report preparation and presentation;
8. Procient in oral and written communications; and
9. Upholds the following audit principles:
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9.1. Integrity - the integrity of auditors establishes trust and thus provides the basis for reliance
on their judgment.
9.2 Objectivity - Auditors exhibit the highest level of professional objectivity in gathering,
evaluating, and communicating information about the activity or process being evaluated. Auditors
make a balanced assessment of all the relevant circumstances and are not unduly inuenced by their own
interests or by others in forming judgments or making decisions
9.3. Condentiality - Auditors respect the value and ownership of information they receive and
do not disclose information without appropriate authority unless there is a legal or professional
obligation to do so
9.4. Competency - Auditors apply the knowledge, skills, and experience needed in the
performance of internal auditing services.
The Intemal Quality Audit Team shall conduct semi-annual Internal Quality Audits to ensure
that all general administrative and support services, social services and hospital services are in
conformance with the requirements of the Quality Management System ISO 9001:12015,
organizational, statutory/legal, client/customer, and product and process.
The Internal Quality Audit Team shall be responsive to the needs of the Provincial Government
of Pangasinan and shall assist top management by performing the audits on the following scope:
a) General Administrative and Support Services which include;
Annual Investment Program
Recruitment, Selection and Placement
Training and Employee Development
Performance Management
Rewards and Recognition
Health and Wellness
Information Technology
Major Repair and Maintenance of Buildings and Fixtures
Major Repair and Maintenance of Buildings and Fixtures
Repair and Maintenance of Service Vehicles
Supply Management
Frontline Financial Services Processing and Obligating Expenditures
b) Social Services - Crisis lntervention
c) Hospital Services - Admission to Discharge of Patients
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With this, the Internal Quality Audit Team Leader and Auditor shall prepare and review the following
documented information for the conduct of the audit:
BEFORE AUDIT
a) Audit Program
b) Audit Plan
c) Previous Intemal Quality Audit Report
d) Internal Quality Audit Checklist (PDCA Checklist)
AFTER AUDIT
a) lntemal Quality Audit Report
b) Executive Audit Summary
c) Corrective Action Request (CAR)
Non-conformities identified as a result of the Internal Quality Audit conducted shall be recorded through
the Corrective Action Request (CAR) and shall be brought to the attention of the concerned process owner. The
Auditors/Audit Teams shall present Audit Findings (Major Non-Conformities, Minor Non-Conformities,
Opportunities for improvements and noted good points of the assigned process to the process owners, as well as
Corrective Action Request (CAR) in case of non-conformity during the Internal Quality Audit Closing Meeting
and Management Review.
The Internal Quality Audit Team Leader shall collect the Corrective Action Request (CAR) and shall
submit the collected Corrective Action Request (CAR) to the Document Controller The Document Controller
then shall distribute the respective CARs to the concerned Process Owners which shall be accomplished to
address non-conformities. Upon receiving the CAR, the process owner shall promptly attend to deficiencies
found through the implementation of immediate correction to address non-conformities. Likewise, the process
owner shall conduct root cause analysis and formulate corrective actions to address the root cause and prevent it
from recurring. Subsequently, process owner shall return the accomplished CAR to the Document Controller.
The Document Controller then forwards the CAR to the concerned auditor for verification of the execution and
effectiveness of the course of action based on the date of implementation indicated. With this, Internal Quality
Audit Team and Process owners shall retain documented information as evidence of the implementation of the
audit program and audit results (See Procedure Manual on Internal Quality Audit).
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9.3. Management Review

9.3.1. General
It is the policy of the Provincial Government to conduct Management Review of its quality management
system semi-annually every May and November of the calendar year or whenever deemed necessary to ensure
its continuing suitability, adequacy and effectiveness in satisfying the requirements of ISO 9001:2015 and its
stated quality policy and objectives. The review shall he venues to assess opportunities for improvement and the
need for changes in the internal and external issues that are relevant to the quality management system.
Reviews shall be conducted twice a year at a venue agreed upon by the DQMRs and approved by the
QMR. The QMR shall plan and preside over the Management Review while the Deputy Quality Management
Representative shall prepare the agenda. The Secretariat shall take and prepare the minutes of meeting.
All minutes of Management Reviews shall be maintained by the Document Controller and form part of
the Quality Record.
9.3.2. Management Review Inputs

Input for the management review process may include, but is not limited to current performance and
improvement opportunities related to the following:
a) Status of Actions from previous management reviews
b) Changes in internal and external issues that are relevant to the Quality Management System
c) Information on the performance and effectiveness of the quality management system including, but
not limited to:
Client/ Customer Satisfaction and Feedback
Results of internal and external audits showing process performance and level of
conformity
Status of the achievement of the quality objectives
Recommendations for improvement
Status of non - conformities and corrective actions
Performance of external providers
Recommendations for improvement
d) Adequacy of Resources (see Clause 7.1)
e) Effectiveness of actions taken to address risks and opportunities (see Clause 6.1)
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f) Opportunities for Improvement (See Clause 10.3)

9.3.3. Management Review Outputs
Outputs from the management review shall include, but are not limited to, any decisions and actions
related to the following:
Improvement of the efficiency and effectiveness of the QMS and its processes
Resource allocations and needs
Review of trends in the achievement of quality objectives
Satisfaction of Internal and Extemal Clients/' Customers
Improvement of Services to meet requirements
Any need for changes to the quality management system
The organization shall retain documented shall retain documented information as evidence of the results
of Management Review (See Procedure Manual on Management Review).
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10 Improvement
10.1. General
The Provincial Government of Pangasinan shall continually improve the effectiveness of the quality
management system through determining opportunities for improvement and implement necessary actions to
meet customer requirements and enhance customer satisfaction. As such, various inputs are considered for
continual improvement, such as: the quality policy, quality objectives, on-site monitoring and inspection audit
results/findings, results of performance review and evaluation, analysis and evaluation, effectiveness of
corrective actions, and management review meetings.
10.2. Non Conformity and Corrective Action
The Provincial Government of Pangasinan established and maintained documented procedures to ensure
that the product/service that does not conform to specified requirements are prevented from delivery to
clients/end users. This procedure enables the agency to identify, evaluate and prevent non-conforming products
and from being used or delivered inadvertently. The controls include identification, documentation, segregation,
evaluation and disposition of non-conforming products and services for notification of the concerned authority.
When a non conformity occurs, including any arising from complaints, the Provincial Government of
Pangasinan shall take action to correct and control the non conformity. The correction of non-conformity is
the responsibility of process owners who are directly involved and possess the knowledge and skill to determine
required actions. Problems that cannot be corrected at this level are referred to the immediate supervisor. When
non-conformities are corrected or modified, they are subject to re-verification to demonstrate conformity to the
requirements. When nonconformities are detected after delivery of the product or service or use has started, a
corrective action will be undertaken and its effectiveness shall be veried by the concerned Auditor, Internal
Quality Audit Team Leader and Continuous Improvement Team leader. The OMS Team examines all non-
conformances and maintains records of the nature of the nonconformities and subsequent actions taken.
With this, process owners shall evaluate the non -- conformity and shall determine its root cause to
eliminate such causes through correction and corrective action in order that it does not recur or occur elsewhere.
lf root cause of the non ~ conformity has been determined, process owners shall implement correction and
corrective actions needed to address the non conformity and its effects. Effectiveness then of corrective
actions taken shall be monitored and measured. If necessary, risks and opportunities determined during the
planning shall be reviewed and updated and quality management system shall have necessary changes.
The organization shall retain documented infonnation as evidence of the occurrence of the identified non
- conformity and the actions taken to address such. Likewise, evidence to support the results and effectiveness
of corrective actions shall be retained.
Page 1 of 2
QUALITY MANUAL 10
l0.3. Continual Improvement

The Provincial Government of Pangasinan shall continually improve the suitability, adequacy and
effectiveness of the quality management system. Data demonstrating the suitability and effectiveness of the
quality management system as well as procedures and tools used to evaluate its continual improvement shall be
undertaken. Data gathered from measurement tools resulting from on-site monitoring activities of products and
services, client satisfaction and feedback, service Delivery Inspection Checklist, performance evaluation and
other relevant procedures shall be accurate and shall be analyzed, interpreted and presented during Management
Review meetings.
Computation of data through mean score, percentage, rating scale and demerit system shall he used for
data analysis from the various measurement tools utilized during audits. Information resulting from analysis of
data using numerical and graphical methods shall include customer satisfaction levels, conformity of
product/service to requirements, characteristics and trends of processes, and products/services as well as
supplier performance.
Likewise, periodic review of the QMS in satisfying the requirements of the International Organization
for Standardization and its stated quality policy and objectives, customer complaints and nonconformities shall
be analyzed, interpreted and acted upon. The CAR form shall be used to document correction and corrective
action upon audit for violations of policies. rules and regulations, other statutory laws and other non-
conformities in the ISO 9000:2015 requirements. The CAR shall also be the tool to be used by process owners
to record the correction and corrective actions performed due to negative feedback from customers, Internal
Quality Audit anchor third party audit findings, employee suggestions or observations, recurring problems,
problems or deficiencies in the QMS, perceived risks or threats to the QMS and the business if performance
gaps occur. (see Procedure Manual on Continual Improvement)
Page 2 of 2

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ISO 9001:2015

QUALITY MANAGEMENT SYSTEM

0.6 Control of the Quality Manual

It is the responsibility of the Document Controller to maintain and retain documented

There is an improvement of the service process; and

0.5 DISTRIBUTION LIST

Copy Number Issued To Functional Unit

0.3 REVISION HISTORY

1. ISO 9001:2015 Quality Management Systems - Requirements

3.8. Risk Management

Prepared by: Approved by:

3. Terms and Definitions

3.13 Correction - action implemented to immediately correct non-conformity.

Prepared by: Approved by:

4. Context of the Organization

Figure 1. Organizational Structure of the ***********************

Put the flowchart of the

Figure 2. QMS Process Model of the *******************

Please put appropriate comments/boxes for

4.2. Understanding the Needs and Expectations of Interested Parties

4.3. Determining the scope of the quality management system

4.4. Quality management system and its process

Prepared by: Approved by:

5.1.2 Customer focus

requirements specied by the clients/patients including service delivery,

5.2.2 Communicating the quality policy

5.3 Organizational roles, responsibilities and authorities

Figure 5: Organizational Structure of the Quality Management Team

HON. AMADO I. ESPINO III

PUT FLOWCHART HERE

Summarizes Internal Quality Audit results as input for Management Review.

Prepared by: Approved by:

Prepared by: Approved by:

7.1.4 Environment for the Operation of Processes

7.1.5 Monitoring and Measuring Resources

7.1.6 Organizational Knowledge

The Department Head:

The Human Resources Department:

a) Quality management system and its processes (4.4.2 b)

(masterlist of maintained documented information, masterlist of retained documented information, masterlist of

Prepared by: Approved by:

8.2.3 Review of the Requirements for Product and Services

8.2.3.2 Documented information of products or service requirements shall be retained regarding:

a. results of the review of the requirements for products and services,

8.2.4 Changes to Requirements for Products and Services

d. Learning and Development activities for continuous improvement of competencies of process

8.3.2 Design and Development Planning

8.3.4 Design and Development Control

8.3.5 Design and Development Outputs

8.3.6 Design and Development Changes

8.4.2 Type and Extent of Control

8.4.3 Information for External Providers

2. methods, processes and equipment

8.5 Production and Service Provision

f. the validation, and schedule of revalidation, of the ability to achieve targets

8.5.2 Identication and Traceability

8.5.3 Property Belonging to Customers or External Providers

8.5.5 Post-delivery Activities

8.5.6 Control of Changes

8.6 Release of Products and Services

8.7 Control of Non-conforming Outputs

9.1.2. Customer Satisfaction

9.1.3. Analysis and Evaluation

c) Performance and effectiveness of the Quality Management_System (see Clause 4.4)