Graphs Depicting MDH Journey Towards Excellence

MDH Journey Towards Excellence

I am happy to see this graph being presented by Dr. Bernadette Hogar, MDH Quality Management Officer in a public forum in March 30, 2017.



Looks familiar. The first graph was made in 2012.



Then, updated in 2013.

MDH Journey_Excellence_rj_diagram_13sept5


Subsequent updating of the graph was done by Dr. Hogar after my retirement from MDH Administration in 2014.

I will ask Dr. Hogar to furnish updated graphs.

Happy to receive this delighful feedback from Dr. Hogar (17mar31): Thanks, Dr. Reynaldo O Joson for this legacy and the vision of continual healthcare improvement for Manila Doctors Hospital and the Asia- Pacific Region!


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Healthcare Decisions Day

Healthcare Decisions Day is a project used to inspire, educate and empower the public and providers about the importance of advance health care planning.

I am glad to hear that America is continually promoting awareness of the importance of the advance directives.

In America, April 16 has been declared on National Healthcare Decisions Day, “part of a national campaign to encourage Americans to complete their advance directives or living wills and document their desires regarding medical treatment at the end of life. ”

I support this project.

In the Philippines, I think we should also have a national campaign similar to that in the USA to encourage more Filipinos to make their advance directives or living wills.   Awareness and advocacy campaigns should be conducted by both physicians and health care institutions regardless of specialty.  The campaigns should not be delegated to the hospice specialists only.

Advance care planning starts with talking with your loved ones, your healthcare providers, and even your friends- all are important steps to making your wishes known. These conversations will relieve loved ones and healthcare providers of the need to guess what you would want if you are ever facing a healthcare or medical crisis.

“Advance Directives” are legal documents (Living Will and Healthcare Power of Attorney) that allow you to plan and make your own end-of-life wishes known in the event that you are unable to communicate.

In 2006, I made a formal declaration of my wishes on how I am going to die.  The other terms for this kind of document is “ advance directive” and “living will.”  I have been regularly updating my advance directive almost every year.

I have not have my living will notarized since 2006.  I felt it is NOT necessary.  I personally think, especially, in the context of my family environment, it is enough that my immediate and extended family members know that I have such a documented will and they know my wishes.

Advance directives will be of great help to my family members, physicians, and also to myself in decision-making during  my end-of-life stage.

Foremost, they will help me die with dignity and with shortest duration of agony.  They will also keep my hospitalization and medical expenses to just a “necessary “minimum.

In the past and at present, I have seen quite a number of patients and relatives suffering, physically, emotionally, and financially, that could have been minimized if not avoided by the presence of advance directives and end-of-life counseling by physicians.

In March 3, 2013, I updated my advance directive (see

In March 25, 2017, I am updating again as follows:

Declaration or Advance Directive

I, Reynaldo O. Joson, residing at ________________, being of sound mind, willfully and voluntarily make this Declaration:

(1) If the situation occurs that I am in a vegetative state or coma from an incurable disease process or injury (as determined by two physicians approved by my wife [___________] or designated successor attorney-in-fact), I desire and direct that life-sustaining procedures and means be withheld or withdrawn, including assisted respiratory ventilation and/or artificially administered fluids or nutrition (intravenous, gastric, jejunal, or other tube feedings), and that I be permitted to die naturally.

(2) If I should develop severe mental impairment to the degree that I am totally unable to perform activities of daily living or at least to recognize and meaningfully communicate with my family and others (as determined by two physicians approved by my wife [___________] or designated successor attorney-in-fact), I do not want intensive or prolonged hospitalizations, major surgery, artificially administered fluids or nutrition (intravenous, gastric jejunal, or other tube feedings), blood transfusions, or assisted ventilation.

(3) If the circumstance occurs that I am in a state of near-death, but a good possibility exists of recovery to a purposeful situation (such as my being able to write or otherwise communicate helpful thoughts and information to my family and others), then I do not restrict my physicians from exercising their skills with prudence, wisdom, and restraint.

However, I do not desire extreme measures such as a heart transplant or the implantation of an artificial heart (other than the use of a temporary bypass pump during surgery). And, if the state of near-death is part of a terminal cancer or other progressively incurable disease process or injury, then I desire that measures be directed at comfort, rather than to delay the moment of death.

(4) Furthermore, if I am in a vegetative state or coma from an incurable disease process or injury, or in a state of near-death with a progressively incurable disease or injury, or if I have developed severe mental impairment to the degree that I am totally unable to perform activities of daily living or at least to recognize and meaningfully communicate with my family and others (as determined by two physicians approved by my wife [______________] or designated successor attorney-in-fact), and if my heart or lungs cease to function, I do not want to be brought back to life with medications or with electrical or mechanical resuscitation or ventilation, or even with ordinary cardiopulmonary resuscitation.

(5) In any of these circumstances, it is my desire to be made comfortable with medications that are used to control pain, knowing that such medications may unintentionally hasten death. However, medications should not be used with the intention of causing death.

(6) It is my desire that the costs of my terminal care be kept to a minimum. Therefore, unless there are compelling reasons to the contrary, I would prefer to spend my last days at home rather than in a hospital or other expensive medical facility – unless being at home would be an unreasonable burden on my family.

I am legally competent to make this Declaration, and I understand its full import.

Witness my hand, this 25th day of March, 2017.

Reynaldo O. Joson, MD (Sgd)

March 25, 2017


In 2013, I came across “5 Wishes” which I added to my current advance directive. These will be applicable in 2017.

Five Wishes is a document that, like other advance directives, makes your wishes known ahead of time. It is unique among other advance directives, however, because it addresses all of a persons needs: medical, personal, emotional, and spiritual.

According to Aging with Dignity ( the organization that created Five Wishes, the document lets your family and health care providers know:

  1. Which person you want to make health care decisions for you when you can’t make them.
  2. The kind of medical treatment you want or don’t want.
  3. How comfortable you want to be.
  4. How you want people to treat you.
  5. What you want your loved ones to know.

Below are my 5 wishes (2017).


The Person I Want To Make Health Care Decisions For Me When I Can’t Make Them For Myself.

1. First Choice: My wife

2 Second Choice: Consensus of my son and daughter



My Wish For The Kind Of Medical Treatment I Want Or Don’t Want.

I believe that my life is precious and I deserve to be treated with dignity. When the time comes that I am very sick and am not able to speak for myself, I want the following wishes, and any other directions I have given to my Health Care Agent, to be respected and followed.

What You Should Keep In Mind As My Caregiver

• I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.

• I want to be offered food and fluids by mouth.

Life-support treatment

Close to death:

I do not want life-support treatment. If it has been started, I want it stopped.

In A Coma And Not Expected To Wake Up Or Recover:

I do not want life-support treatment. If it has been started, I want it stopped.

Permanent And Severe Brain Damage And Not Expected To Recover:

I do not want life-support treatment. If it has been started, I want it stopped.

In Another Condition Under Which I Do Not Wish To Be Kept Alive:

Advanced cancer, stroke, and other severe disability and terminally-ill diseases



My Wish For How Comfortable I Want To Be.

• I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means I will be drowsy or sleep more than I would otherwise.

• If I show signs of depression, nausea, shortness of breath, or hallucinations, I want my care givers to do whatever they can to help me.

• I want my lips and mouth kept moist to stop dryness.

• I wish to have warm baths often. I wish to be kept fresh and clean at all times.

• I wish to be massaged as often as I can be.

• I wish to have my favorite music played when possible until my time of death.

• I wish to have personal care like shaving, nail clipping, hair brushing, and teeth brushing, as long as they do not cause me pain or discomfort.

• I wish to have religious readings and well-loved poems read aloud when I am near death.



My Wish For How I Want People To Treat Me.

• I wish to have people (my family members) with me when possible. I want someone to be with me when it seems that death may come at any time.

• I wish to have my hand held and to be talked to when possible, even if I don’t seem to respond to the voice or touch of others.

• I wish to be cared for with kindness and cheerfulness, and not sadness.

• I wish to have pictures of my loved ones in my room, near my bed.

• If I am not able to control my bowel or bladder functions, I wish for my clothes and bed linens to be kept clean, and for them to be changed as soon as they can be if they have been soiled.

• I want to die in my home, if that can be done.



My Wish For What I Want My Loved Ones To Know.

• I wish to have my family and friends know that I love them.

• I wish to be forgiven for the times I have hurt my family, friends, and others.

• I wish to have my family, friends and others know that I forgive them for when they may have hurt me in my life.

• I wish for my family and friends to know that I do not fear death itself. I think it is not the end, but a new beginning for me.

• I wish for all of my family members to make peace with each other before my death, if they can.

• I wish for my family and friends to think about what I was like before I became seriously ill. I want them to remember me in this way after my death.

• I wish for my family and friends and caregivers to respect my wishes even if they don’t agree with them.

• I wish for my family and friends to look at my dying as a time of personal growth for everyone, including me. This will help me live a meaningful life in my final days.

• I wish for my family and friends to get counseling if they have trouble with my death. I want memories of my life to give them joy and not sorrow.

• After my death, I would like my body to be cremated.

• My remains should be put in Manila Memorial Park.

• The following persons know my funeral wishes: My wife, my son, and my daughter.

• If anyone asks how I want to be remembered, please say the following about me:

To my family –

Good husband –

  • Responsible
  • Loving
  • Faithful
  • Provide material needs
  • Provide emotional needs
  • Support wife’s emotional needs
  • Promote wife as a human being (rights)

Good father –

  • Provide companionship
  • Serve as a role model

Good man –

  • Man for family
  • Man for others

To my acquaintances –

Good man

Man for family

Responsible father

  • Provide
  • Support
  • Promote children as human beings
  • Provide companionship
  • Serve as role model

Man for others


  • For himself
  • For his family
  • For his community

• Epitaph on my tombstone: Good Husband, Father, Man, Physician, and Teacher (with my picture on tombstone)

• I don’t like memorial services.

• I can have a wake for not more than 3 days.  In my wake, I like to have favorite songs played continuously and my autobiography shown (how I have lived my life).

• I will donate organs from my body that are “donatable.”

Reynaldo O. Joson (Sgd)

March 25, 2017



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Every March is Fire Prevention Consciousness Month

March is Fire Prevention Consciousness Month.

Every March, we are again reminded of the importance of fire prevention.  Every March, let’s make it a point to review our fire prevention plans in our house and in our place of work and then continually improve and reinforce.

Let’s all be aware and vigilant against FIRE, particularly on the prevention of its occurrence.


Here are Fire Safety Tips from the Bureau of Fire Protection (2014) –

Fire prevention: What should you have in your home?

  • Smoke alarms
  • Fire extinguishers
  • Emergency exit plan


Fire prevention: How do I prevent fire hazards at home?

Kitchen Area

  • Never leave your cooking unattended.
  • Matches and lighters should be kept out of reach of children.
  • Stoves must be clean and grease-free; check LPG for leaks with soapy water.
  • Do not douse a burning frying pan with water, but instead cover it with a lid or a damp cloth.
  • Unplug all idle electrical appliances.
  • Avoid overloading outlets and using worn-out cords.
  • Do not store items on the stove top.
  • Keep flammable liquids and other combustible items away from the stove when cooking.
  • Replace smoke alarm batteries every six months.

Living room and bedrooms

  • Do not use extension cords as permanent outlets; do not loop them around sharp objects that may cause cords to fray open.
  • Make sure curtains are away from electric fan blades.
  • Do not leave an electric fan switched on when it is no longer rotating; regularly clean and oil household electric fans.
  • Do not delay fixing defective appliances.
  • Unplug rice cookers and clothes irons promptly after use.
  • Never smoke in bed.
  • Place candles in holders or a basin partly filled with water.
  • Put out candles before going to bed.
  • Remove dried leaves, cobwebs, loose paper, and other easy-burning debris from the living area.

Storage and garage areas

  • Keep areas clean and tidy with items properly placed for storage.
  • Do not store large quantities of flammable liquids in the house or basement areas such as:
    • Gas/kerosene
    • Paints and solvents
    • Motor lubricants
    • Floor wax/liquid polishes
    • Adhesives (i.e., rugby)
    • Alcohol products
  • Oily rags, newspapers, and other trash must be disposed in a safe waste bag or container.
  • Clean up spilled oil and grease from vehicles promptly.
  • Plug power tools straight into sockets; if extensions must be used use only heavy-duty extensions.
  • Keep your garage well-ventilated to avoid buildup of fumes and heat from tools.


What do I do when a fire breaks out?

  • A well-rehearsed emergency exit plan greatly alleviates panic during an outbreak of fire.
  • Try to close the door of the burning room and close all the doors behind you as you leave. This is to delay the spread of fire and smoke.
  • Before you open a door, feel it with the back of your hand to determine if the room behind it is burning.
  • Fumes and hot air settle at the ceiling; the best air is one to two feet from the floor. Crawl to the exit with a wet piece of cloth to cover your mouth.
  • Fire spreads at a very fast rate, doubling its volume every 30 seconds. It is of the utmost priority to get everyone out before you consider your possessions.
  • Never go back into the burning building until a firefighter declares it safe to do so. Even after flames have been put out, there is still the risk of a roof collapse, live wires, and a backdraft.*

*A backdraft is an explosion that occurs when oxygen suddenly meets very hot temperatures and fuel.


What do I do if I’m trapped in a fire?

  • Position yourself in a room with windows leading outdoors.
  • Alert that people outside that you are still in the burning building; Shout for help or get a light-colored cloth and wave it outside the window.
  • Seal your room. Close the doors and patch any gaps with towels or sheets to prevent smoke from coming in.
  • If trapped in the upper floors of the building, try to collect bedsheets and foam cushions or mattresses. These could help you when escaping through the window.
  • Do not run if your clothes catch fire. Instead, stop moving, drop to the ground, and roll.
  • Clear flammable debris from the window. Rip off curtains and anything else that may burn.
  • Don’t break the glass. You may need to close it against smoke entering from the outside. If the air outside is fresh, open the window a little.




Posted in Fire Prevention Consciousness Month, Fire Safety | Leave a comment

Handwriting – you are what you handwrite

Handwriting up to now is an essential requirement of communication unless a person has not learned (newborn up to toddler years) or has been incapacitated to write with his / her hands.

Despite the presence of information technology, promoting and facilitating digital writing, handwriting is still needed.  Thus, every person must learn and continue to learn how to handwrite except for the situations mentioned above and he/she must do it legibly to achieve the goals of communication.

There is a cliché – you are what you eat.  Translating, you are what you handwrite.

Handwriting brings out the personality and values of handwriter.

It demonstrates whether the handwriter is a caring person or not.   He / she cares if he /she writes legibly to promote understanding of what he / she wrote.  He / she cares if he / she writes legibly to promote safety of what he wrote (e.g. instructions and medical prescription).

It demonstrates conscientiousness or diligence in making the reader understand what he / she wants to convey.  As one writes, one has to make sure each letter of a word is legible.  Legible letters contribute to legible words.  Legible words contribute to legible handwriting.

As one writes each letter of a word, he / she has to look whether it is legible or not.  If not, he / she has to go back to the letter to make the necessary corrections or adjustments to make sure it is legible.

Going back to correct or adjust to make a letter of a word legible consumes time, but doing do indicates the writer is conscientious.  To save time from repeated corrections or adjustments, one has just to make effort to make sure each letter is legible from the very start by carefully crafting the round curves, dots, slashes, spaces, etc.

If need to do so for legibility sake, write letters and words in print form.  However, just the same, make sure the printed letters are legible.

Handwriting skills and outcomes-based education

The Department of Education and the Commission of Higher Education are currently promoting outcomes-based education.  One of the outcomes should be legible handwriting by all graduates.  There must be course on handwriting and an effective assessment tool to make sure all Filipino graduates (starting at grade school) have acquired the competency of legible handwriting.

Physicians and writing

Physicians are known to have poor handwriting.   They should take a course on handwriting.  Their handwriting is particularly important on the safety of their patients, particularly in orders in the medical charts and prescription.


Some perceptions of patients on doctors’ handwriting

“I thought all the while you doctors are trained to do that kind of handwriting – illegible handwriting.”

“You write beautifully.  You are not a doctor.”


Links to Previous Posts:



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Feeling of a surgeon-mentor over a former mentee

Today, January 11, 2017, I was happy to have a former student, Dr. Sheila Macalindong, assisted me in my difficult operation.  Sheila was a graduate of our general residency and surgical oncology programs in the Philippine General Hospital.  She is now a consultant.

I recalled and assumed that years years ago that my mentors, Dr. Antonio Limson and Dr. George Eufemio, felt the same way when they would ask me, a young consultant then, to assist them in their difficult operations. They trusted me. They were happy to see how I operated that they would ask me to assist them several times.  Most important of all, I assumed they had this feeling as mentors, they were happy to have produced such a skillful surgical graduate.  They never mentioned the last statement to me.  I just assumed because they repeated me asked me to assist them in their difficult operations.

When I was operating with Sheila, as I said,  I was happy.  Sheila had asked me to take a break or rest during the 9-hour operation (she knows I am old already) and she would continue doing the operation for me.  I declined.  I told her I was enjoying watching her operate. I saw her in her my operative moves and decision-making style.  It looked like she had learned from me.  It looked like she was my disciple, my replica. It looked like she had inculcated my operative moves and operative decision-making.

After the operation, I thanked her for assisting me.  I told her I enjoyed watching her operate.

I repeat, as a former mentor, I felt and was happy that I was able to produce a skillful surgical graduate.  I also enjoyed learning new things from her.



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ROJOSON’s Lectures and Teaching Activities – 2016 (Registry as of December 31, 2016)

ROJOSON’s Lectures –Talks – 2016

Target: 12

Total: 14 (more than if teleconferences and face-to-face conferences added)

  Date Title Participants Place
1 February 10, 2016 Preceptorial on Thyroid UPCM LU4 UPCM
2 February 16, 2016 Systematic Approach to Hospital Operations: The Unique Framework Applicable To Every Department UP-CPH MHA 202


3 March 10, 2016 Towards Excellent Hospital; Online Collaborative and Interactive Learning; Systematic Approach to Managment of Hospital Departments Staff of Salubris Medical Center Nueva Vizcaya
4 March 14, 2016 Patient Safety Management Unilab Sharing Program – 13 Hospital Directors from Indonesia Unilab
5 March 22, 2016 The Road to Hospital Accreditation: How Necessary is it? Who Cares? UP-CPH MHA 202


6 April 5, 2016 Disasters and Outbreaks: How Ready is your Hospital? UP-CPH MHA 202


7 April 12, 2016 Project Maternal Death Control Management System in Zamboanga Peninsula Zuellig Family Foundation – Regional and Provincial Account Officers Zuellig Pharma, Paranaque
8 May 16, 2016 Patient Safety Management Unilab Sharing Program – 13 Hospital Directors from Indonesia Unilab
9 August 30, 2016 Patient Safety Management Unilab Sharing Program –   Hospital Directors from Indonesia Unilab
10 September 7, 2016 Application of Management Process to Thyroid Nodules: A 30-year Experience UP-PGH Postgraduate Course (ATR Memorial Lecture) Diamond Hotel
11 September 15, 2016 Value-based Health Care Services (Clinical Pathways – Clinical Practice Guidelines
To Control Cost yet Maintain Quality of Outcomes)
Unilab Sharing Program – Hospital Directors from Indonesia Hennan Regency, Boracay
12 October 1, 2016 The Road to Hospital Accreditation: How Necessary is it? Who Cares? UP-CPH MHA 202


13 October 5, 2016 Systematic Approach to Hospital Operations: The Unique Framework Applicable To Every Department UP-CPH MHA 202


14 October 26, 2016 Organization and Management of the Emergency Department of a Hospital UP-CPH MHA 202


    Skype Conferences – Salubris Medical Center (monthly)    
    Maternal Death Control Management System – Online    
    Neonatal Death Control Management System – Online    
    ZCMC Earthquake Business Continuity Program – Blended Learning (Online – Skype – Face-to-face)    


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Keeping track of licenses and taxes that need renewal and redo every year

At start of the year, first week of January at the latest, or even earlier, December of the previous year, one has to look at the personal licenses that need to renew and taxes that have to be paid in the current year.

Nowadays, not all licenses and taxes are renewed and repaid on a yearly basis.  The renewal of driver’s license is now every 5 years.  Some licences are still required to be renewed every 3 years (I don’t know if there is still a one-year expiration system).

For taxes and car stickers, payment and renewal is usually every year.  One has to remember the deadlines for payment in order not to be fined a surcharge for late payment or better, to get a discount for early payment.

In the past, I and other people have overlooked or forgotten the date of expiration of licenses.  The consequences are surcharges, driving with an expired license, practicing with an expired license, etc.

On a personal basis, I need to keep track of the following deadlines for my licenses:

  • PRC License – to be renewed in 2017
  • S2 License – to be renewed in 201 7
  • PhilHealth License – to be renewed in 2018
  • Driver’s License – to be renewed in 2019

I have to keep track of the deadlines for renewal of car stickers in my village and in places I work like the Philippine General Hospital and Manila Doctors Hospital.

I have to keep track of the deadlines and early-bird discounts on all taxes that I am obliged to pay.


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