this powerpoint presentation is a review material

1. Licenses and
Standardization of Hospitals
Arvin Ray M. delos Santos, RMT
MPH-I | Lyceum Northwestern University

2. OBJECTIVES
• To improve access to quality health
facilities with the efficient use of limited
resources and without compromising the
quality of care.
• To protect and promote health of the
public by ensuring a minimum quality of
service rendered by hospitals and other
regulated health facilities and to ensure
the safety of the patients and personnel.

3. DOH LICENSE
• All DOH licensed hospitals shall be
deemed automatically accredited by
Philhealth as Centers of Safety (Basic
Participation Circular No. 54)
• Stakeholders shall comply with the
standards and requirements prescribed in
the enhanced assessment tool for
licensure of hospitals.

4. Administrative Order No. 2012-0012
“New Classification of Hospitals and
other Heath Facilities”
DEPARTMENT OF HEALTH
Bureau of Health Facilities and Services

5. Old Classification of Hospitals
as per DOH A.O. No. 2005-0029
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
Primary Care Level 1 plus: Level 2 plus: Level 3 plus:
General Medicine Surgery Specialty Clinical Care
with departmentalized
clinical service
Teaching and/or training
with at least 1 accredited
residency training program
for physicians
General Pediatrics
Anesthesia
Emergency and
Out-patient Services
General Dentistry Department of
Emergency Medicine
General Obstetrics Pharmacy Provision for ICU Specialized and sub-
specialized forms of
treatment, surgical
procedure & intensive care
Non-surgical
Gynecology
Secondary Clinical
Laboratory
Tertiary Clinical
Laboratory
Rehabilitation Service
Minor Surgery 1st Level Radiology 2nd Level Radiology 3rd Level Radiology

6. Classification of Hospitals
According to Ownership:
A. Government – created by law; may be under DOH, DND,
DOJ, PNP, LGU, SUCs, GOCC and others
B. Private – may be single proprietorship, partnership,
corporation, cooperative, foundation, religious, non-
government organizations and others

7. Classification of Hospitals
According to Functional Capacity:
A. General Hospital – provides medical and surgical care to the
sick and injured and maternity care and shall have as
minimum, the following clinical services: medicine,
pediatrics, OB-GYNE, surgery and anesthesia, emergency
services, out-patient and ancillary services
B. Specialty Hospital – specializes in a particular disease or
condition or in one type of patient

8. Classification of General Hospitals
OLD CLASSIFICATION NEW CLASSIFICATION
Level I Re-classify to other
Health Facilities
Level II Level 1
Level III Level 2
Level IV Level 3

9. Classification of General Hospitals
GENERAL LEVEL 1 LEVEL 2 LEVEL 3
Clinical Services & Facilities
for In-Patients
Consulting Specialists in:
Medicine, Pedia, OB-GYNE,
Surgery
Level 1 plus all:
Departmentalized Clinical
Sevices
Level 2 plus all:
Teaching/training with accredited
residency training program in the
4 major clinical service
Emergency and Out-patient
Services
Respiratory Unit Physical Medicine and
Rehabilitation Unit
Isolation Facilities General ICU Ambulatory Surgical Clinic
Surgical/Maternity Facilities High Risk
Pregnancy Unit
Dialysis Clinic
Dental Clinic NICU Tertiary Lab w/ Histopath
Ancillary Services Secondary Clinical Lab Tertiary Clinical Lab Blood Bank
Blood Station Blood Station 3rd Level Xray
1st Level Xray 2nd Level Xray w mobile unit
Pharmacy

10. Example of Specialty Hospitals
Particular Disease Particular Organ(s) Particular Group of
Patients
National Orthopedic
Hospital
Lung Center of the
Philippines
Philippine Children’s
Medical Center
National Center for
Mental Health
Philippine Heart
Center
National Children’s
Hospital
San Lazaro
Hospital
National Kidney and
Transplant Institute
Dr. Jose Fabella
Memorial Hospital

11. Classification of Hospitals
According to Trauma Capacity:
A. Trauma-Capable Facility – A DOH Licensed hospital
designated as a trauma center
B. Trauma-Receiving Facility – A DOH licensed hospital within
the trauma service area which receives trauma patients for
transport to the point of care or a trauma center

12. New Classification
HOSPITALS OTHER HEALTH FACILITIES
GENERAL
• Level 1
• Level 2
• Level 3
(Teaching/Training)
A. Primary Care Facility
B. Custodial Care Facility
C. Diagnostic / Therapeutic
Facility
SPECIALTY D. Specialized Out-patient
Facility

13. New Classification of other
Health Facilities
A
Primary Care
Facility
B
Custodial Care
Facility
C
Diagnostic/Therapuetic
Facility
D
Specialized Out-patient
Facility
When In-patient Beds:
• Infirmary/ Dispensary
• Birthing Home
Psychiatric Care
Facility
Laboratories:
• Clinical Lab / HIV
• Blood Service Facilities
• Drug Test Lab
• NB Screening Lab
• Water Analysis Lab
Dialysis Clinic
Ambulatory Surgical Clinic
Without Beds:
• Medical Out-patient
Clinics
• OFW Clinics
• Dental Clinics
Drug Abuse Treatment and
Rehabilitation Center
(DATRC)
Ionizing Machines as Xray,
CT Scan, mammography
and others
In-vitro Fertilization (IVF)
Centers
Sanitarium / Leprosarium Non-ionizing machines as
Ultrasound, MRI and others
Radiation Oncology Facility
Nursing Home Nuclear Medicine Oncology Center / Clinic

14. STANDARDS
• Every health facility shall be organized to
provide safe, quality, effective and
efficient services for patients

15. STANDARDS:
Personnel
• Every health facility shall have a duly licensed physician to
oversee the operations of the facility
• The staff composition ( medical, allied medical nursing,
Administrative & Finance Sections) shall depend on the
workload.
• Staff development and continuing education programs for all
the personnel

16. STANDARDS:
Physical Facilities
• Every facility shall comply with the local and national
regulations for construction, renovation, maintenance and
repair of the facility
• Every facility shall provide enough space for the conduct of
its activities.
• Every facility shall have an approved DOH (Permit to
Construct)

17. STANDARDS:
Equipment and Instruments
• Every facility shall be adequately equipped.
• There shall be a program for calibration, preventive
maintenance and repair of equipment
• There shall be a contingency plan in case of equipment
breakdown and malfunction

18. STANDARDS:
Service Delivery
• Every facility shall have a documented administrative
Standard Operating Procedure (SOP)
• Every facility shall have documented technical policies and
procedures in the different clinical areas
• There should be a documented policies for referral system
• The management shall ensure that blood comes from a
licensed blood bank
– Red Cross or DOH Designated Blood Centers
– MOA shall be entered into hospitals capable of blood transfusion

19. STANDARDS:
Quality Improvement Activities
• Every facility shall have policies and procedures on Quality
Assurance Program (QAP)
• The QAP shall have a written plan and its implementation
• Participation in the National External Quality Assessment
Scheme conducted by the National Reference Laboratories

20. STANDARDS:
Information Management
• Every health facility shall maintain a system of
communication, recording ad reporting of examination
• Contents of Medical Records
• Collection and Aggregation of Data
– Annual Statistical Record of the Hospital
• Records Management
– Confidentiality of patient’s information
– Retention and disposal of medical records

21. STANDARDS:
Environmental Management
• Every health facility shall ensure that the environment is safe
for its patient and staff including members of the public as
necessary and that the measures and/or safeguard shall be
observed
• Well ventilated, lighted, clean, safe and functional workplace
• Proper maintenance and monitoring of physical facilities
• Safe water supply
• Proper disposal of infectious wastes and toxic and hazardous substances
• No smoking policy
• Contingency plan in case of accidents and emergencies

22. PROCEDURAL GUIDELINES
• Application for Certificate of Need (CON)
• Application for DOH-Permit to Construct
(DOH-PTC)
• Application for Initial License to Operate (LTO)
• Application for Renewal of LTO
• Inspection
• Monitoring

23. PROCEDURAL GUIDELINES:
APPLICATION FOR CON
• This is a certificate issued by the Center for Health Development
(CHD-Regional) for the proposed construction of a new general
hospital, which ensures that the facility will be needed at the time
of its completion.
• The certificate issued to an individual or group intending to build
a hospital in order to meet the needs of a community.
• A CON is a required document prior to the issuance of a DOH-
Permission to Construct (DOH-PTC) for construction of a new
general hospital.

24. PROCEDURAL GUIDELINES:
APPLICATION FOR DOH-PTC
• A permit issued by DOH through Bureau of Health Facilities and
Services (BHFS) to an applicant who will establish and operate a
hospital or other health facility, upon compliance with required
documents prior to the actual construction of the subject facility.
• It is also required for hospitals and other health facilities with
substantial alteration, expansion, renovation, or increase in the
number of beds.
• It is a prerequisite for License to Operate (LTO)

25. PROCEDURAL GUIDELINES:
APPLICATION FOR INITIAL LTO
• This is a formal authority issued by DOH to an individual, agency,
partnership or corporation to operate a hospital or other health
facility.
• It is a prerequisite for accreditation of a health facility (regulated
by BHFS) by any accrediting body recognized by DOH.
• All hospital shall follow One-Stop Shop (OSS) Licensure System for
Hospital under the following Administrative Orders (AO)
– AO 2007-0021 (Harmonization & Streamlining of Regulatory Process
– AO 2010-0035 (Recentralization of Issuance of PTC for all levels of Hospitals, LTO for
all new hospital and Renewal of LTO for Levels 3 and 4 hospitals
– AO 2011-0020 (Streamlining of Licensure and Accreditation of Hospitals

26. PROCEDURAL GUIDELINES:
APPLICATION FOR RENEWAL OF LTO
• Each CHD shall renew LTO of Level 1 hospitals following OSS
Licensure System for Hospitals and renew LTO of other health
facilities under Category A (Primary Health Care Facility with in-
patients beds)
• The BHFS shall renew LTO of Level 2 and Level 3 hospitals
following OSS Licensure System for Hospitals and renew
LTO/Accreditation of health facilities covered by other DOH
issuances.
• LTO of a hospital shall be cancelled automatically without notice
upon failure to submit a duly accomplished application form.

27. PROCEDURAL GUIDELINES:
INSPECTION
• The BHFS or CHD shall conduct licensure inspections utilizing the
Assessment Tool for licensure/accreditation of health facilities
within reasonable time and DURING OFFICE HOURS.
• The applicant shall ensure that all key staff, pertinent records,
premises and facilities are made available to BHFS/CHD Director
and/or his authorized representative/s during inspection visits

28. PROCEDURAL GUIDELINES:
MONITORING
• BHFS/CHD shall conduct a regular outright monitoring visit
utilizing the Assessment Tool for licensure/accreditation of health
facilities within reasonable time and during office hours.
• The applicant shall ensure that all key staff, pertinent records,
premises and facilities are made available during such monitoring
visits.
• A Notice of Violation shall be issued immediately for non-
compliance with the rules and regulation.

29. SCHEDULE OF FEES
• A non-refundable fee shall be charged for the
application of LTO/Accreditation of a hospital
or health facility.
• All fees, surcharges and discounts shall
follow the current DOH prescribed schedule
of fees in AO 2007-0023 (Schedule of Fees
for the One-stop Shop Licensure System

30. VALIDITY OF LICENSE TO OPERATE
• The LTO shall be valid for one (1) year
following OSS Licensure System for Hospitals.
• The LTO/Accreditation of other health
facilities covered by other AOs shall follow
the specific issuance/s of the health facility
under evaluation.

31. VIOLATIONS
• Facilities found violating any provisions of
these rules and regulations and its related
issuances by personnel operating the
hospital or health facility shall be penalized,
suspended or revoked.
• AO 2007-0022 (Violations under the OSS
Licensure System for Hospitals)

32. INVESTIGATION OF CHARGES
AND COMPLAINTS
• BHFS/CHD shall investigate the complaint
and verify if the hospital or other health
facility concerned or any of its personnel is
liable for an alleged violation.
• BHFS/CHD after investigation, may suspend,
cancel or revoke LTO of licenses found
violating the provisions and its related
issuances, without prejudice to taking the
case to judicial authority for criminal actions

33. PENALTY
• The imposable penalty for violations shall be
accordance with AO 2007-0022 (Violations
under OSS Licensure for Hospitals)

34. APPEAL
• The management of the hospital aggrieved
by the decision of the Director of BHFS/CHD
may, within 10 days after receipt of the
notice of decision, file a notice of appeal to
the Office of the Secretary of Health.

35. JOINT COMMISSION INTERNATIONAL (JCI)
• JCI accreditation and certification is recognized
as a global leader for health care quality of care
and patient safety.
• JCI Accreditation Standards for Hospitals
provides the basis for accreditation of hospitals
throughout the world.
• The standards define the performance,
expectations, structures and functions that must
be in place for a hospital to be accredited by JCI.

36. JOINT COMMISSION INTERNATIONAL (JCI)

37. CONCLUSION
• A research project was therefore undertaken by
the Department of Health (DOH) through the
Bureau of Health Facilities and Services (BHFS)
to map out the services and equipment available
in all hospitals and to get an overview of the
typology of the existing hospital classification
and other hospital-based facilities. Knowledge
of the distribution of services and equipment
would enable DOH in improving access to the
much needed services in keeping with the goal
of Kalusugang Pangkahalatan or the Universal
Health Care.

38. CONCLUSION
• In addition, this would guide the health
agency in future policy direction.
Consequently, in support of the study, on
April 2011, DOH Issued Department
Memorandum No.2011-0135 entitled “A
Survey of the Services and Equipment
Available in Hospitals Nationwide”. Partial
survey results indicate variations in the
service characteristics of hospitals not only
among the different categories but also
within the same category based on the
facilities and services they provide.

39. CONCLUSION
• Thus, a new classification of hospitals and
other health facilities becomes inevitable in
the compliance with statutory requirements
and the emergence of new health facilities.
The move aims to upgrade the services
offered in health facilities and come up with
a more homogeneous category for health
facilities with similar services. The new
classification of health facilities will simplify
licensing systems and processes and make
the regulatory scheme more effective and
efficient.

40. RECOMMENDATION
• That every hospital and health facility in
the Philippines should be accredited by
the Joint Commission International (JCI).
• That every hospital and health facility in
the Philippines should share best
practices in managing their respective
institutions

41. RECOMMENDATION
• That every hospital and health facility
should be aware to all the benefits for
their employees including additional pay
such as hazard pays and others
• That every law governing the professions
of the employee should have also
standardization in workload and much
especially in the compensation.