Title
DOH Rules on Hospital Registration and Licensure
Law
Doh Administrative Order No. 150, S. 2004
Decision Date
Apr 28, 2004
DOH Administrative Order No. 150, issued on April 28, 2004, revises the rules governing the registration, licensure, and operation of hospitals and health facilities to enhance healthcare quality and ensure compliance with the Hospital Licensure Act, establishing clear guidelines for facility classification, licensing requirements, and regulatory oversight by the Department of Health.
A

Legal Authority

  • Implements Republic Act No. 4226 (Hospital Licensure Act).
  • Consistent with Executive Order No. 102 regarding Department of Health operations.

Purpose of the Rules

  • Protect and promote public health.
  • Ensure right to quality health services appropriate to healthcare level.
  • Regulate hospitals and other health facilities accordingly.

Scope of Application

  • Applies to all government and private hospitals and health facilities in the Philippines.

Regulatory Agency

  • Department of Health (DOH) through Bureau of Health Facilities and Services (BHFS), Office for Health Regulation, is the principal implementing and enforcing body.

Definitions

  • Hospital: Facility for diagnosis, treatment, and care needing 24-hour bed use, covering deformities, diseases, injuries, surgical, obstetrical, medical, or nursing care.

Classification of Hospitals and Health Facilities

  • By Ownership:
    • Government: Operated by national or local government entities.
    • Private: Owned and operated with private funding.
  • By Service Type:
    • General: Services for all deformities, diseases, injuries.
    • Special: Focused on specific clinical care.
  • By Service Capability:
    • Primary Care: Non-departmentalized; basic prevalent clinical services and care.
    • Secondary Care: Departmentalized; includes specialty clinical care, surgical, intensive care.
    • Tertiary Care: Teaching hospital offering specialized and sub-specialized care and training.
    • Infirmary: Emergency care, maternal and newborn care.
    • Birthing Home: Maternity services, normal delivery, newborn care.
    • Acute-Chronic Psychiatric Care Facility: Medical, nursing, pharmacological, psychosocial care for mental illness.
    • Custodial Psychiatric Care Facility: Long-term custodial care for chronic mentally ill.

Licensing - Definition and Purpose

  • Formal authorization issued by DOH to operate.
  • Prerequisite for accreditation by recognized accrediting bodies.

Licensing Requirements

  • Compliance with planning, design, management, personnel, equipment, and physical plant guidelines developed by DOH through BHFS.
  • Construction and alteration require approved architectural and engineering plans.
  • BHFS or Center for Health Development evaluates compliance with:
    • Service capability
    • Personnel qualifications
    • Equipment adequacy
    • Physical plant standards
    • Other evolving criteria.

Procedures for Permits and Licenses

  • Permit to Construct:
    • Required before construction, alteration, expansion, change of classification, or bed capacity increase.
    • Exception: Existing facilities providing maternity and newborn care.
    • Submission of multiple documents including applications, plans, and environmental compliance.
    • Review, possible revision, and approval process.
  • License to Operate:
    • Acquired after construction and completion.
    • Requires application, inspections, and submission of various documents.
    • Procedures involve inspection by licensing teams and approval or disapproval with options for reconsideration and appeal.

Organizational Bodies

  • Health Facility Establishment Review Committee:
    • Reviews applications for Permit to Construct.
    • Composed of multidisciplinary professionals.
  • Health Facility Licensing Teams:
    • Conduct licensing inspections.
    • Include professionals in medicine, engineering, nursing, pharmacy, and biology.
    • Third-party observation allowed through hospital associations.

License Renewal

  • Annual automatic renewal upon application and fee payment ninety days before expiration.
  • Required documents include application form and sworn compliance statement.
  • Procedures managed by Center for Health Development; quarterly reporting to BHFS.
  • Transition period provisions clarify roles between BHFS and Centers for Health Development for various hospital types.

Inspection and Monitoring

  • Regular and unannounced inspections and monitoring by BHFS or Centers for Health Development.
  • Facilities must provide records and allow access.
  • Reporting of illegal or unlicensed operations mandatory.

Technical Assistance

  • BHFS to build capacity of Centers for Health Development.
  • Provides advisory services to local government units and private entities.

Fees

  • Non-refundable fees charged for all permit and license applications and renewals.
  • Payment processed through designated DOH cashiers.
  • Fees conform to DOH schedules.

Terms and Conditions of Licensing

  • No License to Operate without prior appropriate Permit to Construct for applicable facilities.
  • Permit to Construct lapses if work not started within 365 days.
  • License validity and cancellation rules for non-renewal or changes in management/name/ownership.
  • License non-transferability without BHFS consent.
  • Separate licenses for separate premises but not for separate buildings on same premises.
  • Public display of License to Operate required.

Violations

  • Include unpermitted renovations, false statements, unauthorized changes, refusal of inspections or monitoring, and failure to correct deficiencies.
  • Personnel providing medical services deemed hospital staff for regulatory purposes.

Complaint, Investigation, and Hearings

  • Bureau of Health Facilities and Services investigates complaints.
  • Disciplinary actions for violations include suspension, revocation of license, and referral to Professional Regulatory Boards or disciplinary authorities.
  • Judicial actions remain available.

Suspension, Revocation, and Closure

  • BHFS Director empowered to suspend or revoke licenses for violations.
  • Facilities without valid licenses subject to immediate closure with possible government assistance.

Penalties

  • Operating without required permits or licenses constitutes misdemeanor.
  • Fines: P500 for first offense; P1,000 for subsequent offenses.
  • Each day of continued unauthorized operation is a separate offense.

Appeal Process

  • Decisions by BHFS may be appealed to the Secretary of Health within 30 days.
  • Administrative hearings conducted for license refusals, suspensions, or revocations.
  • Secretary of Health decisions are final and executory.

Publication of Licensed Facilities

  • Periodic publication and public availability of licensed hospitals and health facilities by classification.

Repealing Clause

  • Withdrawal of previous related guidelines and amendment or repeal of inconsistent rules.

Transition Period

  • Committee formation within one month for drafting licensing guidelines.
  • Public consultations and approval to be completed within four months.
  • Interim guidelines apply to new facility types not covered in prior orders.
  • Transitional management roles assigned between BHFS and Centers for Health Development.

Effectivity

  • Rules become effective upon approval and publication in a newspaper of general circulation.

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