Amendment on Hospital Accreditation Rules

Law Summary

Alternative Qualification Conditions for Initial Hospital Accreditation

For institutions that have not operated for three years, qualification for accreditation may be based on the following conditions:
1. Work Experience of Managing Health Care Professional:
  - For Ambulatory Surgical Clinics (ASC) and Free-Standing Dialysis Clinics (FSDC):
    - The managing health care professional (Medical Director, Administrator, or Chief of Facility) must have at least three years of relevant experience in a similar or analogous facility or at the same institutional level.
  - For Hospitals:
    - The Medical Director, Hospital Administrator, or Chief of Hospital must have at least three years of experience in a hospital of the same or higher level.
  - The previous institution where experience was gained must have been accredited for at least three years.
  - Proof of Experience:
    - Service Record (for government facilities)
    - Certification from the Board or facility owner (for private facilities)
  - Continuity of Service:
    - If the managing health care professional leaves within one year of initial accreditation, immediate replacement with a similarly qualified professional is mandatory.
    - Failure to do so results in termination of the accreditation effective on the vacancy date.
2. Operation as a Tertiary Facility:
  - Facilities operating as tertiary level hospitals qualify despite the three-year operational rule.
3. Lack of Accredited Similar Facilities in the Locality:
  - For ASCs and FSDCs: No accredited similar facility exists in the same locality.
  - For Hospitals: No accredited hospital of the same level/category exists locally.
  - Certification is required by the concerned PhilHealth Regional Office (PhRO) and validation by the Central Office Accreditation Department.
4. Inadequate Service Provision by Existing Accredited Facilities:
  - Where existing accredited facilities of similar or same level cannot adequately provide health care services.
  - Certification by the Local Chief Executive (LCE) is required.
  - Evidence includes a Certificate of Need (CON) issued by the Department of Health (DOH) and recommendation by the respective PhilHealth Regional Office.

Repeal and Effectivity

All previous policies, guidelines, and administrative issuances inconsistent with this circular are repealed or amended accordingly.
The circular takes effect fifteen (15) days after publication in the Official Gazette or a newspaper of general circulation.