Title
Supreme Court
Streamlining Hospital Licensure and Accreditation
Law
Doh Administrative Order No 2011-0020
Decision Date
Dec 23, 2011
Streamlining of Licensure and Accreditation of Hospitals" simplifies the process for hospitals to obtain licenses and accreditation, promoting collaboration between the Department of Health and the Philippine Health Insurance Corporation to improve access to quality healthcare facilities in the Philippines.

Law Summary

Objective

  • To improve access to quality health facilities while efficiently using limited government resources.
  • To streamline licensure and accreditation by harmonizing DOH minimum licensing safety standards with PhilHealth core indicators.
  • To recognize DOH licensed hospitals as Centers of Safety automatically, eliminating separate PhilHealth surveys.

Scope and Coverage

  • Applies to DOH regulatory offices including BHFS, FDA, CHD, and PhilHealth.
  • Covers all government and private hospitals subject to regulatory policies and standards.

Definition of Terms

  • Applicant: person or entity applying for a hospital License to Operate (LTO).
  • Accreditation: verification process conferring privileges ensuring health service quality.
  • Assessment Tool: checklist for hospital licensure standards used by regulators and hospitals for self-assessment.
  • BHFS: Bureau of Health Facilities and Services – DOH’s licensing body.
  • CHD: Center for Health Development, DOH regional office.
  • CO: Central Office of DOH.
  • DOH Permit to Construct (DOH-PTC): prerequisite approval before hospital construction or expansion, required for LTO.
  • LTO: License to Operate, formal authorization by DOH to operate a hospital after compliance.
  • PhilHealth: Philippine Health Insurance Corporation managing hospital accreditation.
  • Streamlining: strategy to simplify licensing and accreditation through harmonized standards and coordinated processes.

General Guidelines on Streamlining Licensure and Accreditation

  • DOH through BHFS, FDA, and CHD will implement the modified streamlined licensing.
  • Regulatory officers to use the enhanced Assessment Tool available on the DOH website.
  • All DOH licensed hospitals automatically accredited as Centers of Safety by PhilHealth without separate surveys.
  • Licensing processes shall continue following previous relevant DOH administrative orders alongside this new order.

Specific Guidelines: Standards

  • DOH BHFS to incorporate PhilHealth core accreditation indicators into the hospital licensure Assessment Tool.
  • Full compliance with Assessment Tool standards required before granting an LTO.

Specific Guidelines: Application for LTO

  • Applications submitted to DOH Central Office or CHD One-Stop Shop secretariat.
  • Required documents:
    • Approved Certificate of Need for new general hospitals.
    • Approved DOH-PTC for initial or relevant renewal applications.
    • The LTO application form.
    • Proof of ownership (DTI/SEC registration, Articles of Incorporation/By-laws).
    • Most recent hospital statistical report for renewal.
    • Duly accomplished Self-Assessment Tool.

Specific Guidelines: Licensing Process for New LTO

  • Licensing team validates hospital’s submitted Self-Assessment Tool during an initial inspection.
  • DOH CO issues the LTO after full compliance review.

Specific Guidelines: Licensing Process for Renewal of LTO

  • Document completeness evaluated within five working days.
  • Renewal processed only after on-site inspection/monitoring and receipt of required documents.

Monitoring

  • Monitoring teams use the hospital’s Self-Assessment Tool.
  • Unannounced monitoring visits conducted by BHFS, FDA, CHD with frequency determined internally.

Reporting Requirements

  • Regular reports prepared including:
    1. Hospital listings by region.
    2. Quarterly LTO status updates.
    3. Annual consolidated hospital statistical reports.
    4. Semi-annual reports on deficiencies and violations.
    5. Quarterly reports on complaints against hospitals.
    6. Quarterly reports on sanctions and penalties.

Fees

  • Fees governed by current and future DOH BHFS issuances, factoring in inspection and monitoring labor.

PhilHealth Accreditation

  • DOH licensed hospitals deemed automatically accredited as Centers of Safety.
  • No separate PhilHealth survey required for this level.
  • Hospitals applying for higher awards (Center of Quality/Excellence) undergo separate PhilHealth surveys.
  • Failure to meet required scores results in downgrade to Center of Safety or appropriate award.
  • Accredited hospitals subject to PhilHealth monitoring policies per relevant circulars.

Violations and Penalties

  • Non-compliance constitutes violation subject to sanctions under A.O. No. 2007-0022 dealing with licensing violations.

Publication of Licensed Hospitals

  • Annual publication of licensed hospital lists to encourage quality improvements and inform the public.
  • Lists posted on DOH and BHFS websites immediately after LTO issuance.

Repealing Clause

  • Prior inconsistent provisions from earlier issuances are rescinded or modified accordingly.

Separability Clause

  • Invalidated provisions do not affect the validity of remaining parts of the Order.

Effectivity

  • The Order takes effect 15 days post-approval and publication in a newspaper of general circulation.

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