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(NAR) VOL. 13 NOS. 1-2 / JANUARY-MARCH 2002
[ BHFS ADMINISTRATIVE ORDER NO. 70-A S. 2002, JANUARY 3, 2002, January 03, 2002 ]
REVISED RULES AND REGULATIONS GOVERNING THE REGISTRATION, LICENSURE AND OPERATION OF HOSPITALS AND OTHER HEALTH FACILITIES IN THE PHILIPPINES
SECTION 1. Title. — These rules shall be known as the “Revised Rules and Regulations Governing the Registration, Licensure and Operation of Hospitals and Other Health Facilities in the Philippines.”
SECTION 2. Authority. — These rules are issued to implement the provisions of R.A. 4226: Hospital Licensure Act consistent with E.O. 102: Redirecting the Functions and Operations of the Department of Health.
SECTION 3. Purpose. — These rules are promulgated to protect and promote the health of the people by ensuring the rights to quality health service appropriate to the level of care through the regulation of hospitals and other health facilities.
SECTION 4. Scope. — The rules and regulations embodied herein shall apply to all government and private hospitals and other health facilities.
SECTION 5. Regulatory Agency. — The Department of Health through the Bureau of Health Facilities and Services in the Office for Health Regulation shall exercise the regulatory functions.
SECTION 6. Definition. — A hospital is a health facility for the diagnosis, treatment and care of individuals suffering from deformity, disease, illness or injury, or in need of surgical, obstetrical, medical or nursing care. It is an institution where there are installed bassinets or beds for 24-hour use or longer by patients in the management of deformities, diseases, injuries, abnormal physical and mental conditions, maternity cases.
SECTION 7. Classification of Hospitals and other Health Facilities. — Hospitals and other health facilities shall be classified as follows:
7.1 Government or Private
7.1.1 Government. — operated and maintained partially or wholly by the national, provincial, city or municipal government, or other political unit; or by any department, division board of agency thereof.
7.1.2 Private. — privately owned, established and operated with funds through donation, principal, investment, or other means, by any individual, corporation, association, or organization.
7.2 General or Special
7.2.1 General. — provides services for all types of deformity, disease, illness or injury.
7.2.2 Special — primarily engaged in the provision of specific clinical care and management. A first level referral hospital, second level referral hospital, third level referral hospital, or infirmary, may provide special clinical service(s).
7.3 Service Capability
7.3.1 First Level Referral Hospital. —
7.3.1.1 Non-departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality
7.3.1.2 Clinical services include general medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia
7.3.1.3 Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.1.4 Provides nursing care for patients who require intermediate, moderate and partial category of supervised care for 24 hours or longer
7.3.2 Second Level Referral Hospital —
7.3.2.1 Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care
7.3.2.2 Clinical services provided in the First Level Referral Hospital, as well as specialty clinical care
7.3.2.3 Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.2.4 Nursing care provided in the First Level Referral Hospital, as well as total and intensive skilled care
7.3.3 Third Level Referral Hospital -
7.3.3.1 Teaching and training hospital that provides clinical care and management on the prevalent diseases in the locality, as well as specialized and sub-specialized forms of treatment, surgical procedure and intensive care
7.3.3.2 Clinical services provided in the Second Level Referral Hospital, as well as sub-specialty clinical care
7.3.3.3. Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.3.4 Nursing care provided in the Second Level Referral Hospital, as well as continuous and highly specialized critical care
7.3.4 Infirmary. — a health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and arrangement to mothers and newborn babies.
7.3.5 Birthing Home. — a health facility that provides maternity service or prenatal and post natal care, normal spontaneous delivery, and care of newborn babies.
7.3.6 A cute-chronic Psychiatric Care Facility. — a health facility that provides medical service, nursing care, pharmacological treatment and psychosocial intervention for mentally ill patients.
7.3.7 Custodial Psychiatric Care Facility. — a health facility that provides long-term care, including basic human services such as food and shelter, to chronic mentally ill patients.
SECTION 8. License. — A formal authorization issued by the Department of Health to an individual, partnership, corporation or association to operate a hospital and other health facilities. It is a prerequisite for accreditation of a hospital and other health facilities by any accrediting body that is recognized by the Department of Health.
SECTION 9. Licensing Requirements. — All hospitals and other health facilities are required to comply with the requirements for licensing.
9.1 The planning and design of a hospital and other health facilities shall comply with the prescribed guidelines (see Annex 1)
9.2 The management of the service capability, personnel, equipment and physical plant of a hospital and other health facilities shall conform to the prescribed guidelines (see Annex ).
9.3 The construction of a new hospital or other health facilities, and alteration, expansion or renovation of an existing hospital or other health facility shall be implemented in accordance with:
9.3.1 Floor plans prepared by a duly licensed Architect and/or Civil Engineer and approved by the Bureau of Health Facilities and Services; and
9.3.2 Architectural and engineering drawings (based on approved floor plans by the Bureau of Health Facilities and Services), specifications, building permit and fire safety permit prepared by a duly licensed Architect and/or Civil Engineer and approved by the Office of the Building Official and the Bureau of Fire Protection in the locality.
9.4 The Bureau of Health Facilities and Services shall evaluate compliance with the licensing requirements for all hospitals and other health facilities (see Annexes 3-9[1]).
9.4.1 Service Capability. — administrative, clinical, ancillary and other services rendered.
9.4.2. Personnel. — staffing of qualified and trained health and health-related professionals.
9.4.3 Equipment/Instrument. — tools to perform the required services.
9.4.4. Physical Plant. — well ventilated, lighted, clean, safe and functional structure sufficient to accommodate its activities.
SECTION 10. Requirements and Procedures for Application of Permit and License. —
10.1 Permit to Construct. — required for construction of a new hospital or other health facility; alteration, expansion or renovation of an existing hospital or other health facility; change in classification; or increase in bed capacity. It is a prerequisite for a license to operate.
10.1.1. The following are the required documents to be accomplished before a permit to construct can be issued:
10.1.1.1 Letter of Application to the Director of the Center for Health Development
10.1.1.2 Letter of Endorsement to the Director of the Bureau of Health Facilities and Services.
10.1.1.3 Form No. 1-01: Application for Permit to Construct notarized
10.1.1.4 Four (4) Sets of Site Development Plans and Floor Plans signed and sealed by an Architect and/or Engineer
For construction of a new hospital or other health facility; or change in classification, include:
10.1.1.5. Feasibility Study
10.1.1.6. Zoning Certificate or Location Clearance from the City/Municipal Planning and Development Office
10.1.1.7 DTI/SEC Registration (for private hospital or other health facility)
10.1.1.8 Enabling Act (for national government hospital or other health facility)
10.1.1.9 Approved Board Resolution (for local government hospital or other health facility
10.1.2. The following are the procedures for application for permit to construct:
10.1.2.1. Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or internet.
10.1.2.2 Applicant accomplishes required documents and submits them to the Center for Health Development for endorsement to the Bureau of Health Facilities and Services.
10.1.2.3 The Bureau of Health Facilities and Services reviews the documents and approves or disapproves the issuance of permit to construct.
10.1.2.4 If disapproved, the Bureau of Health Facilities and Services returns the documents, together with their findings and recommendations, to the applicant. The applicant makes necessary revisions on the documents. The applicant submits the revised documents to the Bureau of Health Facilities and Services for another review.
10.1.2.5 If approved, the Bureau of Health Facilities and Services issues a permit to construct to the applicant. The applicant pays the corresponding fee for permit to construct to the Cashier of the Department of Health in person, or through postal money order.
10.2 License to Operate. — required for operation of a hospital or other health facility. It is secured after construction and completion of a hospital or other health facility.
10.2.1 The following are the required documents to be accomplished before an initial license to operate can be issued:
10.2.1.1 Letter of Application and Request for Inspection to the Director of the Center for Health Development
10.2.1.2 Letter of Endorsement to the Director of the Bureau of Health Facilities and Services
10.2.1.3 Form No. 2-01: Application for Registration and Issuance of License to Operate notarized
10.2.1.4 List of Personnel notarized
10.2.1.5 List of Equipment/Instrument
10.2.1.6 Photo Album of the Exterior and Interior of the Hospital or Other Health Facility
10.2.2 The following are the procedures for application for initial license to operate:
10.2.2.1 Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or Internet.
10.2.2.2 Applicant accomplishes required documents and submits them to the Center for Health Development for endorsement to the Bureau of Health Facilities and Services. Upon filing of application, the applicant pays the corresponding fees for registration and license to the Cashier of the Department of Health in person, or through postal money order.
10.2.2.3 The Bureau of Health Facilities and Services conducts ocular inspection in accordance with licensing requirements.
10.2.2.4 The Bureau of Health Facilities and Services approves or disapproves the issuance of license to operate.
10.2.2.5 If disapproved, the Bureau of Health Facilities and Services sends the findings and recommendations to the applicant. The applicant requests the Bureau of Health Facilities and Services for another inspection.
10.2.2.6 If approved, the Bureau of Health Facilities and Services registers the hospital or other health facility and issues an initial license to operate to the applicant.
10.3 The Bureau of Health Facilities and Services shall create a Hospital Establishment Review Committee for the effective, judicious, prompt and swift action on the application for permit to construct a hospital and other health facilities.
10.3.1 The committee shall review all applications with respect to compliance with the licensing requirements and the prescribed guidelines in the planning and design of a hospital and other health facilities.
10.3.2 The committee shall meet once a week or when necessary. It shall be composed of, but not limited to, the following staff from the Bureau of Health Facilities and Services:
10.3.2.1 Chairman. — Assistant Director (Bureau of Health Facilities and Services)
10.3.2.2. Vice-Chairman - Head (Standards Development Division)
10.3.2.3. Members. - Architect, Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacists, Physician
10.4 The Bureau of Health Facilities and Services shall create a Hospital Licensing Team(s) for the effective, judicious, prompt and swift action on the application for initial license to operate a hospital and other health facilities.
10.4.1 The team shall inspect all hospitals and other health facilities with respect to compliance with the licensing requirements, the prescribed guidelines in the planning and design of a hospital and other health facilities and in the management of service capability, personnel, equipment and physical plant.
10.4.2 It shall be composed of, but not limited to, the following staff from the Bureau of Health Facilities and Services:
10.4.2.1 Team Leader. — Physician
10.4.2.2 Members. — Architect or Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacists
SECTION 11. Renewal of License. —
11.1 License to operate a hospital and other health facilities shall be renewed every year. However, inspection of a hospital and other health facilities may be done every other year.
11.2 Application for renewal of license to operate shall be filed ninety (90) days before the expiry date to the Center for Health Development under whose jurisdiction the hospital or other health facility is located.
11.3 The following are the required documents to be accomplished before a renewal of license to operate can be issued:
11.3.1 Letter of Application and Request for Inspection to the Director of the Center for Health Development
11.3.2 Form No. 3-01: Application for Renewal of License to Operate notarized
11.3.3 List of Personnel notarized
11.3.4 List of Equipment/Instrument
11.4 The following are the procedures for application for renewal of license to operate:
11.4.1 Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or internet.
11.4.2 Applicant accomplishes required documents and submits them to the Center for Health Development. Upon filing of application, the applicant pays the corresponding fees for renewal of license to operate to the Cashier of the Center for Health Development in person, or through Postal money order.
11.4.3 The Center for Health Development conducts ocular inspection in accordance with licensing requirements.
11.4.4. The Center for Health Development approves or disapproves the issuance of license to operate.
11.4.5 If disapproved, the Center for Health Development sends the findings and recommendations to the applicant. The applicant requests the Center for Health Development for another inspection.
11.4.6 If approved, the Center for Health Development issues a license to operate to the applicant.
11.5 The Center for Health Development shall create a Hospital Licensing Team (s) for the effective, judicious, prompt and swift action on the application for renewal of license to operate a hospital and other health facilities.
11.5.1 The team shall inspect all hospitals and other health facilities with respect to compliance with the licensing requirements, the prescribed guidelines in the planning and design of a hospital and other health facilities and in the management of service capability, personnel, equipment and physical plant.
11.5.2 It shall be composed of, but not limited to, the following staff from the Center for Health Development:
11.5.1 Team Leader. — Physician
11.5.2 Members. — Architect or Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacist
11.6 The Center for Health Development shall submit a quarterly report of all applications for renewal of license to operate to the Bureau of Health Facilities and Services. The report shall include the name of hospital or other health facility, location, type of application, scope of work, findings and recommendations.
SECTION 12. Inspection. —
12.1 All hospitals and other health facilities shall be inspected regularly and records shall be made available to determine compliance with these rules and regulations.
12.2 The Bureau of Health Facilities and Services or the Center for Health Development shall be allowed to inspect the hospital and other health facilities at an appropriate time.
12.3 All hospitals and other health facilities shall make available to the Bureau of Health Facilities and Services or the Center for Health Development records for inspection.
12.4 The Director of the Center for Health Development, and the Chief of the Provincial, City or Municipal Health Office are required to report the existence of all unlicensed hospitals and other health facilities and all violations of these rules and regulations to the Bureau of Health Facilities and Services.
SECTION 13. Monitoring. —
13.1 All hospitals and other health facilities shall be monitored regularly and records shall be made available to determine compliance with these rules and regulations.
13.2 The Bureau of Health Facilities and Services shall be allowed to monitor the hospital and other health facilities at any given time.
13.3 All hospitals and other health facilities shall make available to the Bureau of Health Facilities and Services records for monitoring.
SECTION 14. Technical Assistance. —
14.1 The Bureau of Health Facilities and Services shall develop the capability of the Center for Health Development on enforcement of these rules and regulations.
14.2 The Bureau of Health Facilities and Services shall provide technical assistance and advisory services to the Center for Health Development, Local Government Unit, and Private Institution regarding compliance with the licensing requirements for all hospitals and other health facilities.
SECTION 15. Fees. —
15.1 A non-refundable fee shall be charged for application for permit to construct, for registration, and for license to operate a government and private hospital and other health facilities.
15.2 A non-refundable fee shall be charged for application for renewal of license to operate.
15.3 All fees shall be paid to the Cashier of the Center for Health Development.
15.4 All fees shall follow the current prescribed schedule of fees of the Department of Health.
SECTION 16. Terms and Conditions. —
16.1 No license to operate shall be issued to a hospital and other health facilities without permit to construct secured prior to the construction, alteration, expansion, renovation, or increase in bed capacity, and license for the operation of clinical laboratory, radiology and pharmacy.
16.2 A permit to construct shall be considered lapsed and fee paid shall be forfeited when the work authorized by the permit does not commence within 365 days from date of issuance, or is abandoned during the period specified.
16.3 A license to operate shall be granted in accordance with prescribed licensing requirements and on the basis of specific conditions and limitations established during inspection.
16.4 A license that is not renewed for a period of two (2) years shall be considered lapsed and registration shall be cancelled. A new application for registration and issuance of license to operate shall be required before a hospital and other health facilities can be allowed to operate.
16.5 The license as herein granted as well as any right under the license cannot be assigned or otherwise transferred directly or indirectly to any party without the written consent of the Director of the Bureau of Health Facilities and Services.
16.6 The Bureau of Health Facilities and Services shall be notified of any change in management, name or ownership. In cases of transfer of location, a new application for permit to construct, registration and issuance of license to operate shall be required.
16.7 Failure to report in writing within fifteen (15) days of any substantial change in the condition of the license may be a basis for the suspension or revocation of the license.
16.8 A separate license shall be required for all hospitals and other health facilities or branches maintained in separate buildings in the same premises.
16.9 The license shall be placed in an area readily seen by the public. A copy of the rules and regulations shall be readily available for guidance of all personnel of the hospital and other health facilities.
16.10 The license shall expire on the date of anniversary of issuance.
SECTION 17. Violations. — Violations of the Hospital Licensure Act or the rules and regulations issued in pursuance thereto include the commission of the following acts by any individual, corporation, association, or organization operating a hospital, or persons under their authority.
17.1 Making substantial alteration or renovation of a hospital and other health facilities without securing a permit to construct.
17.2 Any material false statement in the application.
17.3 Change of location, management, name or ownership without informing the Bureau of Health Facilities and Services in writing.
17.4 Refusal to allow inspection of a hospital and other health facilities by the Bureau of Health Facilities and Services or the Center for Health Development at an appropriate time
17.5 Refusal to allow monitoring of a hospital and other health facilities by the Bureau of Health Facilities and Services at any given time.
17.6 Refusal to discharge patients or their relatives, to release cadavers and to issue a duly accomplished death certificate for non-payment of hospital bills.
17.7 Refusal to admit patients for lack of capacity to pay
17.8 Failure to make necessary corrections of deficiencies required by the Bureau of Health Facilities and Services or the Center for Health Development after due notice.
SECTION 18. Investigation and Hearing of Charges or Complaints. — Upon filing of charges or complaints by any individual, corporation, association, or organization against any hospital or other health facility, or any of its personnel who has violated or is violating the provisions of R.A. 4226 or of these rules and regulations, the Bureau of Health Facilities and Services shall investigate and verify if the hospital or other health facility concerned, or any of its personnel is guilty of the charges or complaints. If upon investigation and hearing, the hospital or other health facility concerned, or any of its personnel is found violating the provisions of R.A. 4226 or of these rules and regulations, the Director of the Bureau of Health Facilities and Services shall suspend the license for a definite or indefinite period of time, or revoke the license without prejudice to taking the case to judicial authorities for criminal action.
SECTION 19. Revocation of License. — A license to operate shall be suspended or revoked by the Director of the Bureau of Health Facilities and Services upon violation of the Hospital Licensure Act or the rules and regulations issued in pursuance thereto. The Bureau of Health Facilities and Services shall notify the hospital or other health facility concerned, or any of its personnel by registered mail the particular reasons for the denial or revocation of license.
SECTION 20. Closure. — The Bureau of Health Facilities and Services shall immediately close all hospitals and other health facilities without a license to operate, and may seek assistance of any government agency to effectively enforce the closure.
SECTION 21. Penalty. — Any individual, corporation, association, or organization who establishes a hospital or other health facility without securing the necessary permit to construct and manages a hospital and other health facilities without securing the necessary license to operate from the Bureau of Health Facilities and Services, or violates any supervision of these rules and regulations shall, upon conviction, be liable of not more than five hundred pesos (P500.00) for the first offense and not more than one thousand pesos (P1,000.00) for each subsequent offense. Each day that a hospital or other health facility operates after the first conviction shall be considered a subsequent offense.
SECTION 22. Appeal. — Any hospital or other health facility, or any of its personnel aggrieved by the decision of the Bureau of Health Facilities and Services may, within thirty (30) days after receipt of notice of the decision, file a notice of appeal in the Office of the Secretary, and serve a copy of the notice of appeal to the Bureau of Health Facilities and Services. Thereupon the Bureau of Health Facilities and Services shall promptly certify and file a copy of the decision, including the transcript of the hearings on which the decision is based, with the Office of the Secretary for review. The decision of the Office of the Secretary shall be final and executory.
SECTION 23. Publication of List of Licensed Hospitals and Other Health Facilities. — A list of licensed hospitals and other health facilities according to their classification shall be published periodically and made available to any individual, corporation, association, or organization for legitimate purpose.
SECTION 24. Repealing Clause. — These rules and regulations shall repeal and supersede all administrative orders and other issuances inconsistent thereof.
SECTION 25. Effectivity. — These rules and regulations shall take effect upon approval and publication in a newspaper of general circulation.
SECTION 26. Moratorium. — The Center for Health Development shall prepare all the necessary resources to effectively execute the renewal of license to operate a hospital and other health facilities within two (2) years from the effectivity of these rules and regulations. During this period, the Bureau of Health Facilities and Services shall assist the Center for Health Development in the renewal of license to operate Second and Third Level Referral Hospitals.
Adopted: 03 Jan. 2002
A hospital and other health facilities shall be planned and designed to observe appropriate architectural practices, to meet prescribed functional programs, and to conform to applicable codes as part of normal professional practice. References shall be made to the following:
- P.D. 1096 — National Building Code of the Philippines and its Implementing Rules and Regulations
- P.D. 1185 — Fire Code of the Philippines and Its Implementing Rules and Regulations
- P.D. 856 — Code on Sanitation of the Philippines and Its Implementing Rules and Regulations
- B.P. 344 — Accessibility Law and Its Implementing Rules and Regulations
- R.A. 1378 — National Plumbing Code of the Philippines and Its Implementing Rules and Regulations
- R.A. 184 — Philippine Electrical Code’
- Manual on Technical Guidelines for Hospitals and Health Facilities Planning and Design. Department of Health, Manila. 1994
- Signage Systems Manual for Hospitals and Offices. Department of Health, Manila. 1994
- Health Facilities Maintenance Manual. Department of Health, Manila 1995
- Manual on Hospital Waste Management. Department of Health, Manila. 1997
- District Hospitals: Guidelines for Development. World Health Organization Regional Publications, Western Pacific Series. 1992
- Guidelines for Construction and Equipment of Hospital and Medical Facilities. American Institute of Architects, Committee on Architecture of Health. 1992
- De Chiara, Joseph. Time-Saver Standards for Building Types. McGraw-Hill Book Company. 1980
1. Environment. — A hospital and other health facilities shall be located that it is readily accessible to the community and reasonably free from undue noise, smoke, dust, foul odor, flood, and shall not be located adjacent to railroads, freight yards, children’s playgrounds, airports, industrial plants, disposal plants.
2. Occupancy. — A building designed for other purpose shall not be converted into a hospital. The location of a hospital shall comply with all local zoning ordinances.
3. Safety. — A hospital and other health facilities shall provide and maintain a safe environment for patients, personnel and public. The building shall be of such construction so that no hazards to the life and safety of patients, personnel and public exist. It shall be capable of withstanding weight and elements to which they may be subjected.
3.1 Exits shall be restricted to the following types: door leading directly outside the building, interior stair, ramp, and exterior stair.
3.2 A minimum of two (2) exits, remote from each other, shall be provided for each floor of the building.
3.3 Exits shall terminate directly at an open space to the outside of the building.
4. Security. — A hospital and other health facilities shall ensure the security of person and property within the facility.
5. Patient Movement. — Spaces shall be wide enough for free movement of patients, whether they are on beds, stretchers, or wheelchairs. Circulation routes for transferring patients from one area to another shall be available and free at all times.
5.1 Corridors for access by patient and equipment shall have a minimum width of 2.44 meters.
5.2 Corridors in areas not commonly used for bed, stretcher and equipment transport may be reduced in width to 1.83 meters.
5.3 A ramp or elevator shall be provided for ancillary, clinical and nursing areas located on the upper floor.
5.4 A ramp shall be provided as access to the entrance of the hospital not on the same level of the site.
6. Lighting. — All areas in a hospital and other health facilities shall be provided with sufficient illumination to promote comfort, healing and recovery of patients and to enable personnel in the performance of work.
7. Ventilation. — Adequate ventilation shall be provided to ensure comfort of patients, personnel and public.
8. Auditory and Visual Privacy. — A hospital and other health facilities shall observe acceptable sound level and adequate visual seclusion to achieve the acoustical and privacy requirements in designated areas following the unhampered conduct of activities.
9. Water Supply. — A hospital and other health facilities shall use an approved public water supply system whenever available. The water supply shall be potable, safe for drinking and adequate, and shall be brought into the building free of cross connections.
10. Waste Disposal. — Liquid waste shall be discharged into an approved public sewerage system whenever available, and solid waste shall be collected, treated and disposed of in accordance with applicable codes, laws or ordinances.
11. Sanitation. — Utilities for the maintenance of sanitary system, including approved water supply and sewerage system, shall be provided through the buildings and premises to ensure a clean and healthy environment.
12. Housekeeping. — A hospital and other health facilities shall provide and maintain a healthy and aesthetic environment for patients, personnel and public.
13. Maintenance. — There shall be an effective building maintenance program in place. The buildings and equipment shall be kept in a state of good repair. Proper maintenance shall be provided to prevent untimely breakdown of buildings and equipment.
14. Material Specification. — Floors, walls and ceilings shall be of sturdy materials that shall allow durability, ease of cleaning and fire resistance.
15. Segregation. — Wards shall observe segregation of sexes. Separate toilet shall be maintained for patients and personnel male and female, with a ratio of one (1) toilet for every eight (8) patients or personnel.
16. Fire Protection. — There shall be measures for detecting fire such as fire alarms in walls, peepholes in doors or smoke detectors in ceilings. There shall be devices for quenching fire such as fire extinguishers or fire hoses that are easily visible and accessible in strategic areas.
17. Signage. — There shall be an effective graphic system composed of a number of individual visual aids and devices arranged to provide information, orientation, direction, identification, prohibition, warning and official notice considered essential to the optimum operation of a hospital and other health facilities.
18. Parking. — A hospital and other health facilities shall provide a minimum of one (1) parking space for every twenty-five (25) beds.
19. Zoning. — The different areas of a hospital shall be grouped according to zones as follows:
19.1 Outer zone. — areas that are immediately accessible to the public: emergency service, outpatient service, and administrative service. They shall be located near the entrance of the hospital.
19.2 Second Zone. — areas that receive workload from the outer zone: laboratory, pharmacy, and radiology. They shall be located near the outer zone.
19.3 Inner Zone. — areas that provide nursing care and management of patients: nursing service. They shall be located in private areas but accessible to guests.
19.4 Deep Zone. — areas that require asepsis to perform the prescribed services: surgical service, delivery service, nursery, and intensive care. They shall be segregated from the public areas but accessible to the outer, second and inner zones.
19.5 Service Zone. — areas that provide support to hospital activities: dietary service, housekeeping service, maintenance and motorpool service, and mortuary. They shall be located in areas away from normal traffic.
20. Function. — The different areas of a hospital shall be functionally related with each other.
20.1 The emergency service shall be located in the ground floor to ensure immediate access. A separate entrance to the emergency room shall be provided.
20.2 The administrative service, particularly admitting office and business office, shall be located near the main entrance of the hospital. Offices for hospital management can be located in private areas.
20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement.
20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement. The nursery shall be separate but immediately accessible from the delivery room.
20.5 The nursing service shall be segregated from public areas. The nurse station shall be located to permit visual observation of patients. Nurse stations shall be provided in all inpatient units of the hospital with a ratio of at least one (1) nurse station for every thirty-five (35) beds. Rooms and wards shall be of sufficient size to allow for work flow and patient movement. Toilets shall be immediately accessible from rooms and wards.
21. Space: Adequate area shall be provided for the people, activity, furniture, equipment and utility.
Space
Area in Square Meters
Administrative Service
Lobby
Waiting Area
0.65/person
Information and Receiving Area
5.02/staff
Toilet
1.67
Business Office
5.02/staff
Medical Records
Work Area
5.02/staff
Storage Area
4.65
Office of Hospital Administrator
5.02/staff
Office of the Chief of Hospital
5.02/staff
Conference Room
1.40/person
Staff Toilet
1.67
Housekeeping Area
5.02/staff
Laundry and Linen Area
5.02/staff
Maintenance Area
5.02/staff
Garage Area
9.29
Supply Room
5.02/staff
Waste Holding Room
4.65
Pharmacy
15.00
Dietary
Dietitian Area
5.02/staff
Supply Receiving Area
4.65
Cold and Dry Storage Area
4.65
Food Preparation Area
4.65
Cooking and Baking Area
4.65
Serving and Food Assembly Area
4.65
Washing Area
4.65
Garbage Disposal Area
1.67
Dining Room
1.40/person
Staff Locker Room and Toilet
2.32
Social Service Area
5.02/staff
Cadaver Holding Room
7.43/bed
Clinical Service
Emergency Room
Waiting Area
0.65/person
Toilet
1.67
Nurse Station
5.02/staff
Examination and Treatment Area with Lavatory/Sink
7.43/bed
Observation Area
7.43/bed
Equipment and Supply Storage Area
4.65
Wheeled Stretcher Area
1.08/stretcher
Outpatient Department
Waiting Area
0.65/person
Toilet
1.67
Admitting and Records Area
5.02/staff
Consultation Area
5.02/staff
Examination and Treatment Area with Lavatory/Sink
7.43/bed
Dental Clinic
8.36/dental chair
Surgical and Obstetrical Service
Major Operating Room
33.45
Recovery Room
9.29
Delivery Room
33.45
Labor Room with Toilet
9.29
Sub-sterilizing Room
4.65
Sterile Instrument, Supply and Storage Area
4.65
Anesthesia Storage Area
4.65
Scrub-up Area
4.65
Clean-up Area
4.65
Male Dressing Room and Toilet
2.32
Female Dressing Room and Toilet
2.32
Nurse Station
5.02/staff
Wheeled Stretcher Area
1.08/stretcher
Janitor’s Closet
3.90
Nursery
Pathologic Room
3.72/bassinet
Premature Room
3.72/bassinet
Work Area with Sink
4.65
Viewing Area
3.90
Breastfeeding Area
3.72/bassinet
Nursing Unit
Private Room with Toilet
9.29
Semi-Private Room and Toilet
7.43/bed
Female Ward with Toilet
7.43/bed
Male Ward with Toilet
7.43/bed
Isolation Room with Toilet
9.29
Nurse Station with Work Area and Lavatory/Sink
7.43/bed
Central Sterilizing and Supply Room
Receiving and Releasing Area
5.02/staff
Work Area
5.02/staff
Sterilizing Room
4.65
Sterile Supply Storage Area
4.65
Nursing Service
Office of the Chief Nurse
5.02/staff
Staff Locker Room and Toilet
2.32
Ancillary Service
Laboratory
Toilet
1.67
Clinical Work Area with Sink
10.00
Pathologist Area
5.02/staff
Radiology
Waiting Area
0.65/person
Dressing Area
1.67
Toilet
1.67
X-ray Room with Control Booth
14.00
Dark Room
4.65
Film File and Storage Area
4.65
Radiologist Area
5.02/staff
Pharmacy 15.00
Notes:
1. 0.65/person. — Unit area per person occupying the space at one time.
2. 5.02/staff . — Work area per staff that includes space for one (1) desk and one (1) chair, space for occasional visitor, and space for aisle.
3. 1.40/person. — Unit area per person occupying the space at one time.
4. 7.43/bed. — Clear floor area per bed that includes space for one (1) bed, space for occasional visitor, and space for passage of equipment.
5. 1.08/stretcher. — Clear floor area per stretcher that includes space for one (1) stretcher.
6. 8.36/dental chair. — Clear floor area per dental chair that includes space for one (1) dental chair, space for movement of person, and space for passage of equipment.
7. 3.72/bassinet. — Clear floor area per bassinet that includes space for one (1) bassinet, space for movement of person, and space for passage of equipment.
1. A hospital and other health facilities shall render quality health services appropriate to the level of care.
1.1 The Administrative Service shall perform the functions of personnel, accounting, medical records, supply, housekeeping, maintenance, motorpool, dietary, and social service.
1.2 The Clinical Service shall provide services in medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia, and dentistry.
1.3 The Nursing Service shall provide care and management for
1.3.1 Intermediate, moderate and partial category of health care to 60% of patients who require assistance on special treatment and specific personal care
1.3.2 Total and intensive category of health care to 70% of patients who require assistance on special treatment and specific personal care.
1.3.3 Continuous and highly specialized category of health care to 80% of patients who are acutely or critically ill, in constant danger of death, in serious injury, and require class monitoring
1.3.4 Nursing intervention on physiological, psychological, social, emotional and spiritual needs of patients
1.3.5 Health Education
1.4 The Ancillary Service shall perform the functions of clinical laboratory, radiology and pharmacy.
2. A hospital and other health facilities shall have an organized staffing of qualified and trained health and health-related professionals and non-professionals.
2.1 A hospital shall have a governing body responsible for the governance of the hospital in making available quality patient care.
2.1.1 The governing body shall adopt by-laws in accordance with legal requirements and with its community responsibility, identifying the purposes of the hospital and the means of fulfilling them.
2.1.2 There shall be a chief of hospital designated to execute its policies.
2.2 There shall be an organized administration responsible for the execution of directions of the governing body and the discharge of support services in the areas of finance, personnel, property and supply, housekeeping, laundry, security, transport and maintenance.
2.2.1 The Administrative Service shall be under the supervision of a qualified administrative officer.
2.2.2 The administrative staff shall provide a continuing program of professional education or give evidence of participation in such a program.
2.3 There shall be an organized medical staff responsible for the quality of patient care, and for the ethical conduct and professional practices of its members.
2.3.1 Each member of the medical staff shall be qualified for affiliation and for exercise of the clinical privileges granted to him.
2.3.2 The medical staff shall provide a continuing program of professional education or give evidence of participation.
2.4 There shall be an organized nursing staff responsible for the quality of nursing care for the needs of the patients, and for the professional performance of its members.
2.4.1 The Nursing Service shall be under the supervision of a qualified registered nurse.
2.4.2 Individual staffing patterns shall be developed for each nursing units, including the emergency, outpatient, surgical and obstetrical.
2.4.3 The staffing patterns shall provide for sufficient personnel and for adequate supervision by registered nurses consistent with the size and complexity of the hospital.
2.4.4 The nursing staff shall provide a continuing program for professional education or give evidence of participation in such a program.
3. A hospital and other health facilities shall have properly maintained and sufficient equipment, instruments, and physical plant to facilitate safe and effective position of services.
4. A hospital and other health facilities shall have effective written policies and procedures relating to the staff, patients, functions of the different services, medical records, equipment, and physical plant in order to assure the health and safety of the patients.
5. A hospital and other health facilities shall implement a quality assurance program through an effective system of assessment, monitoring, evaluation and feedback.
_______________________
[1]Text Available at Office of National Administrative Register, U.P. Law Complex, Diliman, Quezon City.
SECTION 2. Authority. — These rules are issued to implement the provisions of R.A. 4226: Hospital Licensure Act consistent with E.O. 102: Redirecting the Functions and Operations of the Department of Health.
SECTION 3. Purpose. — These rules are promulgated to protect and promote the health of the people by ensuring the rights to quality health service appropriate to the level of care through the regulation of hospitals and other health facilities.
SECTION 4. Scope. — The rules and regulations embodied herein shall apply to all government and private hospitals and other health facilities.
SECTION 5. Regulatory Agency. — The Department of Health through the Bureau of Health Facilities and Services in the Office for Health Regulation shall exercise the regulatory functions.
SECTION 6. Definition. — A hospital is a health facility for the diagnosis, treatment and care of individuals suffering from deformity, disease, illness or injury, or in need of surgical, obstetrical, medical or nursing care. It is an institution where there are installed bassinets or beds for 24-hour use or longer by patients in the management of deformities, diseases, injuries, abnormal physical and mental conditions, maternity cases.
SECTION 7. Classification of Hospitals and other Health Facilities. — Hospitals and other health facilities shall be classified as follows:
7.1 Government or Private
7.1.1 Government. — operated and maintained partially or wholly by the national, provincial, city or municipal government, or other political unit; or by any department, division board of agency thereof.
7.1.2 Private. — privately owned, established and operated with funds through donation, principal, investment, or other means, by any individual, corporation, association, or organization.
7.2 General or Special
7.2.1 General. — provides services for all types of deformity, disease, illness or injury.
7.2.2 Special — primarily engaged in the provision of specific clinical care and management. A first level referral hospital, second level referral hospital, third level referral hospital, or infirmary, may provide special clinical service(s).
7.3 Service Capability
7.3.1 First Level Referral Hospital. —
7.3.1.1 Non-departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality
7.3.1.2 Clinical services include general medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia
7.3.1.3 Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.1.4 Provides nursing care for patients who require intermediate, moderate and partial category of supervised care for 24 hours or longer
7.3.2 Second Level Referral Hospital —
7.3.2.1 Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care
7.3.2.2 Clinical services provided in the First Level Referral Hospital, as well as specialty clinical care
7.3.2.3 Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.2.4 Nursing care provided in the First Level Referral Hospital, as well as total and intensive skilled care
7.3.3 Third Level Referral Hospital -
7.3.3.1 Teaching and training hospital that provides clinical care and management on the prevalent diseases in the locality, as well as specialized and sub-specialized forms of treatment, surgical procedure and intensive care
7.3.3.2 Clinical services provided in the Second Level Referral Hospital, as well as sub-specialty clinical care
7.3.3.3. Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy)
7.3.3.4 Nursing care provided in the Second Level Referral Hospital, as well as continuous and highly specialized critical care
7.3.4 Infirmary. — a health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and arrangement to mothers and newborn babies.
7.3.5 Birthing Home. — a health facility that provides maternity service or prenatal and post natal care, normal spontaneous delivery, and care of newborn babies.
7.3.6 A cute-chronic Psychiatric Care Facility. — a health facility that provides medical service, nursing care, pharmacological treatment and psychosocial intervention for mentally ill patients.
7.3.7 Custodial Psychiatric Care Facility. — a health facility that provides long-term care, including basic human services such as food and shelter, to chronic mentally ill patients.
SECTION 8. License. — A formal authorization issued by the Department of Health to an individual, partnership, corporation or association to operate a hospital and other health facilities. It is a prerequisite for accreditation of a hospital and other health facilities by any accrediting body that is recognized by the Department of Health.
SECTION 9. Licensing Requirements. — All hospitals and other health facilities are required to comply with the requirements for licensing.
9.1 The planning and design of a hospital and other health facilities shall comply with the prescribed guidelines (see Annex 1)
9.2 The management of the service capability, personnel, equipment and physical plant of a hospital and other health facilities shall conform to the prescribed guidelines (see Annex ).
9.3 The construction of a new hospital or other health facilities, and alteration, expansion or renovation of an existing hospital or other health facility shall be implemented in accordance with:
9.3.1 Floor plans prepared by a duly licensed Architect and/or Civil Engineer and approved by the Bureau of Health Facilities and Services; and
9.3.2 Architectural and engineering drawings (based on approved floor plans by the Bureau of Health Facilities and Services), specifications, building permit and fire safety permit prepared by a duly licensed Architect and/or Civil Engineer and approved by the Office of the Building Official and the Bureau of Fire Protection in the locality.
9.4 The Bureau of Health Facilities and Services shall evaluate compliance with the licensing requirements for all hospitals and other health facilities (see Annexes 3-9[1]).
9.4.1 Service Capability. — administrative, clinical, ancillary and other services rendered.
9.4.2. Personnel. — staffing of qualified and trained health and health-related professionals.
9.4.3 Equipment/Instrument. — tools to perform the required services.
9.4.4. Physical Plant. — well ventilated, lighted, clean, safe and functional structure sufficient to accommodate its activities.
SECTION 10. Requirements and Procedures for Application of Permit and License. —
10.1 Permit to Construct. — required for construction of a new hospital or other health facility; alteration, expansion or renovation of an existing hospital or other health facility; change in classification; or increase in bed capacity. It is a prerequisite for a license to operate.
10.1.1. The following are the required documents to be accomplished before a permit to construct can be issued:
10.1.1.1 Letter of Application to the Director of the Center for Health Development
10.1.1.2 Letter of Endorsement to the Director of the Bureau of Health Facilities and Services.
10.1.1.3 Form No. 1-01: Application for Permit to Construct notarized
10.1.1.4 Four (4) Sets of Site Development Plans and Floor Plans signed and sealed by an Architect and/or Engineer
For construction of a new hospital or other health facility; or change in classification, include:
10.1.1.5. Feasibility Study
10.1.1.6. Zoning Certificate or Location Clearance from the City/Municipal Planning and Development Office
10.1.1.7 DTI/SEC Registration (for private hospital or other health facility)
10.1.1.8 Enabling Act (for national government hospital or other health facility)
10.1.1.9 Approved Board Resolution (for local government hospital or other health facility
10.1.2. The following are the procedures for application for permit to construct:
10.1.2.1. Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or internet.
10.1.2.2 Applicant accomplishes required documents and submits them to the Center for Health Development for endorsement to the Bureau of Health Facilities and Services.
10.1.2.3 The Bureau of Health Facilities and Services reviews the documents and approves or disapproves the issuance of permit to construct.
10.1.2.4 If disapproved, the Bureau of Health Facilities and Services returns the documents, together with their findings and recommendations, to the applicant. The applicant makes necessary revisions on the documents. The applicant submits the revised documents to the Bureau of Health Facilities and Services for another review.
10.1.2.5 If approved, the Bureau of Health Facilities and Services issues a permit to construct to the applicant. The applicant pays the corresponding fee for permit to construct to the Cashier of the Department of Health in person, or through postal money order.
10.2 License to Operate. — required for operation of a hospital or other health facility. It is secured after construction and completion of a hospital or other health facility.
10.2.1 The following are the required documents to be accomplished before an initial license to operate can be issued:
10.2.1.1 Letter of Application and Request for Inspection to the Director of the Center for Health Development
10.2.1.2 Letter of Endorsement to the Director of the Bureau of Health Facilities and Services
10.2.1.3 Form No. 2-01: Application for Registration and Issuance of License to Operate notarized
10.2.1.4 List of Personnel notarized
10.2.1.5 List of Equipment/Instrument
10.2.1.6 Photo Album of the Exterior and Interior of the Hospital or Other Health Facility
10.2.2 The following are the procedures for application for initial license to operate:
10.2.2.1 Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or Internet.
10.2.2.2 Applicant accomplishes required documents and submits them to the Center for Health Development for endorsement to the Bureau of Health Facilities and Services. Upon filing of application, the applicant pays the corresponding fees for registration and license to the Cashier of the Department of Health in person, or through postal money order.
10.2.2.3 The Bureau of Health Facilities and Services conducts ocular inspection in accordance with licensing requirements.
10.2.2.4 The Bureau of Health Facilities and Services approves or disapproves the issuance of license to operate.
10.2.2.5 If disapproved, the Bureau of Health Facilities and Services sends the findings and recommendations to the applicant. The applicant requests the Bureau of Health Facilities and Services for another inspection.
10.2.2.6 If approved, the Bureau of Health Facilities and Services registers the hospital or other health facility and issues an initial license to operate to the applicant.
10.3 The Bureau of Health Facilities and Services shall create a Hospital Establishment Review Committee for the effective, judicious, prompt and swift action on the application for permit to construct a hospital and other health facilities.
10.3.1 The committee shall review all applications with respect to compliance with the licensing requirements and the prescribed guidelines in the planning and design of a hospital and other health facilities.
10.3.2 The committee shall meet once a week or when necessary. It shall be composed of, but not limited to, the following staff from the Bureau of Health Facilities and Services:
10.3.2.1 Chairman. — Assistant Director (Bureau of Health Facilities and Services)
10.3.2.2. Vice-Chairman - Head (Standards Development Division)
10.3.2.3. Members. - Architect, Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacists, Physician
10.4 The Bureau of Health Facilities and Services shall create a Hospital Licensing Team(s) for the effective, judicious, prompt and swift action on the application for initial license to operate a hospital and other health facilities.
10.4.1 The team shall inspect all hospitals and other health facilities with respect to compliance with the licensing requirements, the prescribed guidelines in the planning and design of a hospital and other health facilities and in the management of service capability, personnel, equipment and physical plant.
10.4.2 It shall be composed of, but not limited to, the following staff from the Bureau of Health Facilities and Services:
10.4.2.1 Team Leader. — Physician
10.4.2.2 Members. — Architect or Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacists
SECTION 11. Renewal of License. —
11.1 License to operate a hospital and other health facilities shall be renewed every year. However, inspection of a hospital and other health facilities may be done every other year.
11.2 Application for renewal of license to operate shall be filed ninety (90) days before the expiry date to the Center for Health Development under whose jurisdiction the hospital or other health facility is located.
11.3 The following are the required documents to be accomplished before a renewal of license to operate can be issued:
11.3.1 Letter of Application and Request for Inspection to the Director of the Center for Health Development
11.3.2 Form No. 3-01: Application for Renewal of License to Operate notarized
11.3.3 List of Personnel notarized
11.3.4 List of Equipment/Instrument
11.4 The following are the procedures for application for renewal of license to operate:
11.4.1 Applicant requests relevant information and prescribed form from the Center for Health Development under whose jurisdiction the proposed hospital or other health facility is located in person, or through mail, email or internet.
11.4.2 Applicant accomplishes required documents and submits them to the Center for Health Development. Upon filing of application, the applicant pays the corresponding fees for renewal of license to operate to the Cashier of the Center for Health Development in person, or through Postal money order.
11.4.3 The Center for Health Development conducts ocular inspection in accordance with licensing requirements.
11.4.4. The Center for Health Development approves or disapproves the issuance of license to operate.
11.4.5 If disapproved, the Center for Health Development sends the findings and recommendations to the applicant. The applicant requests the Center for Health Development for another inspection.
11.4.6 If approved, the Center for Health Development issues a license to operate to the applicant.
11.5 The Center for Health Development shall create a Hospital Licensing Team (s) for the effective, judicious, prompt and swift action on the application for renewal of license to operate a hospital and other health facilities.
11.5.1 The team shall inspect all hospitals and other health facilities with respect to compliance with the licensing requirements, the prescribed guidelines in the planning and design of a hospital and other health facilities and in the management of service capability, personnel, equipment and physical plant.
11.5.2 It shall be composed of, but not limited to, the following staff from the Center for Health Development:
11.5.1 Team Leader. — Physician
11.5.2 Members. — Architect or Engineer, Health Physicist, Nurse, Pathologist or Medical Technologist, Pharmacist
11.6 The Center for Health Development shall submit a quarterly report of all applications for renewal of license to operate to the Bureau of Health Facilities and Services. The report shall include the name of hospital or other health facility, location, type of application, scope of work, findings and recommendations.
SECTION 12. Inspection. —
12.1 All hospitals and other health facilities shall be inspected regularly and records shall be made available to determine compliance with these rules and regulations.
12.2 The Bureau of Health Facilities and Services or the Center for Health Development shall be allowed to inspect the hospital and other health facilities at an appropriate time.
12.3 All hospitals and other health facilities shall make available to the Bureau of Health Facilities and Services or the Center for Health Development records for inspection.
12.4 The Director of the Center for Health Development, and the Chief of the Provincial, City or Municipal Health Office are required to report the existence of all unlicensed hospitals and other health facilities and all violations of these rules and regulations to the Bureau of Health Facilities and Services.
SECTION 13. Monitoring. —
13.1 All hospitals and other health facilities shall be monitored regularly and records shall be made available to determine compliance with these rules and regulations.
13.2 The Bureau of Health Facilities and Services shall be allowed to monitor the hospital and other health facilities at any given time.
13.3 All hospitals and other health facilities shall make available to the Bureau of Health Facilities and Services records for monitoring.
SECTION 14. Technical Assistance. —
14.1 The Bureau of Health Facilities and Services shall develop the capability of the Center for Health Development on enforcement of these rules and regulations.
14.2 The Bureau of Health Facilities and Services shall provide technical assistance and advisory services to the Center for Health Development, Local Government Unit, and Private Institution regarding compliance with the licensing requirements for all hospitals and other health facilities.
SECTION 15. Fees. —
15.1 A non-refundable fee shall be charged for application for permit to construct, for registration, and for license to operate a government and private hospital and other health facilities.
15.2 A non-refundable fee shall be charged for application for renewal of license to operate.
15.3 All fees shall be paid to the Cashier of the Center for Health Development.
15.4 All fees shall follow the current prescribed schedule of fees of the Department of Health.
SECTION 16. Terms and Conditions. —
16.1 No license to operate shall be issued to a hospital and other health facilities without permit to construct secured prior to the construction, alteration, expansion, renovation, or increase in bed capacity, and license for the operation of clinical laboratory, radiology and pharmacy.
16.2 A permit to construct shall be considered lapsed and fee paid shall be forfeited when the work authorized by the permit does not commence within 365 days from date of issuance, or is abandoned during the period specified.
16.3 A license to operate shall be granted in accordance with prescribed licensing requirements and on the basis of specific conditions and limitations established during inspection.
16.4 A license that is not renewed for a period of two (2) years shall be considered lapsed and registration shall be cancelled. A new application for registration and issuance of license to operate shall be required before a hospital and other health facilities can be allowed to operate.
16.5 The license as herein granted as well as any right under the license cannot be assigned or otherwise transferred directly or indirectly to any party without the written consent of the Director of the Bureau of Health Facilities and Services.
16.6 The Bureau of Health Facilities and Services shall be notified of any change in management, name or ownership. In cases of transfer of location, a new application for permit to construct, registration and issuance of license to operate shall be required.
16.7 Failure to report in writing within fifteen (15) days of any substantial change in the condition of the license may be a basis for the suspension or revocation of the license.
16.8 A separate license shall be required for all hospitals and other health facilities or branches maintained in separate buildings in the same premises.
16.9 The license shall be placed in an area readily seen by the public. A copy of the rules and regulations shall be readily available for guidance of all personnel of the hospital and other health facilities.
16.10 The license shall expire on the date of anniversary of issuance.
SECTION 17. Violations. — Violations of the Hospital Licensure Act or the rules and regulations issued in pursuance thereto include the commission of the following acts by any individual, corporation, association, or organization operating a hospital, or persons under their authority.
17.1 Making substantial alteration or renovation of a hospital and other health facilities without securing a permit to construct.
17.2 Any material false statement in the application.
17.3 Change of location, management, name or ownership without informing the Bureau of Health Facilities and Services in writing.
17.4 Refusal to allow inspection of a hospital and other health facilities by the Bureau of Health Facilities and Services or the Center for Health Development at an appropriate time
17.5 Refusal to allow monitoring of a hospital and other health facilities by the Bureau of Health Facilities and Services at any given time.
17.6 Refusal to discharge patients or their relatives, to release cadavers and to issue a duly accomplished death certificate for non-payment of hospital bills.
17.7 Refusal to admit patients for lack of capacity to pay
17.8 Failure to make necessary corrections of deficiencies required by the Bureau of Health Facilities and Services or the Center for Health Development after due notice.
SECTION 18. Investigation and Hearing of Charges or Complaints. — Upon filing of charges or complaints by any individual, corporation, association, or organization against any hospital or other health facility, or any of its personnel who has violated or is violating the provisions of R.A. 4226 or of these rules and regulations, the Bureau of Health Facilities and Services shall investigate and verify if the hospital or other health facility concerned, or any of its personnel is guilty of the charges or complaints. If upon investigation and hearing, the hospital or other health facility concerned, or any of its personnel is found violating the provisions of R.A. 4226 or of these rules and regulations, the Director of the Bureau of Health Facilities and Services shall suspend the license for a definite or indefinite period of time, or revoke the license without prejudice to taking the case to judicial authorities for criminal action.
SECTION 19. Revocation of License. — A license to operate shall be suspended or revoked by the Director of the Bureau of Health Facilities and Services upon violation of the Hospital Licensure Act or the rules and regulations issued in pursuance thereto. The Bureau of Health Facilities and Services shall notify the hospital or other health facility concerned, or any of its personnel by registered mail the particular reasons for the denial or revocation of license.
SECTION 20. Closure. — The Bureau of Health Facilities and Services shall immediately close all hospitals and other health facilities without a license to operate, and may seek assistance of any government agency to effectively enforce the closure.
SECTION 21. Penalty. — Any individual, corporation, association, or organization who establishes a hospital or other health facility without securing the necessary permit to construct and manages a hospital and other health facilities without securing the necessary license to operate from the Bureau of Health Facilities and Services, or violates any supervision of these rules and regulations shall, upon conviction, be liable of not more than five hundred pesos (P500.00) for the first offense and not more than one thousand pesos (P1,000.00) for each subsequent offense. Each day that a hospital or other health facility operates after the first conviction shall be considered a subsequent offense.
SECTION 22. Appeal. — Any hospital or other health facility, or any of its personnel aggrieved by the decision of the Bureau of Health Facilities and Services may, within thirty (30) days after receipt of notice of the decision, file a notice of appeal in the Office of the Secretary, and serve a copy of the notice of appeal to the Bureau of Health Facilities and Services. Thereupon the Bureau of Health Facilities and Services shall promptly certify and file a copy of the decision, including the transcript of the hearings on which the decision is based, with the Office of the Secretary for review. The decision of the Office of the Secretary shall be final and executory.
SECTION 23. Publication of List of Licensed Hospitals and Other Health Facilities. — A list of licensed hospitals and other health facilities according to their classification shall be published periodically and made available to any individual, corporation, association, or organization for legitimate purpose.
SECTION 24. Repealing Clause. — These rules and regulations shall repeal and supersede all administrative orders and other issuances inconsistent thereof.
SECTION 25. Effectivity. — These rules and regulations shall take effect upon approval and publication in a newspaper of general circulation.
SECTION 26. Moratorium. — The Center for Health Development shall prepare all the necessary resources to effectively execute the renewal of license to operate a hospital and other health facilities within two (2) years from the effectivity of these rules and regulations. During this period, the Bureau of Health Facilities and Services shall assist the Center for Health Development in the renewal of license to operate Second and Third Level Referral Hospitals.
Adopted: 03 Jan. 2002
(SGD.) MANUEL M. DAYRIT, M.D., M.S.C
Secretary of Health
Secretary of Health
ANNEX 1
Guidelines in Planning and Design of a Hospital and Other Health Facilities
A hospital and other health facilities shall be planned and designed to observe appropriate architectural practices, to meet prescribed functional programs, and to conform to applicable codes as part of normal professional practice. References shall be made to the following:
- P.D. 1096 — National Building Code of the Philippines and its Implementing Rules and Regulations
- P.D. 1185 — Fire Code of the Philippines and Its Implementing Rules and Regulations
- P.D. 856 — Code on Sanitation of the Philippines and Its Implementing Rules and Regulations
- B.P. 344 — Accessibility Law and Its Implementing Rules and Regulations
- R.A. 1378 — National Plumbing Code of the Philippines and Its Implementing Rules and Regulations
- R.A. 184 — Philippine Electrical Code’
- Manual on Technical Guidelines for Hospitals and Health Facilities Planning and Design. Department of Health, Manila. 1994
- Signage Systems Manual for Hospitals and Offices. Department of Health, Manila. 1994
- Health Facilities Maintenance Manual. Department of Health, Manila 1995
- Manual on Hospital Waste Management. Department of Health, Manila. 1997
- District Hospitals: Guidelines for Development. World Health Organization Regional Publications, Western Pacific Series. 1992
- Guidelines for Construction and Equipment of Hospital and Medical Facilities. American Institute of Architects, Committee on Architecture of Health. 1992
- De Chiara, Joseph. Time-Saver Standards for Building Types. McGraw-Hill Book Company. 1980
1. Environment. — A hospital and other health facilities shall be located that it is readily accessible to the community and reasonably free from undue noise, smoke, dust, foul odor, flood, and shall not be located adjacent to railroads, freight yards, children’s playgrounds, airports, industrial plants, disposal plants.
2. Occupancy. — A building designed for other purpose shall not be converted into a hospital. The location of a hospital shall comply with all local zoning ordinances.
3. Safety. — A hospital and other health facilities shall provide and maintain a safe environment for patients, personnel and public. The building shall be of such construction so that no hazards to the life and safety of patients, personnel and public exist. It shall be capable of withstanding weight and elements to which they may be subjected.
3.1 Exits shall be restricted to the following types: door leading directly outside the building, interior stair, ramp, and exterior stair.
3.2 A minimum of two (2) exits, remote from each other, shall be provided for each floor of the building.
3.3 Exits shall terminate directly at an open space to the outside of the building.
4. Security. — A hospital and other health facilities shall ensure the security of person and property within the facility.
5. Patient Movement. — Spaces shall be wide enough for free movement of patients, whether they are on beds, stretchers, or wheelchairs. Circulation routes for transferring patients from one area to another shall be available and free at all times.
5.1 Corridors for access by patient and equipment shall have a minimum width of 2.44 meters.
5.2 Corridors in areas not commonly used for bed, stretcher and equipment transport may be reduced in width to 1.83 meters.
5.3 A ramp or elevator shall be provided for ancillary, clinical and nursing areas located on the upper floor.
5.4 A ramp shall be provided as access to the entrance of the hospital not on the same level of the site.
6. Lighting. — All areas in a hospital and other health facilities shall be provided with sufficient illumination to promote comfort, healing and recovery of patients and to enable personnel in the performance of work.
7. Ventilation. — Adequate ventilation shall be provided to ensure comfort of patients, personnel and public.
8. Auditory and Visual Privacy. — A hospital and other health facilities shall observe acceptable sound level and adequate visual seclusion to achieve the acoustical and privacy requirements in designated areas following the unhampered conduct of activities.
9. Water Supply. — A hospital and other health facilities shall use an approved public water supply system whenever available. The water supply shall be potable, safe for drinking and adequate, and shall be brought into the building free of cross connections.
10. Waste Disposal. — Liquid waste shall be discharged into an approved public sewerage system whenever available, and solid waste shall be collected, treated and disposed of in accordance with applicable codes, laws or ordinances.
11. Sanitation. — Utilities for the maintenance of sanitary system, including approved water supply and sewerage system, shall be provided through the buildings and premises to ensure a clean and healthy environment.
12. Housekeeping. — A hospital and other health facilities shall provide and maintain a healthy and aesthetic environment for patients, personnel and public.
13. Maintenance. — There shall be an effective building maintenance program in place. The buildings and equipment shall be kept in a state of good repair. Proper maintenance shall be provided to prevent untimely breakdown of buildings and equipment.
14. Material Specification. — Floors, walls and ceilings shall be of sturdy materials that shall allow durability, ease of cleaning and fire resistance.
15. Segregation. — Wards shall observe segregation of sexes. Separate toilet shall be maintained for patients and personnel male and female, with a ratio of one (1) toilet for every eight (8) patients or personnel.
16. Fire Protection. — There shall be measures for detecting fire such as fire alarms in walls, peepholes in doors or smoke detectors in ceilings. There shall be devices for quenching fire such as fire extinguishers or fire hoses that are easily visible and accessible in strategic areas.
17. Signage. — There shall be an effective graphic system composed of a number of individual visual aids and devices arranged to provide information, orientation, direction, identification, prohibition, warning and official notice considered essential to the optimum operation of a hospital and other health facilities.
18. Parking. — A hospital and other health facilities shall provide a minimum of one (1) parking space for every twenty-five (25) beds.
19. Zoning. — The different areas of a hospital shall be grouped according to zones as follows:
19.1 Outer zone. — areas that are immediately accessible to the public: emergency service, outpatient service, and administrative service. They shall be located near the entrance of the hospital.
19.2 Second Zone. — areas that receive workload from the outer zone: laboratory, pharmacy, and radiology. They shall be located near the outer zone.
19.3 Inner Zone. — areas that provide nursing care and management of patients: nursing service. They shall be located in private areas but accessible to guests.
19.4 Deep Zone. — areas that require asepsis to perform the prescribed services: surgical service, delivery service, nursery, and intensive care. They shall be segregated from the public areas but accessible to the outer, second and inner zones.
19.5 Service Zone. — areas that provide support to hospital activities: dietary service, housekeeping service, maintenance and motorpool service, and mortuary. They shall be located in areas away from normal traffic.
20. Function. — The different areas of a hospital shall be functionally related with each other.
20.1 The emergency service shall be located in the ground floor to ensure immediate access. A separate entrance to the emergency room shall be provided.
20.2 The administrative service, particularly admitting office and business office, shall be located near the main entrance of the hospital. Offices for hospital management can be located in private areas.
20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement.
20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement. The nursery shall be separate but immediately accessible from the delivery room.
20.5 The nursing service shall be segregated from public areas. The nurse station shall be located to permit visual observation of patients. Nurse stations shall be provided in all inpatient units of the hospital with a ratio of at least one (1) nurse station for every thirty-five (35) beds. Rooms and wards shall be of sufficient size to allow for work flow and patient movement. Toilets shall be immediately accessible from rooms and wards.
21. Space: Adequate area shall be provided for the people, activity, furniture, equipment and utility.
Space
Area in Square Meters
Administrative Service
Lobby
Waiting Area
0.65/person
Information and Receiving Area
5.02/staff
Toilet
1.67
Business Office
5.02/staff
Medical Records
Work Area
5.02/staff
Storage Area
4.65
Office of Hospital Administrator
5.02/staff
Office of the Chief of Hospital
5.02/staff
Conference Room
1.40/person
Staff Toilet
1.67
Housekeeping Area
5.02/staff
Laundry and Linen Area
5.02/staff
Maintenance Area
5.02/staff
Garage Area
9.29
Supply Room
5.02/staff
Waste Holding Room
4.65
Pharmacy
15.00
Dietary
Dietitian Area
5.02/staff
Supply Receiving Area
4.65
Cold and Dry Storage Area
4.65
Food Preparation Area
4.65
Cooking and Baking Area
4.65
Serving and Food Assembly Area
4.65
Washing Area
4.65
Garbage Disposal Area
1.67
Dining Room
1.40/person
Staff Locker Room and Toilet
2.32
Social Service Area
5.02/staff
Cadaver Holding Room
7.43/bed
Clinical Service
Emergency Room
Waiting Area
0.65/person
Toilet
1.67
Nurse Station
5.02/staff
Examination and Treatment Area with Lavatory/Sink
7.43/bed
Observation Area
7.43/bed
Equipment and Supply Storage Area
4.65
Wheeled Stretcher Area
1.08/stretcher
Outpatient Department
Waiting Area
0.65/person
Toilet
1.67
Admitting and Records Area
5.02/staff
Consultation Area
5.02/staff
Examination and Treatment Area with Lavatory/Sink
7.43/bed
Dental Clinic
8.36/dental chair
Surgical and Obstetrical Service
Major Operating Room
33.45
Recovery Room
9.29
Delivery Room
33.45
Labor Room with Toilet
9.29
Sub-sterilizing Room
4.65
Sterile Instrument, Supply and Storage Area
4.65
Anesthesia Storage Area
4.65
Scrub-up Area
4.65
Clean-up Area
4.65
Male Dressing Room and Toilet
2.32
Female Dressing Room and Toilet
2.32
Nurse Station
5.02/staff
Wheeled Stretcher Area
1.08/stretcher
Janitor’s Closet
3.90
Nursery
Pathologic Room
3.72/bassinet
Premature Room
3.72/bassinet
Work Area with Sink
4.65
Viewing Area
3.90
Breastfeeding Area
3.72/bassinet
Nursing Unit
Private Room with Toilet
9.29
Semi-Private Room and Toilet
7.43/bed
Female Ward with Toilet
7.43/bed
Male Ward with Toilet
7.43/bed
Isolation Room with Toilet
9.29
Nurse Station with Work Area and Lavatory/Sink
7.43/bed
Central Sterilizing and Supply Room
Receiving and Releasing Area
5.02/staff
Work Area
5.02/staff
Sterilizing Room
4.65
Sterile Supply Storage Area
4.65
Nursing Service
Office of the Chief Nurse
5.02/staff
Staff Locker Room and Toilet
2.32
Ancillary Service
Laboratory
Toilet
1.67
Clinical Work Area with Sink
10.00
Pathologist Area
5.02/staff
Radiology
Waiting Area
0.65/person
Dressing Area
1.67
Toilet
1.67
X-ray Room with Control Booth
14.00
Dark Room
4.65
Film File and Storage Area
4.65
Radiologist Area
5.02/staff
Pharmacy 15.00
Notes:
1. 0.65/person. — Unit area per person occupying the space at one time.
2. 5.02/staff . — Work area per staff that includes space for one (1) desk and one (1) chair, space for occasional visitor, and space for aisle.
3. 1.40/person. — Unit area per person occupying the space at one time.
4. 7.43/bed. — Clear floor area per bed that includes space for one (1) bed, space for occasional visitor, and space for passage of equipment.
5. 1.08/stretcher. — Clear floor area per stretcher that includes space for one (1) stretcher.
6. 8.36/dental chair. — Clear floor area per dental chair that includes space for one (1) dental chair, space for movement of person, and space for passage of equipment.
7. 3.72/bassinet. — Clear floor area per bassinet that includes space for one (1) bassinet, space for movement of person, and space for passage of equipment.
ANNEX 2
Guidelines in the Management of the Service Capability, Personnel, Equipment and Physical Plant of a Hospital and Other Health Facilities
1. A hospital and other health facilities shall render quality health services appropriate to the level of care.
1.1 The Administrative Service shall perform the functions of personnel, accounting, medical records, supply, housekeeping, maintenance, motorpool, dietary, and social service.
1.2 The Clinical Service shall provide services in medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia, and dentistry.
1.3 The Nursing Service shall provide care and management for
1.3.1 Intermediate, moderate and partial category of health care to 60% of patients who require assistance on special treatment and specific personal care
1.3.2 Total and intensive category of health care to 70% of patients who require assistance on special treatment and specific personal care.
1.3.3 Continuous and highly specialized category of health care to 80% of patients who are acutely or critically ill, in constant danger of death, in serious injury, and require class monitoring
1.3.4 Nursing intervention on physiological, psychological, social, emotional and spiritual needs of patients
1.3.5 Health Education
1.4 The Ancillary Service shall perform the functions of clinical laboratory, radiology and pharmacy.
2. A hospital and other health facilities shall have an organized staffing of qualified and trained health and health-related professionals and non-professionals.
2.1 A hospital shall have a governing body responsible for the governance of the hospital in making available quality patient care.
2.1.1 The governing body shall adopt by-laws in accordance with legal requirements and with its community responsibility, identifying the purposes of the hospital and the means of fulfilling them.
2.1.2 There shall be a chief of hospital designated to execute its policies.
2.2 There shall be an organized administration responsible for the execution of directions of the governing body and the discharge of support services in the areas of finance, personnel, property and supply, housekeeping, laundry, security, transport and maintenance.
2.2.1 The Administrative Service shall be under the supervision of a qualified administrative officer.
2.2.2 The administrative staff shall provide a continuing program of professional education or give evidence of participation in such a program.
2.3 There shall be an organized medical staff responsible for the quality of patient care, and for the ethical conduct and professional practices of its members.
2.3.1 Each member of the medical staff shall be qualified for affiliation and for exercise of the clinical privileges granted to him.
2.3.2 The medical staff shall provide a continuing program of professional education or give evidence of participation.
2.4 There shall be an organized nursing staff responsible for the quality of nursing care for the needs of the patients, and for the professional performance of its members.
2.4.1 The Nursing Service shall be under the supervision of a qualified registered nurse.
2.4.2 Individual staffing patterns shall be developed for each nursing units, including the emergency, outpatient, surgical and obstetrical.
2.4.3 The staffing patterns shall provide for sufficient personnel and for adequate supervision by registered nurses consistent with the size and complexity of the hospital.
2.4.4 The nursing staff shall provide a continuing program for professional education or give evidence of participation in such a program.
3. A hospital and other health facilities shall have properly maintained and sufficient equipment, instruments, and physical plant to facilitate safe and effective position of services.
4. A hospital and other health facilities shall have effective written policies and procedures relating to the staff, patients, functions of the different services, medical records, equipment, and physical plant in order to assure the health and safety of the patients.
5. A hospital and other health facilities shall implement a quality assurance program through an effective system of assessment, monitoring, evaluation and feedback.
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[1]Text Available at Office of National Administrative Register, U.P. Law Complex, Diliman, Quezon City.