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(NAR) VOL. 5 NO. 2/APRIL-JUNE 1994

[ DOH ADMINISTRATIVE ORDER NO. 24, s. 1994, February 15, 1994 ]


SECTION 1.       Title — These rules and regulations shall be known as the "Rules and Regulations Governing the Accreditation of Ambulatory Surgical Clinics".

SECTION 2.       Authority — These rules and regulations are issued pursuant to Section 4, paragraph H of Executive Order 119, which states that the Department of Health (DOH) has the power and function to:

. . ."regulate the operation of and issue licenses and permits to government and private hospitals, clinics, and dispensaries, laboratories, blood banks, drug stores, and such other establishments which by the nature of their functions are required to be regulated by the ministry. . ."

SECTION 3.       Purpose — These rules and regulations are promulgated to ensure the general public of quality services by the Ambulatory Surgical Clinics.

SECTION 4.       Scope — These regulations shall apply to all ambulatory surgical clinics independent of a hospital.

SECTION 5.       Regulatory Authority — The Department through Office for Health Facilities, Standards and Regulations shall exercise regulatory functions under these rules and regulations.

SECTION 6.       Definition of Terms — As used in these rules and regulations:

6.1       Ambulatory Surgical Clinic a medical clinic independent of a hospital performing surgical operations on an outpatient basis and duly accredited by the Department of Health. It shall be referred to in these rules as the "clinic".

6.2       Diplomate of Specialty Society a doctor of medicine who has completed specialty training in a hospital accredited by the specialty society concerned and duly certified by its Board.

6.3       Tertiary Hospital is fully departmentalized and equipped with the service capabilities needed to support certified medical specialists and other licensed physicians rendering services in the field of medicine, pediatrics, obstetrics and gynecology, surgery, their subspecialties and ancillary services.

6.4       Department shall mean the Department of Health.

6.5       Bureau shall refer to the Bureau of Licensing and Regulation.

SECTION 7.       Accreditation Requirements (Technical Standards) — The following requirements shall be complied with by an ambulatory surgical clinic applying for accreditation.

7.1       Personnel

7.1.1        Physician surgeon who is a diplomate in his chosen field of specialty: At least one of the medical staff of the clinic shall be a member of the medical staff of a tertiary hospital located within a reasonable distance from the clinic for ease in admitting emergency cases that may arise from the procedures. If the above is not possible the clinic shall have a Memorandum of Agreement with a tertiary hospital within a reasonable distance from the former regarding acceptance of emergency cases that may arise from the procedures. This shall include provision of ambulance services.

7.1.2        Certified Anesthesiologist

7.1.3        Registered Nurse

7.1.4        Nursing Aide

7.1.5        Administrative Personnel

7.1.6        Utility Man

7.2   Equipment/Instruments

7.2.1        Stethoscope

7.2.2        Sphygmomanometer with Stand

7.2.3        Examining Light

7.2.4        Oxygen Unit with Gauge

7.2.5        Surgical Instrument Set

7.2.6        Instrument Table

7.2.7        Treatment Table

7.2.8        Tracheostomy Set

7.2.9        Thoracostomy Set

7.2.10      Paracentesis Set

7.2.11      Patient's Bed(s) with Guard Rails - 90 cm width - 70 cm length

7.2.12      Operating Table

7.2.13      Suction Apparatus

7.2.14      Operating Room Light

7.2.15      Stand-by Operating Room Light

7.2.16      Anesthesia machine for each Operating Room

7.2.17      Anesthesia Table

7.2.18      Laryngoscope with different sizes of blades

7.2.19      Endotracheal tube, different sizes

7.2.20      Ambu Bag

7.2.21      Sterilizer

7.2.22      ECG Machine

7.2.23      Defibrillator

7.2.24      Lumbar Set

7.2.25      Stretcher

7.2.26      Wheelchair

7.2.27      Other Requirements:       Stand-by Generator       Fire Extinguisher       Transport Vehicle for Patient's use (Ambulance) or a contract with providers of such ambulance services.

7.3       Physical Plant

7.3.1   Administrative Services:           Lobby

—      Information counter/admitting area
—      Communication Area
—      Waiting Area
—      Toilet Facilities           Business Office

—      Cashier/billing
—      Finance/budget/auditor
—      Toilet facilities

7.3.2   Recovery Room with Toilet facilities

7.3.3   Surgical Service Complex           Major operating room with airconditioning unit.           Minor Operating room with airconditioning unit.           Scrub-up area           Sterile Instrument, supply and anesthesia storage area           Sub-sterilization room           Clean-up area           Doctor's locker room and lounge with toilet            Nurse locker room and lounge with toilet            Janitor's closet           Central sterilization and supply service           Receiving and releasing area           Sterilizing and work area           Sterile supply storage area

SECTION 8.       Basic Accreditation Requirements — Any person, firm or corporation desiring to establish or operate and maintain an ambulatory surgical clinic shall submit to the Bureau of Licensing and Regulation the following requirements:

8.1       Letter of application on the prescribed form of the Bureau of Licensing and Regulation.

8.2       Certificate of Registration from the Bureau of Domestic Trade for single proprietorship, or from the Securities and Exchange Commission for partnership or corporation.

8.3       Mayor's Permit to Operate a clinic.

8.4       Tax Identification Number (TIN) of the proprietor for single proprietorship; or that of the managing partner or the corporation as the case maybe.

8.5       Valid professional Regulation Commission (PRC) Identification Card of the Medical and Paramedical Staff.

8.6       Professional Tax Receipts (PTR) of practitioner staff of the clinic.

8.7       License to operate and maintain a laboratory from the Bureau of Research and Laboratories for clinics that have their own laboratory.

8.8       License to operate an x-ray facility from the Bureau of Licensing and Regulations for clinics that have their own x-ray facility.

SECTION 9.       Application for Accreditation — Application for accreditation shall be filed at the Bureau of Licensing and Regulation in the form prescribed by the Bureau.

9.1       Each application shall be signed under oath or affirmation by the applicant or the person duly authorized to act for and in his behalf.

9.2       Any material false statement in this application or failure to comply with the requirements may serve as basis for denial of accreditation.

9.3       An application fee of P600.00 shall accompany the application.

SECTION 10.    Accreditation Fee —

10.1    A non-refundable fee of six hundred (P600.00) shall be paid upon approval of accreditation.

10.2    All fees shall be payable to the Bureau of Licensing and Regulation to be paid to the Cashier of the Department of Health.

10.3    A penalty of P300.00 for late renewal shall be charged in addition to the renewal fee if the application is filed during the next thirty (30) days after the anniversary date of accreditation.

10.4    The accreditation shall be considered lapsed if not renewed within thirty (30) days after expiration. Subsequent re-accreditation shall be applied for which shall be subject to an application fee.

SECTION 11.    Separate Accreditation — Separate Accreditation shall be required for clinics or branches thereof, maintained in separate premises even though they are operated under the same management.

SECTION 12.    Inspection — Accredited clinics shall be inspected regularly and records shall be made available to determine compliance with the rules and regulations.

12.1    Each accredited clinic shall give the Director of the Bureau or his authorized representative(s) at any reasonable time the opportunity to inspect the clinic.

12.2    Each accredited clinic shall make available to the Director of the Bureau or his authorized representative(s) their records pursuant to these regulation.

12.3    The Director of the Bureau or his representative(s) may be assisted by duly designated experts from professional associations in such inspections.

12.4    Directors of Regional Field Offices in coordination with the Local Government Units are hereby empowered to report to the Bureau the existence of ambulatory surgical clinics without proper accreditation and for any violation of these rules and regulations.

SECTION 13.    Issuance of Certificate of Accreditation

13.1    After the clinic is found to have met all the requirements including payment of accreditation fees and after ocular inspection, the application shall be approved by the Undersecretary of Health for Health Facilities, Standards and Regulation (OHFSR) upon recommendation by the Director of the Bureau.

13.2    The Certificate of Accreditation shall have a one year period of validity from the date of issuance.

SECTION 14.    Terms and Conditions of the Accreditation Certificate —         

14.1    The certificate of accreditation and any right granted under the accreditation shall not be assigned or transferred.

14.2    Accreditation shall be automatically terminated upon change of ownership or management or change in location, therefore, a re-accreditation has to be applied for and approved by the Undersecretary of Health for Standards and Regulation (OHFSR) upon recommendation of the Director of the Bureau.

14.3    Change of ownership in management or location shall be reported in writing to, and acknowledged by the Bureau fifteen (15) days from the effectivity of such change.

SECTION 15.    Exhibition of Certificate — The certificate of accreditation of the clinic shall be posted in a conspicuous area readily seen by the public. A copy of these rules and regulation shall be readily available for reference and guidance of the clinic staff and personnel.

SECTION 16.    Renewal

16.1    Application for renewal of accreditation shall be filed within sixty (60) days prior to the date of expiration. A penalty shall be paid if the application is filed after the anniversary date in accordance with Section 10 of these rules.

16.2    The Bureau shall process the application for renewal immediately upon receipt thereof and after an ocular inspection of the facilities has been conducted by the inspection team. The accredited clinic shall continue its operation while waiting for the final action on its application unless otherwise ordered by the Director of the Bureau.

16.3    An accreditation that has not been renewed thirty (30) days from expiration shall be considered lapsed, therefore re-accreditation shall be applied for and approved by the Undersecretary of Health, OHFSR.

SECTION 17.    Publication of List of Accredited Ambulatory Surgical Clinics — A list of accredited clinics shall be published periodically and shall made available to any person, agency or company for legitimate purpose.

SECTION 18.    Sanction — The Department may suspend or revoke the certificate of accreditation of an ambulatory surgical clinic if upon investigation it shall be found guilty of violation of the provisions under these rules or any law or rule related to operation of such clinics in the Philippines.

Any ambulatory surgical clinic operating without proper accreditation from the Department of Health shall be guilty of misdemeanor and shall be fined not less than one thousand (P1,000.00) pesos but not more than five thousand (P5,000.00) pesos. It shall be barred from participating in any health program requiring accreditation from the DOH.

SECTION 19.    Effectivity — These rules and regulations shall take effect fifteen (15) days after publication in the official gazette or in a newspaper of general circulation.

Adopted: 15 Feb. 1994

Secretary of Health
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