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The following are the supplemental guidelines on processing of applications of hospitals for accreditation:

I.TYPES OF APPLICATIONS AND DOCUMENTARY REQUIREMENTS FOR ACCREDITATION

Type of Application	Description	Documentary Requirements
A. Initial Accreditation	No previous accreditation
B. Renewal of Accreditation	1. A hospital with active accreditation that filed its application within the incentive or prescribed filing period.	See Annex B of Circular 50 s.2009
	2. Late filer - a hospital with active accreditation that filed its application beyond the prescribed filing period but before the expiry of its accreditation
C. Re-accreditation	1. Previous accreditation has lapsed regardless of length of gap in accreditation	Same as application for renewal of accreditation
	2. Previous application for renewal of accreditation was denied
	3. Upgrading a. Level of Hospital Service Capability (to Level 2, 3, or 4) b. Accreditation Award
	4. Transfer of location
	5. Increase in accredited beds
	6. Additional Services (dialysis service Chemotherapy, CT Scan, etc.)
	7. Change in ownership	1. Same as application for renewal of accreditation; and
		2. Proof of ownership a. SEC/DTI Certificate b. MOA/Deed of Sale/etc.
	8. Resumption of operation after closure/cease of operation	Same as application for renewal of accreditation

1. Hospitals applying for renewal of accreditation after the prescribed filing period (late filers) but prior to the expiry of their accreditation may incur a gap in their accreditation depending on the length of the processing time.

2. Applications for renewal of accreditation with concomitant changes in the status of the hospital, e.g. bed capacity, hospital level, additional services, transfer of location, change in ownership, shall take effect on May 1 of the applicable accreditation year. The application shall be considered as renewal of accreditation. For each cases, the abovementioned applicable documentary requirements for re-accreditation shall be submitted. Should the hospital prefer an earlier date of effectivity of the change, a separate application for re-accreditation shall be required.

3. Applications of hospitals shall be filed together with the Statements of Intent (SOI) indicating (a) the preferred start date of accreditation and (b) acceptance of downgrading of accreditation if it did not qualify for the award it applied for. Once the application is received and stamped complete by the Corporation, the SOI shall no longer be changed.

4. Hospital applying for renewal of accreditation may change the accreditation award they applied for prior to the pre-accreditation survey and before March 31 of the current year.

In such a case, the hospital shall:

a. Submit a letter of intent to the concerned PhilHealth Regional Office; and

b. File another application for re-accreditation (upgrading) and pay the corresponding regular application fee;

The previously paid application fee for renewal of accreditation shall be forfeited. The validity of accreditation shall start on May 1 of the applicable accreditation year.

5. Accredited hospitals that apply for re-accreditation due to increase in beds, additional services or change in ownership shall not require a pre-accreditation survey.

II. CRITICAL FILE UPDATES

The following information shall be critical file updates to the accreditation status of the hospital that the Corporation shall incorporate in the database upon receipt of the corresponding documentary requirements:

Critical File Update	Documentary Requirements
1. Downgrading of hospital category (E.g., L2 to L1, L4 to L3, etc.)
2. Decrease in accredited beds
3. Change in validity of accreditation as reflected in in the DOH-OSS license	DOH license
4. Reduction in service capability (e.g., removal of dialysis service, etc.)
5. Change in name of IHCP	1. Letter of Intent (LOI) which indicates the date of effectivity, and
	2.DOH license/SB resolution for LGU/Provincial Health Board Resolution indicating the change in name of the hospital
6. Change in medical director/head of the facility	1. LOI which indicates the date of effectivity and
	2. Appointment paper/board resolution or its equivalent
7. Termination of accreditation due to closure/cease	1. Validation report of PhRO and of operation
	2. Notice of Closure of hospital (if available)

These critical file updates shall not require application fees and survey. File Updates 1,2,3, and 4 shall take effect based on the date indicated in the DOH license. File updates 5 and 6 shall take effect on the date of the conduct of the PhRO Accreditation Subcommittee Meeting or on the date reflected in the Letter of Intent. File update 7 shall take effect on the date of actual closure of hospital.

III. CONDUCT OF SURVEY

1. Each survey team shall be composed of at least two (2) surveyors.
2. In accordance with the DOH licensing requirements (Annex A: Department Memorandum No. 2010-0081 re: Reiteration of Hospital Licensing Requirement on Ramps and Corridors) ramps shall be required only for new hospitals or for an existing hospital that has undergone expansion, upgrading of category involving physical plant/ facility, or transfer of site after March 24, 2010. Otherwise, this requirement shall not be applicable to the hospital and the evidence shall be marked as N/A in the self-assessment and survey tools.

IV. COMPLIANCE AND RE-SURVEY OF PROVISIONALLY ACCREDITED HOSPITALS

1. The hospital may only be re-surveyed after the hospital is granted provisional accreditation.
2. Compliance/correction of deficiencies which require only documentary proof (licenses, permits, certifications, written policies for current practices, etc.) shall no longer require a re-survey. The hospital shall submit a copy of said documents to Phil-Health.
3. Review of documents like medical charts to determine compliance shall be limited to those dated at least one (1) week after the last day of the previous pre-accreditation survey and onwards.

V. EVALUATION OF PRE-ACCREDITATION SURVEY FINDINGS AND ACCREDITATION DECISION

The Accreditation Subcommittee and Accreditation Committee shall evaluate the pre-accreditation survey findings and recommend action on the applications. The Accreditation Committee shall correlate the survey findings with monitoring findings on the performance of health care providers as well as with other pertinent data that are relevant in ensuring access to quality health care by PhilHealth members. Based on the result of such evaluation, the Committee shall recommend to the President and CEO; such recommendation may modify that of the surveyors. The President and CEO, based on his discretionary authority, shall have the prerogative to approve, modify or deny the recommendation of the Accreditation Subcommittees and Accreditation Committee.

VI. ACCREDITATION OF HEADS OF THE HOSPITAL

The head of the facility (medical director/chief of hospital administrator) who is a physician should have a valid PHIC accreditation prior to the approval of the application for accreditation of the concerned hospital.

VII. EXTENSION OF ACCREDITATION FOR ACCREDITATION YEAR 2010

In accordance with PhilHealth Board Resolution No. 1380 s. 2010, the accreditation of all accredited hospitals as of April 30, 2010 whose applications for renewal of accreditation or re-accreditation (due to upgrading, change in service capability or late filing) for the 2010 accreditation year are still on process, shall be extended up to October 31,2010. Relative thereto, the provisions of PhilHealth Circular No. 8, s. 2008 regarding any change in the DOH One Stop Shop (OSS) license being reflected in the accreditation of hospitals shall still hold. As such, their accreditation shall be based on the validity of their Department of Health – OSS License.

VIII. PROVISIONAL ACCREDITATION FOR HOSPITALS

A. DOH-OSS LICENSE

1. All hospitals that were given provisional accreditation for the period of January 1 to April 30, 2010 due to the pended DOH license shall be granted regular accreditation. Starting 2011, hospitals shall be granted full accreditation validity period from May 1 of the current year to April 30 of the ending year of award. Claims of said hospitals for patients with admission dates starting January 1 shall only be processed upon submission of their updated DOH licenses. The Corporation shall update the accreditation record of hospitals upon receipt of their DOH-OSS license to reflect the Critical File Updates.

2. Hospitals with gaps in their DOH-OSS license shall also incur gaps in their accreditation corresponding to the gaps in the validity of their DOH-OSS license.

3. Previously paid claims for services rendered during the accreditation gaps and periods of reduction in service capability shall be charged to the pending and/or future claims of the facility.

B. PROVISIONAL ACCREDITATION FOR HOSPITALS DUE TO PARTIAL COMPLIANCE OF THE BENCHBOOK STANDARDS

1.The six (6) month extension of the validity of accreditation overlaps with the period intended for provisional accreditation for 2010 accreditation year. As such, application of provisional accreditation shall be as follows:

Status of Applications	Remarks
1. Applications decided before May 1, 2010	Provisional Accreditation starts on May 1, 2010
2. Applications still on process	Extended accreditation up to October 31, 2010 and provisional accreditation afterwards shall be on a case to case basis.

2. All applications recommended for provisional accreditation including those extended up to October 31, 2010 shall comply within four (4) months after the date of survey to give ample time for the Corporation to validate the compliance before the end validity of provisional accreditation. Early compliance shall result in the hospital being granted regular accreditation earlier.

3. The hospital shall send a notification of compliance to the PhRO within four (4) months from the start of its provisional accreditation to indicate the readiness of the hospital to be re-surveyed.

4. Hospitals that applied for initial accreditation or re-accreditation that qualify only for provisional accreditation shall be granted provisional accreditation for six (6) months or for the remaining period of the accreditation cycle, whichever is shorter.

5. Hospitals granted provisional accreditation should first correct their deficiencies to qualify at least as a Center of Safety within the validity of their provisional accreditation before they may apply for re-accreditation for a higher accreditation award unless they are due for renewal for the succeeding accreditation period. In such cases, the application shall supersede the provisional accreditation and rules for renewal shall apply.

IX. VALIDITY OF ACCREDITATION OF HOSPITALS AWARDED AS CENTERS OF QUALITY/EXCELLENCE

1. Hospitals awarded as Center of Quality or Center of Excellence with two and three years of accreditation, respectively, shall be given full accreditation up to April 30 of the end year of the accreditation period. To Illustrate:

A. Center of Quality:

Example	Date of Compliance to Standards	Start Date of Accreditation	End Date of Accreditation
Hospital A (renewal)	February 20, 2010	May 1, 2010	April 30, 2012
Hospital B (Initial or re-accreditation	January 20, 2010	January 20, 2010	April 30, 2011
Hospital C (Initial or re- accreditation)	September 3, 2010	September 3, 2010	April 30, 2012

B. Center of Excellence:
 

Example	Date of Compliance to Standards	Start Date of Accreditation	End Date of Accreditation
Hospital AA (renewal)	February 20, 2010	May 1, 2010	April 20, 2013
Hospital BB (initial or re-accreditation)	January 20, 2010	January 20, 2010	April 30, 2012
Hospital CC (initial or re-accreditation	September 3, 2010	September 3, 2010	April 30, 2013

2. The validity of accreditation for each succeeding accreditation year shall be provisional pending the submission of updated DOH-OSS licenses and payment of application fees.

3. Non-submission of updated DOH-OSS license and payment of fees on or before January 31 of the applicable accreditation year shall result in the suspension of processing of claims for patients admitted starting January 1 of the applicable year.

All existing issuances inconsistent with this circular are hereby repealed and/or amended.

  (SGD.) DR. REY B. AQUINO
  President and CEO