Guidelines for Accreditation of Hospitals Using the Benchbook Standards, New Application Form, Checklist and Warranties, etc.

November 10, 2009

PHILHEALTH CIRCULAR NO. 50-09

 

Rule IX, Section 50 of the Revised Implementing Rules and Regulations of the National Health Insurance Act (RA 7875) as amended by RA 9241 states that "The Corporation shall implement a Quality Assurance Program applicable to all health care providers for the delivery of health services nationwide." The goal of this program is to achieve the desired health outcomes and member satisfaction through quality health services rendered by accredited health care providers.

In accordance with PhilHealth Board Resolution No. 453, s. 2002, the Benchbook shall be the new accreditation standards of the Corporation. Subsequent issuances provided the initial guidelines towards the full implementation of the Benchbook standards. Circular No. 12, s. 2005, adopted the Benchbook as its main reference for assessing and evaluating the performance of accredited health care providers and made it as the basis for accreditation of hospitals. It also enjoined providers to participate in trainings, workshops and orientations on Benchbook provided or organized by the Corporation. Circular 12, s. 2006 required the establishment of a continuous quality improvement (CQI) program for hospitals applying for accreditation starting 2007. In line with these, the following guidelines, checklist, forms and new warranties of accreditation for hospitals are hereby issued:

Guidelines for Accreditation of Hospitals:

The PhilHealth Benchbook Standards for Health Care Provider Organizations shall be the basis for accreditation of hospitals starting the 2010 accreditation year.

I. Conduct of Self-Assessment:

A hospital that intends to apply for accreditation shall determine its level of achievement/compliance in relation to the PhilHealth Benchbook standards by conducting a self-assessment of its organization, thereby determining which accreditation award it will apply for. The hospital shall institute corrective actions to address the areas for improvement identified during the self-assessment.

A self-assessment shall be conducted by a hospital prior to the submission of its application for accreditation. A copy of the self assessment and survey form shall be secured from the PhROs or may be downloaded from the PhilHealth website at www.philhealth.gov.ph. This form is composed of three parts, namely: 1) Self-assessment and Survey Tool, 2) Score Sheet and 3) Self-assessment Summary.

II. Accreditation Awards:

The following are the Accreditation Awards and the corresponding requirements and accreditation coverage: SCIAaT

Table 1: Accreditation Awards

Accreditation		Requirement	Accreditation
Award				Coverage
Center of	a.	Compliance with 100% of CORE indicators and	1 year
Safety	b.	At least 60% compliance with each of the following
		performance areas:
		1.	Patient Rights and Organizational Ethics
		2.	Patient Care
		3.	Safe Practice and Environment
Center of	a.	Compliance with 100% of CORE indicators and	2 years
Quality	b.	At least 75% compliance with each of the following
		performance areas:
		1.	Patient Rights and Organizational Ethics
		2.	Patient Care
		3.	Safe Practice and Environment
		4.	Leadership and Management
		5.	Human Resource Management
		6.	Information Management
Center of	a.	Compliance with 100% of CORE indicators and	3 years
Excellence	b.	At least 90% compliance with each of the following
		performance areas:
		1.	Patient Rights and Organizational Ethics
		2.	Patient Care
		3.	Safe Practice and Environment
		4.	Leadership and Management
		5.	Human Resource Management
		6.	Information Management
		7.	Improving Performance

III. Filing of Applications

1. PhilHealth shall accept only applications for accreditation with complete documentary requirements.

2. An application fee shall be charged appropriate to the level the hospital is applying for (see payment scheme below).

A. Documentary requirements for application for accreditation of hospitals (Annex B):

1. PhilHealth application form — properly accomplished. (Annex A)

2. Warranties of Accreditation — duly notarized

3. DOH License — with validity applicable to accreditation period applied for

4. Certificate of Membership in PHA/PHAP — with validity applicable to accreditation period applied for

5. Benchbook Self-Assessment and Survey Form — fully accomplished; for 2010 accreditation period, this is optional if hospital already submitted its baseline self-assessment or accomplished Manual II.

a. Self-assessment and survey tool

b. Score sheet cIaCTS

c. Self-assessment summary

6. Accreditation fee — proof of payment

7. Statement of Intent (SOI) — if applicable

a. For Hospitals applying for initial/re-accreditation from January to April (see section III.E, Option A and B regarding validity of accreditation), and/or

b. For hospitals applying as Centers of Quality/Excellence (see section V.2)

 Additional Documentary Requirement for Initial Accreditation:

• DOH licenses for 3 previous years or its required equivalent document/s (Cir. No. 21 s. 2009).

 A hospital shall file its application for accreditation at the designated PhRO/SO where the said institution is located and pay the corresponding application fee. It shall indicate in the application form the accreditation award it is applying for, namely: Center of Safety, Center of Quality or Center of Excellence.

B. Schedule of Filing of Applications:

1. Applications for initial accreditation and re-accreditation may be submitted anytime of the year.

2. For 2010 renewal of accreditation, a hospital shall submit its application for accreditation starting December 1, 2009 until February 1, 2010.

3. The incentive period for filing of 2010 renewal of accreditation is December 1 to 31, 2009. The regular filing period is January 1, 2010 to February 1, 2010. Applications filed after February 1, 2010 shall be subject to a corresponding surcharge as shown in Table 2. Filing date shall be reckoned from the date of submission of complete documents.

C. Applications with Incomplete Documentary Requirements:

1. Applications with incomplete documentary requirements shall be returned and a notice of deficiency/ies on documentary requirements shall be issued to the applicant according to the following schedules: ICTDEa

a. Walk-in applicant: immediately upon receipt of the incomplete application

b. Mailed application: within five (5) working days from receipt of incomplete application

2. The applicant hospital shall be advised to complete the required document/s within thirty (30) days from receipt of notice of deficiency/ies.

D. Payment Scheme:

1. Applications for 2010 renewal of accreditation that are received during the incentive period of from December 1 to 31, 2009 shall be given a ten percent (10%) discount from the amount of the regular accreditation fees.

2. Applications for renewal of accreditation received after the prescribed filing period shall incur penalty charges in addition to the regular accreditation fee and shall be tagged as re-accreditation.

3. Schedule of Accreditation Fees.

 The schedule of accreditation fees is as follows:

Table 2: Application Fees for Accreditation of Hospitals

4. The application fee is non-refundable.

5. A hospital awarded as a Center of Quality or a Center of Excellence shall pay the application fee for the level and submit its updated DOH license and PHA/PHAP Certificate of Membership every January of the succeeding year, in accordance with the regular accreditation filing period. For hospitals that failed to submit their updated licenses, the rule on provisional accreditation due to absence of DOH license (Section VI.1 of this circular) shall apply. DEIHSa

E. Applications of IHCPs for initial/re-accreditation filed and surveyed within the months of January to April

 As a result of the fixed accreditation period that ends on April 30 of each year, hospitals that filed their applications from January 1 to April 30, and are surveyed on or before April 30 may be granted accreditation only for four (4) months or less. Therefore, these hospitals shall have the following options:

 OPTION A.

1. The start date of the accreditation shall be on the date of the last day of the conduct of pre-accreditation survey. It shall be valid until April 30 of the accreditation year. Thus, for 2010 applications, the hospitals' accreditation shall be valid only until April 30, 2010.

2. The hospital shall renew its accreditationwithin thirty (30) days from receipt of the letter of approval of accreditation by submitting the following:

a. Application form for renewal of accreditation — duly accomplished

b. Warranties of Accreditation — duly notarized

c. Accreditation fee

3. Said hospital shall be exempted from the penalty charges for late filers and therefore shall pay the applicable accreditation fee as reflected in Table 2, Prescribed Filing Period column.

4. The succeeding accreditation period shall be valid from May 1 to December 31 of the accreditation year and provisional from January 1 to April 30 of the succeeding year (See Section VI.1).

5. Hospitals that file their application for renewal of accreditation after thirty (30) days from receipt of the letter of approval may incur a gap in their accreditation and their application shall be considered as an application for re-accreditation. 

 OPTION B. The hospital agrees that the validity date of accreditation shall start on May 1 of the accreditation year:

1. The hospital shall inform the Corporation that in case their application for initial or re-accreditation is approved on or before April 30 of the accreditation year, they agree that the start date of their accreditation shall be valid from May 1 to December 31 of the accreditation year, by signing the statement of intent contained on Annex C. Provisional accreditation shall be granted from January 1 to April 30 of the succeeding year as a result of the pendency of the hospital license (See Section VI.1). EaCSTc

2. Failure of the hospital to sign the statement of intent contained on Annex C regarding the start date of the validity of accreditation shall result in the application of Option A.

IV. Pre-Accreditation Survey:

1. PhilHealth shall conduct pre-accreditation survey only in hospitals that have submitted applications with complete documentary requirements.

2. The hospital shall be notified within thirty (30) days from receipt of its complete application for accreditation regarding the date of the conduct of pre-accreditation survey.

3. The PhilHealth Survey Team shall utilize the same survey tool used by the hospital to validate its compliance to the Benchbook Standards.

4. The pre-accreditation survey shall be conducted for a maximum duration of one (1) day for a Level 1 hospital, two (2) days for a Level 2 hospital and three (3) days for a Level 3 or 4 hospital.

5. The PhilHealth survey team shall provide feedback to the hospital management regarding their findings from the survey.

6. Pre-accreditation survey results shall be valid for six (6)-months from the last day of the survey. Therefore, the PhRO may not conduct another pre-accreditation survey for subsequent application filed unless necessary.

V. Deliberation of Applications for Accreditation

1. All applications evaluated shall be deliberated by the Accreditation Committee or the PhRO Accreditation Sub-committee within thirty (30) days from the last day of the pre-accreditation survey.

2. A hospital that does not qualify for the accreditation award it is applying for may be downgraded to the accreditation award it is compliant with as reflected in the statement of intent signed by the authorized hospital representative upon filing its application for accreditation. Otherwise, the said application shall be denied by the Corporation.

3. If the accreditation is denied or downgraded, the hospital is given the opportunity to seek for a review of the decision through a motion for reconsideration (MR) on the final decision of the Corporation within thirty (30) days from receipt of notice on the status of its application for accreditation. The PhRO may conduct a survey within two (2) weeks from receipt of the MR to validate the compliance of a hospital whose application for accreditation was denied or downgraded. Should the hospital decide not to file an MR, it may file another application for accreditation.

VI. Validity of Accreditation

The accreditation granted by the Corporation to hospitals is valid in accordance with the following schedule: CacTSI

Table 3: Validity of Accreditation

Type of	Start Date	End Date	Provisional
Accreditation			Accreditation
Initial	Date of the last day of conduct of	December 31	January 1-
Re-Accreditation	pre-accreditation survey	of the	April 30 of the
Renewal	May 1 of the accreditation year	accreditation	succeeding
		year	year

A provisional accreditation may be granted for a period as may be determined by the Corporation in accordance with the following conditions:

1. Secondary to DOH — One Stop Shop license

Accreditation of hospitals for the succeeding year (January 1 to April 30) shall be provisional pending the submission of their updated DOH licenses and PHA/PHAP Certificate of Membership. Processing of claims shall be put on hold beginning January 1 admissions. Failure to submit the said documents before the end of the filing period (month of January) shall invalidate the provisional accreditation. Claims filed for admissions during the said period shall not be paid.

2. Secondary to partial compliance of the Benchbook Standards

The Corporation may grant provisional accreditation for six (6)-months to a DOH-licensed hospital based on any of the two (2) following conditions:

a. Compliance with the Benchbook standards:

1. At least 70% but below 100% compliance to core indicators or

2. Below 60% compliance to any of the following performance areas, with no scores less than 50% to each:

a. Patient Rights and Ethics

b. Patient Care

c. Safe Practice and Environment

b. The hospital is located in a far flung area as determined by the Corporation

Upon compliance with accreditation standards and requirements within the six (6)-month period, the hospital shall be granted accreditation as a Center of Safety. Inability of the hospital to achieve compliance within the duration of its provisional accreditation shall result in the termination of its accreditation.

The hospital may apply for initial or re-accreditation anytime.

VII. Performance of Hospitals

Accredited hospitals are enjoined to show improvement of its compliance with the Benchbook standards upon filing of applications for subsequent renewal of accreditation. aSAHCE

Hospitals are responsible and solely accountable for the quality of their services and overall performance. In order to improve and sustain the level of performance of accredited hospitals, PhilHealth shall conduct monitoring activities on hospitals in accordance with the Benchbook standards.

VIII. Upgrading of Hospitals

A currently accredited hospital may apply for re-accreditation for upgrading for the following reasons:

1. The DOH has issued a license to the hospital for a higher level of service capability, or

2. the hospital has achieved a higher level of performance such that it now aspires for a higher award — e.g., Center of Quality or Center of Excellence.

IX. Certificates and Letters of Accreditation

1. A Certificate of Accreditation reflecting the Accreditation Award and the date of validity shall be issued for all approved applications.

2. The PhROs shall send the Certificates of Accreditation and all communications to the concerned hospital within five (5) working days from the date of approval of accreditation by the Corporation.

All existing policies, orders and other issuances that are inconsistent with this Circular are hereby repealed and/or amended accordingly.

This circular shall take effect immediately.

 

(SGD.) DR. REY B. AQUINOPresident and CEO

ANNEX A

Application Form for Accreditation

Institutional Health Care Provider

Warranties of Accreditation for Institutional Health Care Providers

A. Representation of Eligibilities

1. We are a ____(indicate type of institution)____ duly registered and licensed by the Department of Health (DOH); (applicable to licensed institutions only, namely: hospitals, ASCs and FSDCs)

2. All our officers, employees, other personnel and staff are members in good standing of the NHIP and we undertake to maintain active membership in the NHIP by regularly remitting the corresponding PHIC premium contributions of all our employees not only during the entire validity of our accreditation as an Institutional Health Care Provider (IHCP) but also during the corporate existence of our health care institution;

3. We have read, understood and are fully aware of the provisions of R.A. 7875 including its Implementing Rules & Regulations particularly that pertaining to and governing the extent and limits of the grant of our privilege to be an accredited IHCP of the NHIP administered by the PHIC.

B. Compliance to Pertinent Laws/Rules & Regulations/Policies/Administrative Orders and Issuances

4. We shall conduct our health care service operations strictly and faithfully in accordance with the provisions of the Republic Act 7875 as amended as the National Health Insurance Law of the Philippines including all its Implementing Rules & Regulations (IRR);

5. We shall strictly abide with all the implementing rules and regulations, memorandum circulars, office orders, special orders and other administrative issuances issued by the PHIC governing our accreditation;

6. We shall strictly abide with all Administrative Orders, Circulars and such other policies, rules and regulations issued by the Department of Health (DOH) and all other government agencies and instrumentalities governing the operations of IHCPs and affecting our accreditation with the PHIC;

7. We shall strictly adhere and abide with all the pertinent statutory laws affecting the operations of IHCPs and affecting our accreditation including, but not limited to, the Expanded Senior Citizens Act of 2003 (R.A. 9257), the Breastfeeding Act (R.A. 7600), the Newborn Screening Act (R.A. 9288), the Cheaper Medicines Act (R.A. 9502), the Pharmacy Law (R.A. 5921), the Magna Carta for Disabled Persons (RA 9442) and all other laws that may thereafter be passed by the Congress of the Philippines or any other authorized instrumentalities of the government. CcTIAH

C. Conduct of Clinical Services, Records, Preparation of Claims and Undertakings of Participation in the NHIP

8. We are fully aware and we hereby acknowledge that accreditation with the NHIP administered by the PHIC is not a right but a mere privilege as provided under Section 31, Article VII of R.A. 7875 on the 'Authority to Grant Accreditation' by the PHIC;

9. We are fully aware and we hereby acknowledge that our accreditation being a mere privilege extended by the NHIP, the grant of which may be provisional, temporary and limited within a particular period as may be determined by the PHIC. We further acknowledge and accept that our accreditation including the appurtenant benefits and opportunities incident thereto, being a mere privilege may be suspended, shortened, pre-terminated and/or revoked at any time during the term of our accreditation as may be determined by the PHIC to protect the interests of the NHIP;

10. We are fully aware and we unconditionally acknowledge and agree that any violation of any provision of our warranties of accreditation whether directly or indirectly, shall constitute 'breach of warranties' and shall be a ground at the sole discretion of the PHIC, to suspend, shorten, pre-terminate and/or revoke our accreditation including the appurtenant benefits and opportunities incident thereto at any time during the term of our accreditation as may be determined by the PHIC to protect the interests of the NHIP;

11. We are fully aware and we unconditionally acknowledge and agree that any indication(s), adverse reports/findings of pattern or any other similar incidents which may be indicative of any illegal, irregular or improper and/or unethical conduct of our operations may be a ground at the discretion of the PHIC, to suspend, shorten, pre-terminate and/or revoke my accreditation including the appurtenant benefits and opportunities incident thereto at any time during the term of our accreditation as may be determined by the PHIC to protect the interests of the NHIP;

12. We undertake that all qualified NHIP beneficiaries shall be given high quality of health care service due them without delay and that we shall deduct without delay the correct amount of chargeable benefits due to qualified members and beneficiaries upon discharge;

13. We shall promote and protect the NHI Program against abuse, violation and/or over-utilization of its Funds and we will not allow our institution to be a party to any act, scheme, plan or contract that may directly or indirectly be prejudicial to the Program;

14. We shall not directly or indirectly engage in any form of ethical or improper practices as an accredited provider such as, but not limited to, solicitation of patients for purposes of compensability under the NHIP, the purpose and/or the end consideration of which tends unnecessary financial gain rather than promotion of the NHIP thereby ultimately undermining the greater interests and noble purpose of the NHIP; SHaIDE

15. We hereby undertake that we shall immediately report to the PHIC, its Officers and/or to any of its personnel, any act(s) of illegal, improper and/or unethical practices of IHCP of the NHIP ^* that may have come to our knowledge directly or indirectly;

16. We shall undertake measures to ensure that we only enter true and correct data in all patients' records, shall take full responsibility for any inaccuracies and/or falsities entered into and/or reflected in our patients' records as well as in any omission, addition, inaccuracies and/or falsities entered into and/or reflected in claims submitted to PHIC by our institution, and we further undertake to file before the PHIC only legitimate claims recognizing the period of filing within the sixty (60) calendar days after the patient's discharge;

17. We shall make available immediately and promptly upon request for PHIC purposes, make available a complete listing of our schedule of standard provider fees readily available to PHIC Officers and authorized personnel, members, dependents and/or representatives;

D. Management Information System

18. We shall have a PhilHealth Bulletin Board for the posting of updated information of the NHIP (circulars, memoranda, IEC materials, price reference index, etc.) located at the Billing Section or in a conspicuous place accessible to patients, members and dependents of the NHIP within our health care facility;

19. We shall, at all times make available the necessary forms for patient's use;

20. We shall, at all times make available a copy of the PNDF for use of health care professionals;

21. In the event of suspension or revocation of our accreditation, we shall voluntarily cover/remove our "PhilHealth-Accredited" Signage posted within our health care facility to accordingly inform the members and dependents of the NHIP. We further undertake and agree that in the event of our failure and/or refusal to accordingly cover/remove the "PhilHealth-Accredited" Signage posted within our health care facility, the PHIC shall have the right to cover/remove the same the costs of which shall be directly chargeable to our institution. We finally undertake and agree that any misrepresentation and/or resulting damage and/or liabilities arising out or a consequence of our failure to cover/remove the "PhilHealth-Accredited" Signage shall be the exclusive responsibility of our institution;

22. We shall accordingly seek prior consent of the PHIC when the official PhilHealth Logo will be included in any information campaign material(s) or the like outside the regular information drive activities conducted by the PHIC.

E. Administrative Investigations/Regular Surveys/Domiciliary Visitations on the Conduct of Operations in the Exercise of the Privilege of Accreditation

23. We unconditionally recognize the authority of the PHIC, its Officers and personnel and/or its duly authorized representatives to conduct regular surveys, domiciliary visits and/or conduct administrative assessment(s) at any time relative to the exercise of our privilege and conduct of our operations as an accredited IHCP of the NHIP; HDAaIS

24. We undertake that we shall fully cooperate with duly recognized authorities of the PHIC and any other authorized personnel and instrumentalities to provide access to patient records and submit to any assessment to be conducted by the PHIC relative to any findings, adverse reports, pattern of utilization and/or any other acts indicative of any illegal, irregular and/or unethical practices in our operations as an accredited IHCP of the NHIP that may be prejudicial or tends to undermine the noble purpose of the NHIP and make available all pertinent official records and other pertinent documents including the provision of copies thereof;

25. We undertake that we shall accordingly instruct our officers, employees and personnel to extend full cooperation as well extend due courtesy and respect to all PHIC officers, employees and staff during the conduct of assessment/visitation/investigation of our operations as an accredited IHCP of the NHIP;

26. We undertake that we shall comply without delay any and all PHIC's summons, subpoena, subpoena 'duces tecum' and other legal or quality assurance processes;

27. We undertake that at any time during the period of our accreditation, upon request of the PHIC, we shall voluntarily and unconditionally sign and execute a new 'warranties of accreditation' to cover the remaining portion of our accreditation or to renew our accreditation as the case may be, as a sign of our good faith and continuous dedication and commitment to comply with the warranties of our accreditation, to support and promote the NHIP being administered by the PHIC;

28. Finally, we hereby declare under penalties of perjury that the above-stated statements are true and correct without any conditions and free from misrepresentations.

IN WITNESS HEREOF, I have hereunto set my hand this ___ day of ________________, 2____ at _________________, Philippines.

_______________________________________

REPUBLIC OF THE PHILIPPINES

SUBSCRIBED AND SWORN to before me this ____ day of _________, 2____, Affiant exhibiting to me his/her Community Tax Certificate No. ________ issued at ______ on ____________.

NOTARY PUBLIC 

ANNEX B

Checklist of Requirements for Application for Accreditation

Institutional Health Care Providers

I. General Requirements: ADHaTC

___ 1. PhilHealth application form — properly accomplished

___ 2. Warranties of Accreditation — duly notarized

___ 3. Accreditation fee — proof of payment (see back for appropriate fee schedule).

II. Specific Requirements: (in addition to the above, the following are specific requirements per type of institution)

A. Hospitals (Levels 1, 2, 3 and 4)

___ 1. DOH License — with validity applicable to the accreditation period applied for

___ 2. Certificate of Membership in PHA or PHAP — with validity applicable to the accreditation period applied for

___ 3. Benchbook Self-Assessment and Survey Form — fully accomplished; for 2010 accreditation period, this is optional if hospital already submitted its baseline self-assessment or accomplished Manual II.

a. Self Assessment and Survey Tool

b. Score Sheet

c. Self-Assessment Summary

___ 4. Statement of Intent (SOI) — if applicable

a. For Hospitals applying for initial/re-accreditation from January to April regarding to validity of accreditation, and/or

b. For hospitals applying as Centers of Quality/Excellence

 Additional Requirement for Initial Accreditation:

___ DOH licenses for 3 previous years or its required ^* alternative document

B. Ambulatory Surgical Clinics & Free Standing Dialysis Clinics

___ Current DOH license

 Additional Requirements for Initial Accreditation:

___ DOH license for 3 previous years or its required ^* alternative document

C. Out Patient Benefit Package, Maternity Care Package, and Anti-TB/DOTS Package Providers: DACTSH

___ 1. Location map

___ 2. PhilCAT Certificate — optional for initial accreditation of DOTS Providers.

* NOTE: Applications for initial accreditation that are non-compliant with the three (3) year rule requirement may refer to PhilHealth Cir. 21 s. 2009 for alternative requirements.

III. Schedule of Application Fees:

 

* Applications filed after the validity of their accreditation

** Applications filed after the prescribed filing period but within the validity period

*** Only applicable to government facilities

ANNEX C

Statement of Intent

For Institutional Health Care Providers

Date: ______________________________

Name of Hospital: ___________________________________________________

Address: ___________________________________________________________

Sign the applicable items if you agree to the statements below:

1. For Initial/Re-accreditation

a. I agree that, in case the pre-accreditation survey is conducted in my hospital on or before April 30, and the application is deliberated before May 1 of the accreditation year, the start of my accreditation will be prior to May 1 and I will file my application for renewal of accreditation within thirty (30) days from receipt of notice of approval of accreditation. (Option A).

____________________________________________

b. I agree that, in case the pre-accreditation survey is conducted in my hospital on or before April 30, and the application is deliberated before May 1 of the accreditation year, the start of my accreditation will be on May 1 (Option B). DCcHAa

____________________________________________

2. Downgrading of Accreditation Award

I agree that, in case my hospital does not qualify for the accreditation award it has applied for, the hospital be granted the Accreditation Award it is compliant with.

____________________________________________