Department of Health BUREAU OF HEALTH FACILITIES AND SERVICES Building 15, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Trunk Line: 743-83-01; Direct Line: 711-6982; Fax: 781-4179 URL: http://www.doh.gov.ph/
LICENSING REQUIREMENTS OF A DIALYSIS CLINIC
PERSONNEL
1. A Board Certified Nephrologist shall be the head of the clinic. In areas where there is no Board Nephrologist, as certified by the Philippine Society of Nephrology, a board-qualified physician shall be the head of the clinic for a maximum period of three (3) years. After this three-year period, a Board Certified Nephrologist must head the clinic.
2. A Duty Physician who must meet the following requirements: Completed an accredited Internal Medicine Residency Program Experience in the care of patients with end stage renal disease Certificates of training on Basic and Advanced Life Support
He shall be physically available to patients during hours of operation. The ratio of duty physician to patient bed shall be 1:15.
3. Dialysis Nurse must meet the following requirements: Duly licensed Current member of the Renal Nursing Association of the Philippines (ReNAP) or its equivalent Certified IV therapy nurse Hospital/clinical work experience for at least six (6) months Certificates of training on Dialysis for not less than thirty (30) days and on Basic Life Support
The ratio of nurse to patient bed shall be 1:4.
4. There shall be adequate number of administrative personnel to facilitate non- related work in the facility.
5. A personnel record folder shall be maintained for each employee. The folder shall contain physical examination, laboratory test results, resume, and current job description that reflect the employees responsibilities and work assignments.
Page 2 of 5 PHYSICAL PLANT
1. Dialysis Service Complex Dialysis station shall be designed to provide adequate space area and safe treatment as well as to ensure the privacy of patients. The area shall not be less than 6 square meters to accommodate a chair, the dialysis equipment and emergency equipment if needed. Separate dialysis machine shall be designated solely for use of Hepatitis B patients. Nursing station shall be located in an area that allows adequate surveillance of patients on dialysis machines. It shall also be the releasing area for post-hemodialysis patients. Storage area for sterile instrument/supplies and other materials. Work area that contains a work counter, hand washing sink, storage cabinets. Toilet facility for the staff/patients with urinal, water closet, and lavatory. Water treatment area
2. Non-Treatment Area Business area for information service, admitting section, cashier Waiting area with sufficient seats for patients and visitors Pantry
3. Water supply for all purposes shall be adequate in volume and pressure. Water used for dialysis purposes must be analyzed for bacteria at least monthly, for chemicals at least every six months and treated as necessary to maintain a continuous water supply that is biologically and chemically compatible with acceptable dialysis techniques. The bacterial count shall be <200 col/cc. The minimum chemicals to be analyzed are aluminum, chlorine, fluoride and copper.
4. All plumbing shall be installed in such a manner as to prevent back flow or cross-contamination between potable and non-potable water supplies.
5. The facility shall be provided with effective and suitable ventilation to maintain comfortable room temperature.
6. The facility shall be provided with sufficient intensity of illumination to provide effective nursing care.
EQUIPMENT/SUPPLIES
1. Stethoscope 2. Sphygmomanometer 3. Examining light 4. Oxygen unit with gauge 5. Minor surgical instrument set 6. Instrument table Page 3 of 5 7. Dialysis machine(s) *
8. Dialysis chair(s), capable of full recline and the trendelenberg position 9. E-cart with the following supplies: (a) IV fluids (b) IV line (c) Insyte/abbocath (d) Intubation set (endotracheal tubes, laryngoscope, ambu bag) (e) Emergency drugs such as: Dopamine IV infusion Isosorbide dinitrate tablets Diazepam (tablets and IV) Diphenhydramine maleate 50 mg/amp Hypertonic saline D 50 W 50cc vial Parenteral antihypertensive medications Others (Clonidine tablets, Calcium gluconate, Epinephine, Lidocaine, Salbutamol, Sodium bicarbonate IV solution)
10. Goose neck lamp 11. Standby rechargeable light 12. ECG machine 13. Suction machine 14. Defibrillator with cardiac monitor 15. Stretcher 16. Wheelchair 17. Others (a) Standby generator (at least 20 kva) (b) Fire extinguisher (c) Ambulance or transport vehicle or contract with providers such as ambulance services (d) Water treatment equipment Multi-media filter Bulk filters Carbon filter Softener Reverse Osmosis machine Storage tank for Reverse Osmosis (e) Acceptable Disinfectant for re-use procedure
TRANSFER AGREEMENT/REFERRALS
Each clinic shall have a Memorandum of Agreement with one or more hospitals, with service capability of at least a secondary care hospital, for the provision of in-patient care especially emergencies and other hospital services. However, the patients of their relatives should be allowed fo choose which hospital to patronize.
* At least one of the dialysis machines uses bicarbonate as dialysate buffer Page 4 of 5 RECORDS
The clinic shall maintain a record system to provide readily available information on the following: 1. Patient care Dialysis charts Standing order for hemodialysis updated quarterly Physicians order Completed consent form updated annually Patients monitoring sheet Standing order for medication Laboratory results Confinements with corresponding date and name of hospital History and physical examination Problem list Transfer/referral slip (for patients that will be transferred or referred to another health facility)
2. Incident and accident (in logbooks) Complications related to dialysis procedure Complications related to vascular access Complications related to disease process Dialysis adequacy of patients on thrice weakly treatments Outcomes Staff/patients hepatitis status
3. Staff and patient vaccination Hepatitis B (double dose) 0, 1,2,6 months Influenza annually Pneumococcal every 5 years
4. Water treatment Bacteriological Chemical
5. Administrative Minutes of the facilitys staff meetings Reports of DOH inspections
6. Facility and equipment maintenance schedule Preventive maintenance Corrective measures
RECORDING AND REPORTING
The clinic shall register their patients to the Renal Disease Registry in support to the REDCOP of the DOH and in coordination with the Philippine Society of Nephrology. Likewise, an annual statistical report shall be submitted to REDCOP.
Page 5 of 5 POLICIES AND PROCEDURES
The clinic shall provide a policy and procedure manual, which is designed to ensure professional and safe care for the patients.
QUALITY ASSURANCE PROGRAM
The clinic shall provide a quality assurance program to evaluate the provision of patient care. The program shall have a written plan and implementation shall be continuous with periodic review.
WASTE MANAGEMENT PROGRAM
The clinic shall have written and established waste management program with special treatment on infectious/pathological waste. Waste management shall be in accordance with the revised Manual on Health Care Waste Management.
EXHIBITION OF LICENSE
The license to operate of the clinic shall be posted in a conspicuous space readily seen by the public. A copy of these rules and regulations shall be readily available for reference and guidance of the clinic staff and personnel.