1. ADMINISTRATIVE ORDER No. 2016-0029 Rules and Regulations Governing the Licensure of Ambulance and Ambulance Service Providers ATTY. NICOLAS B. LUTERO III, CESO III Director IV Health Facilities and Services Regulatory Bureau

2. Outline of the Issuance  Rationale/Background  Objectives  Scope  Definition of Terms  Implementing Mechanisms  Procedural Guidelines  Schedule of Fees  Violations  Investigation of Charges and Complaints  Penalty  Appeal  Transitory Provision  Repealing Clause  Separability Clause  Effectivity

3. Rationale/Background  Administrative Order 2010-0003  National Policy on Ambulance Use and Services  Section VI.A.4  Bureau of Health Facilities and Services shall establish licensing standards for ambulance services and ensures their implementation through regulation. The license of hospital-based ambulance service shall be part of the hospital license. All other ambulance services shall require a separate license  In line with the Kalusugan Pangkalahatan strategic thrust to improve access to safe, quality and affordable ambulance services in the pre-hospital setting

4. Objectives  To set the minimum standards and requirements for ambulances and ambulance service providers.  To ensure the safety of patients, personnel and the general public.

5. Scope and Coverage Shall apply to all government and private land ambulances and ambulance service providers.

6. Implementing Mechanisms: General Guidelines  Ambulance service providers shall secure registration for all vehicles at the Land Transportation Office (LTO) prior to application for license to operate.  Ambulance service providers shall secure DOH-LTO per vehicle to be issued by HFSRB.  Ambulance service providers shall ensure that they are part of a functional referral network within the area/vicinity where they are allowed to operate.  Stakeholders shall strictly comply with the standards, criteria and requirements prescribed in the Assessment Tool for licensure of ambulances and ambulance service providers.

7. Implementing Mechanisms: General Guidelines  The DOH-LTO of ambulance service providers shall be valid for three (3) years, from January of the first year to December of the third year.  Institution-based ambulance services shall be included in the One-Stop Shop (OSS) licensure system for hospitals and other health facilities. The DOH-LTO of the ambulance shall be reflected in the health facility DOH-LTO. Hence, a separate DOH-LTO is not required.  Non-institution-based ambulance service providers shall secure a separate DOH-LTO.  The plate or conduction sticker number AND Certificate of Registration (CR) number of each ambulance vehicle shall be reflected in the DOH-LTO of the ambulance service providers  Ambulance vehicles from non-licensed ambulance service providers shall be forwarded to the Land Transportation Office for appropriate action.

8. Implementing Mechanisms: Specific Guidelines (Classification)  Ownership: Government or Private  Functional Capacity: Land, Air and Water Ambulance  Institutional Character: Institution-based and Non-institution-based

9. Implementing Mechanisms: Specific Guidelines (Standards)  Ambulance Service Provider  Personnel  Ambulance (vehicle)  Equipment, Medicines and Supplies  Service Delivery  Information Management  Environmental Management

10. Implementing Mechanisms: Specific Guidelines (Standards)  Ambulance Service Provider  A private ambulance service provider shall be registered with the Department Trade and Industry (DTI) or with the Securities and Exchange Commission (SEC), whichever is applicable. For government ambulance services, a local government ordinance or board resolution stating ownership of ambulance vehicles shall be required.  The ambulance service provider shall be housed in a business office / space that can also serve as the Operations Control and Dispatch Center of the ambulances. The office shall have adequate parking spaces for the ambulance/s they own.  The ambulance service provider shall have a minimum ratio of 1 set of personnel for every 2 ambulances owned. A minimum set of personnel consists of two (2) responders and a driver.  The ambulance service provider shall ensure that each personnel has obtained the minimum trainings stipulated in this Order.

11. Implementing Mechanisms: Specific Guidelines (Standards)  Personnel  A minimum of at least two (2) responders, excluding the driver, is required for every ambulance dispatched. Additional staff depends on the nature of the emergency as determined by the management of the service provider.  There shall be staff development and continuing education program to upgrade the knowledge, attitude and skills of staff.  Responders shall be Standard First Aid, BLS, EMT and ACLS-trained from a DOH-recognized training provider.

12. Implementing Mechanisms: Specific Guidelines (Standards)  Ambulance  An ambulance vehicle shall be able to accommodate the patient, and the required number of personnel and equipment.  The ambulance vehicle shall be registered with the LTO under the name of the ambulance service provider.  Ambulances shall bear the following markings:  The word AMBULANCE shall be seen at the back and at front of the vehicle, which is spelled out in reverse. The height of each letter shall be no less than 0.15 meters and the word shall be seen at least six (6) meters away.  The prescribed DOH logo (Refer to Annex-A: Official DOH Ambulance Logo). This logo shall be placed on both sides of the ambulance. On top of the DOH Logo, the phrase LICENSED BY DOH shall be placed.  Any signage and other images outside of what is prescribed by DOH are not allowed.

13. LICENSED BY THE DOH

14. Implementing Mechanisms: Specific Guidelines (Standards)  Ambulance  Vehicles labeled as ambulances which are used outside of its intended scope/purpose shall not be allowed. Violators shall be dealt accordingly.  i.e. Funeral parlors using and misusing the term ‘AMBULANCE’ in their multipurpose transport vehicles shall be reported to the concerned Local Government Unit (LGU) or to Department of Health (DOH) for appropriate action.  Ambulance vehicles shall have Emergency Warning Light System and Siren- Public Address System.

15. Implementing Mechanisms: Specific Guidelines (Standards)  Equipment, Medicines and Supplies  Each ambulance shall be adequately equipped with appropriate equipment, medicines and supplies. (Refer to Annex B: Required Emergency Equipment, Supplies and Medicines)  Each ambulance shall have adequate and stable cabinet/s that can appropriately store the required equipment, medicines and supplies. These storage shall be easily accessible but properly secured at all times.  The use of Personal Protective Equipment (PPEs) and adherence to infection control policies shall be strictly observed.  There shall be a program for calibration, preventive maintenance and repair of equipment, including decontamination and disinfection.  There shall be a contingency plan in case of equipment breakdown and malfunction, especially during patient transport.

16. Implementing Mechanisms: Specific Guidelines (Standards)  Service Delivery  Each ambulance service provider shall have documented policies and procedures on its administrative and technical Standard Operating Procedures (SOP) for the provision of its services.  Each ambulance service provider shall have documented policies and procedures on the establishment of its referral system.  The inter-facility referral network shall be strengthened through linkages of all levels of care and partnerships (of hospital and EMS).  Ambulance service providers shall have a Memorandum of Agreement (MOA) with hospital facilities. The MOA shall not apply when the patient expresses preference for a certain facility and in cases of extreme medical emergencies.

17. Implementing Mechanisms: Specific Guidelines (Standards)  Service Delivery  Ambulances shall have communication devices linked to the operations center of the ambulance service provider and the referral hospital for recording and effective management of cases.  Medical direction shall be part of the ambulance service.  All patients being transported by ambulance shall have standard patient record form.

18. Implementing Mechanisms: Specific Guidelines (Standards)  Information Management  Hospital Referral Form  Each form shall be kept confidential and shall contain sufficient information to identify the patient and to justify the treatment provided, which includes the information of transfer/referral of patient to another physician or health facility.  Logbook  Ambulance service providers shall maintain a logbook which shall be signed by the head of the DOH licensing team during inspection and/or monitoring visits. The logbook shall contain, but not be limited to, the following information (Refer to Annex C: Logbook of Accomplishments for Inspection and Monitoring):  Name, sex and age of patient;  Name of attending physician, when applicable;  Origin and destination;  Date and time of dispatch and return of ambulance;  Reason for transfer/transport.  Disposition of patient.

19. Implementing Mechanisms: Specific Guidelines (Standards)  Information Management  Submission of Reports  Ambulance service providers shall submit an annual report utilizing the template provided by DOH on or before 31 March. The report shall contain, but not be limited to, the following information. (Refer to Annex-D: DOH Annual Statistical Report for Ambulance Service Providers)  Number of ambulance conductions stating Regional Office, Province, Municipality, City, including the type of the health facility:  Inter-facility hospital to hospital  Other health facilities to hospital (e.g. Medical Out-Patient Clinics, RHU, birthing facility, infirmary, drug abuse and treatment centers, psychiatric custodial care facility, nursing homes)  Home to hospital  Hospital to Home  Other routes, specify. (i.e. Hospital to Airport/Ports or vice versa)  Reason for referral/transport  Date, time and description of Adverse Events e.g. number of deaths en route, if any. In case of ambulance death referred by a hospital, the referring hospital shall issue the death certificate. Otherwise, the City/Municipal Health Officer, where the patient died, shall issue the death certificate.

20. Implementing Mechanisms: Specific Guidelines (Standards)  Environmental Management  The ambulance shall be properly ventilated, lighted, clean and safe.  The ambulance shall have a partition between the driver and the compartment or body. The partition shall be air-tight bulkhead with transparent viewing panel.  There shall be a written plan and program of proper disinfection and preventive maintenance of the ambulance vehicles  There shall be procedures for the proper disposal of infectious wastes and toxic and hazardous substances in accordance with R.A. 6969 known as “Toxic and Hazardous Substances and Nuclear Wastes Act” and other related policy guidelines and/or issuances.

21. Procedural Guidelines: Initial DOH-LTO  Ambulance owners and ambulance service providers shall submit the following relevant documents to HFSRB:  Duly accomplished application form. This form can be downloaded from http:/hfsrb.doh.gov.ph/. http:/hfsrb.doh.gov.ph/  Proof of ownership  Department of Trade and Industry (DTI);  Securities and Exchange Commission (SEC) Registration with Articles of Incorporation and By-laws;  Enabling Act or Board Resolution for government;  Cooperative Development Authority Registration with Articles of Cooperation and By-laws, whenever applicable  Registration of the vehicle(s) from the Land Transportation Office  License of the ambulance driver/s as Professional Driver, from the Land Transportation Office

22. Procedural Guidelines: Initial DOH-LTO  Pay the corresponding fee, and submit a copy of the official receipt to HFSRB.  Once the application has been approved, the ambulance service provider shall be given a copy of the Official DOH Ambulance Logo and this shall be mounted accordingly to each ambulance vehicle prior to the issuance of the DOH-LTO. Each ambulance vehicle shall have a copy of DOH-LTO of the ambulance service provider.

23. Procedural Guidelines: Renewal DOH-LTO  Ambulance owners and ambulance service providers shall prepare following relevant documents prior to application.  Duly accomplished application form. This form can be downloaded from http:/hfsrb.doh.gov.ph/. http:/hfsrb.doh.gov.ph/  DOH annual ambulance statistical report  other relevant records as may be required by DOH  Applicants shall submit the application to the following offices, which shall receive and process the renewal application  HFSRB for non-institution-based ambulance service providers and level 2 and 3 hospital-based ambulance service providers.  Regional Offices for Infirmary and Level 1 hospital-based ambulance service providers

24. Procedural Guidelines: Renewal DOH-LTO  Pay the corresponding fee, and submit a copy of the official receipt to HFSRB or Regional Office, whichever is applicable.  Once the application has been approved, the ambulance service provider shall be given a copy of the Official DOH Ambulance Logo and this shall be mounted accordingly to each ambulance vehicle prior to the issuance of the DOH-LTO. Each ambulance vehicle shall have a copy of DOH-LTO of the ambulance service provider  The DOH-LTO of an ambulance shall be cancelled automatically without notice upon failure to submit a duly accomplished application form and to pay the proper fee beyond thirty (30) days from the date of expiration stated in its license. Thereafter, the service provider shall apply as initial DOH-LTO

25. Procedural Guidelines: Inspection  The HFSRB or RO, as the case may be, shall conduct licensure inspections utilizing the Assessment Tool for licensure of ambulances within a 15 working days upon submission of complete requirements  The applicant shall ensure that all key staff, pertinent records, and ambulances are made available to HFSRB/RO Director and/or his authorized representative(s) during inspection visits

26. Procedural Guidelines: Monitoring  Ambulances and ambulance service providers shall be monitored regularly.  The HFSRB or RO Director and/or his authorized representative(s) shall conduct periodic monitoring visits utilizing the Assessment Tool for licensure of ambulances  The applicant shall ensure that all key staff, records, premises and facilities are made available to HFSRB or RO Director and/or his authorized representative(s) during monitoring activities.  A Notice of Violation shall be issued immediately for non-compliance with these rules and regulations.

27. Schedule of Fees All fees, surcharges and discounts shall follow the current DOH prescribed schedule of fees in A.O. No. 2007 – 0001 “Revised Schedule of Fees for Certain Services Rendered by the Bureau of Health Facilities and Services and Centers for Health Development…”, A.O. No. 2007 – 0023 regarding “Schedule of Fees for the One-Stop Shop Licensure System for Hospitals”, and A.O. No. 2008 – 0028 “Schedule of Fees for the One-Stop Shop Licensure System for Non-Hospital Based Facilities…”, other policy guidelines and/or relevant issuances.

28. Schedule of Fees Per year (PhP) Ambulance Service Provider5,000.00 Ambulance (unit)1,000.00

29. Investigation of Charges and Complaints The HFSRB or the RO Director and/or his authorized representative(s) shall investigate the complaint and verify if the hospital or other health facility concerned or any of its personnel is liable for an alleged violation. The HFSRB or RO Director may order the preventive suspension of operation of the concerned ambulance service provider. The preventive suspension shall not be more than ninety (90) days. Upon completion of the deficiencies noted during the investigation, the preventive suspension can be lifted immediately, and impose the appropriate penalty for the violation

30. Sanctions and Penalties Number of OffensePenaltyFine First OffenseSuspension of LTO for 30 daysPhP 20,000.00 Second OffenseSuspension of LTO for 90 daysPhP 50,000.00 Third OffenseCancellation of LTOPhP 100,000.00 In case of serious injury or death of the patient, passengers, pedestrians or the general public due to the negligence or misuse of the ambulance service, the DOH-LTO of the ambulance service provider shall be automatically revoked. This is without prejudice to any criminal or civil charges or both that may be filed by the aggrieved party against the ambulance service provider.

31. Transitory Provision Non-institution-based ambulance service providers shall be given one (1) year from approval of this Order to comply with the requirements. For hospital-based ambulance service providers, these requirements shall apply immediately. Once the one year moratorium has lapsed, all applications shall be subjected to the requirements set forth by this Order.

32. Repealing Clause Provisions from previous issuances that are inconsistent or contrary to the provisions of this Order shall be deemed impliedly or expressly amended or revoked. Separability Clause In the event that any provision or part of this Order is declared unauthorized or rendered invalid by any Court of law, those provisions not affected by such declaration shall remain valid and effective. Effectivity The AO shall take effect after fifteen (15) days following the completion of publication in two newspapers of general circulation.

33. Thank You!