Republic of the Philippines

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 employee’s responsibilities and work
assignments.

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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

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 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
• D50W 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

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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
• Physician’s order
• Completed consent form – updated annually
• Patient’s 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/patient’s 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 facility’s 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.

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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.

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