• Office of the Medical Center Chief;
• Allied Health Professional Service;
• Nursing Service;
• Hospital Operations and Patient Support Service; and

• Finance Service.

As agreed by both the DOH and the DBM, a separate issuance shall be provided for the Phase II of the Revised Organizational Structure and Staffing Standards for Level III Government Hospitals with 200 to 1,500 beds for the Health Emergency and Disaster Management Unit (HEDMU), the Medical Service, and the optional staffing for Level III General Hospitals.

The number of positions reflected in the matrix of the Phase II Revised Organizational Structure and Staffing Standards for the Level III Government Hospitals considered the updating of the standards in determining the necessary human resource by utilizing the principles of workload indicators for the staffing in the Medical Service and the Optional Units.

PART II - MODEL ORGANIZATIONAL STRUCTURE

As defined under the DOH Administrative Order (AO) No. 2012-0012, a general hospital shall provide appropriate services for various medical and surgical conditions. This covers the sick and injured, maternity care, newborn care, and child-care. In order to provide the requisite services, the hospital must be equipped with adequate and eligible medical professionals.

In particular, such services to be covered in the Phase II standards shall include the following:

> Office of the Medical Center Chief

o Health Emergency and Disaster Management Unit

> Medical Service

• o Clinical Departments
  • Pulmonary/Respiratory Unit
  • Heart Station
  • Acute Stroke Unit
• o Family and Community Medicine Department
• o Physical Medicine and Rehabilitation Department
• o Outpatient Department
• o Emergency Medicine Department
• o Dental Department
• o Department of Pathology
• o Department of Radiology and Imaging Science

> Optional Units

• o Under the Medical Service
  • Electrophysiology Unit
  • Endoscopy Unit
• o Under the Department of Pathology
  • " Molecular Laboratory
• o Under the Department of Radiology and Imaging Science
  • Magnetic Resonance Imaging Section
  • Mammography Section
  • Interventional Radiology Section

This section includes the standard model of the organizational structure for the abovementioned units and services of tertiary hospitals with bed capacity ranging from 200 to 1,500 beds.

Organization Configuration

Phase II of the revised standards on organizational structure and staffing pattern of Level III government hospitals consider the following:

• a. Minimum DOH licensing requirements (AO 2012-0012, 2012-0012-A) and Accreditation Requirements of the Philippine Health Insurance Corporation
• b. Specialty Society Training Accreditation Requirements
• c. Philippine Health Facility Development Plan 2020-2040
• d. DBM'S Index of Occupational Services, Occupational Groups, Classes and Salary Grades (IOS) CY 2022 Edition
• e. Expanded services of the hospitals and health facility based programs required for licensing
• f. Increase in the number of patients catered in tertiary hospitals
• g. Twenty-four (24)-hour operations of hospital services
• h. People-centeredness of health facilities pursuant to the Philippine Health Facility Development Plan
• i. Enacted laws, policies, and implementing rules and regulations for the creation and establishment of various units, including but not limited to the following:
  • I. Republic Act No. 11223, Universal Health Care Act
  • li. Republic Act No. 10754, An Act Expanding the Benefits and Privileges of Persons
  • iii. DOH Administrative Order No. 2020-0019, Guidelines on the Service Delivery Design of Health Care Provider Networks
  • iv. DOH Department Order No. 2013-0171, Policy and Guidelines on Establishing/Expanding Family Medicine Residency Programs in DOH Hospitals
  • V. DOH Administrative Order No. 168 s. 2004, National Policy on Health Emergencies and Disasters
  • vi. Administrative Order No. 29 s. 2010, Policies and Guidelines on the Establishment of Operation Center for Emergencies and Disasters
  • vii. DOH Administrative Order No. 2019-0046, National Policy on Disaster Risk Reduction and Management in Health (DRRM-H)
  • viii. DOH Administrative Order No. 2013-0014, Policies and Guidelines on Hospitals Safe from Disasters

Organizational Chart

A. Office of the Medical Center Chief

B. Medical Service and Optional Units

PART III - STANDARD STAFFING PATTERN AND RATIONALE

The Revised Organizational Structure and Staffing Standards for Level III Government Hospitals with 200 to 1,500 Beds will cover units that contribute to the overall efficiency of hospital operations and the effective implementation of policies, plan, programs, and projects of the health facility. The rationale and functions of these units are provided hereunder:

Office of the Medical Center Chief Health Emergency and Disaster Management Unit

According to the 2017 World Risk Report, the Philippines ranked 3rd highest among 171 countries in terms of disaster risk and exposure. By virtue of its geographic circumstances, the Philippines has been struck many times by natural disasters over the past years which include but is not limited to earthquakes, floods, typhoons, and volcanic eruptions. Recently, disasters have caused technological and human induced hazards such as fire and armed conflicts which brought a significant effect on the lives of many. These are only among the several types of disasters that initially disrupted the delivery of the different health services and subsequently disrupted even the social and economic development of the country. The creation of the Health Emergency Disaster Management Unit (HEDMU) supports the initiative of the Philippines to comply with the global Emergency Medical Teams (EMT) standards.

Hospitals are always at the frontline of health service delivery. They respond to the internal events and disasters caused by various hazards ranging from natural, biological, technological, and societal reasons. Moreover, they respond to the needs of their immediate community or other surrounding areas. During disasters, the surge capacity is identified to be a significant challenge for hospitals. This is further supported by the Sendai Framework on Disaster Risk Reduction (SFDRR), which promotes the important role of health in disaster risk reduction and management and highlights the roles of hospitals in building health resilience. Thus, the human resource requirements are crucial to ensure the continuity of hospital services.

Republic Act No. 10121, also known as the Philippine Disaster Risk Reduction and Management Act of 2010, mandates the Department of Health (DOH) as the lead sector in medical/public health, nutrition, water, sanitation and hygiene, and mental health in times of emergencies and disasters.

The health sector has roles in all four (4) of the thematic phases of disaster management, namely: prevention/mitigation, preparedness, response, and recovery. The DOH is expected to contribute to disaster management through the provision of special tertiary healthcare services to the public. DOH Administrative Order No. 168 s. 2004 "National Policy on Health Emergencies and Disasters" defines the roles of hospitals to decrease

mortality and morbidity, and prevent injury and disability to the victims of any emergencies or disasters.

Further, DOH Administrative Order No. 29 s. 2010 or the Policies and Guidelines on the Establishment of Operation Center for Emergencies and Disasters also provides a mandate for the creation of this unit.

Medical Service

The Medical Service is responsible for providing inpatient and outpatient care, as well as high standards of clinical training for medical personnel, promotion of research activities, implementation of clinical resource management system, and advising and assisting the Medical Center Chief in the formulation and implementation of policies, plans, and programs of the hospitals.

Functions

• Provide quality inpatient and outpatient care;
• Ensure high standards of clinical training for medical personnel;
• Promote research activities; and
• Implement clinical resource management system, advising, and assisting the Medical! Center Chief in the formulation and implementation of policies, plans, and programs for the clinical care in the hospital.

Staffing

Shannon's formula used in the computation of the required number of medical specialists and medical officers in the 2013 Revised Organizational Structure and Staffing Standards is no longer responsive to the needs of hospitals due to the following reasons:

• 1. It did not consider the health human resource needs in the special care areas;
• 2. It did not consider duty cycles and duty hours;
• 3. The numbers were insufficient to fulfill the prescribed consultant-to-resident ratios for teaching and training hospitals; and
• 4. There was no differentiation across the different position title for physicians (i.e. Medical Officer III and Medical Officer IV, Medical Specialist II, III, and IV).

Based on a review of literature, new models in evaluating and defining staffing standards should consider the estimated workload, which is dependent on the defined component of daily work and set of activities (WISN). Further, based on the study entitled, "Association between Physician Staff Numbers and Mortality in English Hospitals, certain ratios such as Senior, Middle, and Junior Doctor per provider and Bed to Senior, Middle, and Junior Doctor per provider are necessary in establishing staffing standards^.

In the Philippine context, there is limited data on defining the workload standards available for Medical Officer and Medical Specialist positions. This, however, may be attributed to the current patient care-related activities required in the training of resident physicians (e.g., patient load, exposure/rotation, and required procedures). In terms of ratios, residency and fellowship training programs provide minimum required consultantto-resident ratios.

There are main considerations to be used in rationalizing the Medical Officer and Medical Specialist positions, which include the following:

1. Workload indicators as represented by Patient Episode

Patient episode is defined as a set of medical services received continuously by a patient over a period of time. Each department may have a different set of patient episode assumptions depending on the nature of their medical services (Clinical vs. Surgical).

Particularly, for these updated standards on patient episode assumption per clinical department was subjected to a series of consultations with government medical practitioners in each field.

In addition, academic and research-related activities in the workload of trainees were included in the overall computation of the staffing standards which includes the following assumptions:

• a. As agreed by the Technical Working Group, eight (8) hours of dedicated time will be allocated for each resident per week.
• b. Assuming each resident has an eighty (80) hour workweek or two (2) full duty cycles (Pre-duty - 8 hours. Duty - 24 hours, Post-duty - 8 hours) per week, dedicating eight (8) hours per week would be 10% of the workweek. Thus, to account for this, an additional 10% was added to the calculated number of residents.
• c. Hence, the number of residents (x) shall be multiplied by 1.10 to account for the eight (8) hour academic workload of the eighty (80) hour workweek.

^* Harvey, P. R. & Trudgill, N. J. (2021). The association between physician staffnumbers and mortality in English hospitals. EclinicalMedicine. 32,100709. https://doi.Org/I0Z10I6/j.eclinm.2020.100709

2. Role Assumption per plantilla position

The table below provides the general role assumptions per Medical Officer and Medical Specialist positions based on the current practice in teaching and training hospitals:

3. Ratio and Training Assumptions

Ratios for the consultant to resident/trainee of each specialty were provided by the accrediting body of the specialty societies. These ratios were used as the basis for the minimum requirement of consultants or MS-II positions for each department.

4. Assumptions for Z7for each Department under the Clinical Department

In order to compute an absolute number for the Medical Specialist positions, the following specialty services were considered, and each hospital may have more than the aforementioned specialty services:

Annex A shows the specific formula for the Medical Officer and Medical Specialist positions for each department of the Medical Service.

Components

Under the Medical Service, specialty and sub-specialty units available in the hospitals shall be responsible for the provision of services intended for a particular type of illness or for a particular condition requiring a range of treatment for patients suffering from diseases of a particular organ or groups of organs, and treatment of patients belonging to a particular group such as children, women, elderly, and others.

At the minimum, ^a Level III General Hospital shall be composed of the following:

A. Clinical Department

• a. Department of Internal Medicine: The Department of Internal Medicine is in charge of managing a wide and comprehensive spectrum of illnesses that affect the adult population.
  • I. Intensive Care Unit: The Intensive Care Unit is a dedicated unit intended to deliver critical care and life support to patients that are critically and acutely ill and injured adult and geriatric patients.
  • ii. Pulmonary/Respiratory Unit: Per the DOH AO No. 2012-0012, the Pulmonary/Respiratory Therapy Unit is a unit in the hospital with the necessary equipment needed for the provision of respiratory care. It is headed by a duly licensed physician and staffed by personnel trained in the treatment and care of patients with cardiopulmonary disorders. In compliance with the licensing requirements under the abovementioned order and its amendments, all level III government hospitals shall be supported in the establishment and upgrading of pulmonary/respiratory units.
  • iii. Heart Station: The Heart Station is a dedicated unit that provides facilities for specialized procedures in the diagnosis and evaluation of patients with heart-related symptoms and disorders.
  • iv. Acute Stroke Unit; The Acute Stroke Unit, which is regarded as a dedicated intensive care unit, is intended for the management of patients with lifethreatening neurological diseases.
• b. Department of Pediatrics: The Department of Pediatrics is in charge of managing a wide and comprehensive spectrum of illnesses that affect the pediatric and neonatal population.
  • I. Neonatal Intensive Care Unit: The Neonatal Intensive Care Unit is a dedicated unit intended to provide critical care and life support to patients that are critically and acutely ill and injured neonates.
  • II. Pediatric Intensive Care Unit: The Pediatric Intensive Care Unit is a dedicated unit intended to deliver critical care and life support to patients that are critically and acutely ill and injured pediatric patients.
• c. Department of General Surgery; The Department of General Surgery is in charge of delivering a continuum of care for patients with a wide variety of general surgical problems. It is responsible for providing preoperative, operative, and postoperative management of patients with a broad spectrum of diseases.
• d. Department of Obstetrics and Gynecology; The Department of Obstetrics and Gynecology is in charge of delivering the full spectrum of women's healthcare services. It is responsible for providing both clinical, diagnostic, and surgical services needed for the management of pregnancies of patients, as well as the

detection and diagnosis of pathology and abnormalities related to the women's reproductive anatomy.

• I. High-Risk Pregnancy Unit: The High-Risk Pregnancy Unit is intended to deliver critical care and life support to high-risk pregnant patients by providing comprehensive perinatal services.
• e. Department of Anesthesiology: The Department of Anesthesiology is in charge of delivering safe anesthesia, ensuring patient hemostasis, and management of pain in patients undergoing surgical procedures.
• B. Department of Family and Community Medicine: Pursuant to DOH Department Order No 2013-0171, the DOH hospitals shall establish a Family and Community Medicine training program pursuing either a traditional track or a practice-based residency training program. This is in support of the implementation of the Universal Health Care Act.
• C. Physical Medicine and Rehabilitation Department: The Physical Medicine and Rehabilitation Department is in charge of providing the maximal restoration or development of physical, psychological, social, occupational, and vocational functions in persons whose abilities have been limited by disease, trauma, congenital disorders, and chronic pain to enable people to achieve their maximum functional ability. As required by the Republic Act No. 10754 "An Act Expanding the Benefits and Privileges of Persons", the Department shall offer holistic services for various disabilities and impairments.
• D. Outpatient Department: The Outpatient Department is part of the hospital designated for the treatment of outpatients. Staffing for this Department shall focus on the provision of additional outpatient services not covered by the staffing provided in the clinical department.
• E. Emergency Medicine Department: The Emergency Medicine Department is a specialized area in the hospital that provides acute care and resuscitation. It serves as an entry point to the provision of both inpatient and outpatient services by the hospital. The staffing provided in this section shall cover the minimum staffing to operate the emergency department, including provisions for training in emergency medicine.
• F. Dental Department: The Dental Department is in charge of providing specialized dental services, which include but are not limited to oral examination, preventive, curative, and rehabilitative services.
• G. Department of Pathology: The Department of Pathology is a major source of information needed in the prevention, diagnosis, and treatment of diseases. It provides critical and relevant data valuable for patient care and treatment including

epidemiology and surveillance. Services under the Department of Pathology include but are not limited to:

• I. Blood Bank
• ii. Anatomic Laboratory and Clinical Laboratory
  • 1. Hematology
  • 2. Clinical Chemistry
  • 3. Immunology-Serology
  • 4. Clinical Microscopy
  • 5. Microbiology
  • 6. Histopathology
  • 7. Anatomic Pathology
• H. Department of Radiology and Imaging Science: The Department of Radiology and Imaging Science provides comprehensive imaging services that provide support to the accurate diagnosis of patients.

Optional Department/ Units:

a. Optional Department/ Units under Medical Service

• I. Electrophysiology Unit: caters to both adult and pediatric patients with neuromuscular disorders, including a wide range of diseases affecting the peripheral nervous system, which consists of all motor and sensory nerves that connect the brain and spinal cord to the rest of the body. The following procedures are performed:
  • 1. Electroencephalography Study (EEG) being used to record the brain activity of patients suffering from or suspected to have seizures or other cerebral problems.
  • 2. Electromyography Nerve Conduction Velocity Study (EMG-NCV) is an examination done to calculate the conductive function of the nerve and muscle activity at rest and during contraction.
  • 3. Repetitive Nerve Stimulation (RNS) is recommended to be performed for patients with neuromuscular junction disease.
• ii. Endoscopy Unit is a dedicated unit for endoscopy procedures, a minimally invasive surgical or medical procedure utilizing an instrument called an endoscope which is a long flexible tube that has a lens at one end and a fiber optic camera at the other.

Procedures undertaken in the Endoscopy Unit may be done on an out-patient or an in-patient basts. The procedures are performed by consultant Gastroenterologists, Bronchoscopist, and Surgeons along with counterpart anesthesiologists.

b. Optional Department/Units under Pathology

I. Molecular Laboratory is a specially designed laboratory for purposes of running molecular diagnostic tests, which are increasingly being used for clinical and public health investigation of the human, viral, and microbial genomes, its genes and their products. Areas of specialties that utilize these tests include but are not limited to Oncology, Infectious Diseases, Clinical Chemistry, and Clinical Genetics^.

c. Optional Department/Units under Radiology and Imaging Science

• 1. Magnetic Resonance Imaging (MRI) Section is in charge of operating, maintaining, and interpreting the images captured using the MRI.
• ii. Mammography Section is in charge of operating, maintaining, an(d interpreting the images captured using the Mammogram which is used both as a screening and diagnostic tool.
• iii. Interventional Radiology is a medical specialty that provides minimally invasive Image-guided diagnosis and treatment of disease. Although the range of procedures performed by interventional radiologists is broad, the unifying concept behind these procedures is the application of image guidance and minimally invasive techniques in order to minimize risk to the patient. Interventional radiologists commonly perform both diagnostic and therapeutic procedures, although diagnostic angiography is becoming less common as the quality and reliability of Computed Tomography (CT) Scan and MRI angiography have allowed for alternative forms of non-invasive evaluation.

Centers for Disease Control and Prevention. (2019, November 5). Molecular Diagnostic Methods. CDC. Retrieved October 18,2022, from https://www.cdc.gov/labquality/molecular-inethods.hlml

Part IV- Implementing Guidelines

The implementation of the Phase II of the Revised Organizational Structure and Standard Staffing Pattern for Level III Government Hospitals with 200 to 1,500 Beds shall be guided by the following:

• 1. The DOH-DBM staffing standards shall be followed in filling the positions, in addition to the published qualification standard competencies for each position, to ensure the provision of quality services in al) levels of government hospitals.
• 2. The requesting party shall provide the manifest of the hospital's filled and unfilled positions prior to the requisition of any additional positions. The request will then be evaluated accordingly based on the needs and demands of the hospital, and the comparison of the existing positions, including those which are filled, vis-a-vis the herein standards.
  • Further, the evaluation and the approval of the staffing proposals could be pursued in tranches, in consultation with the DOH and the hospital concerned, depending on the availability of appropriate funds for the purpose, as determined by the DBM.
• 3. The DBM shall only evaluate and process requests from the requesting hospital concerned provided that its proposed organizational and staffing modifications have been endorsed by the Secretary of Health or his/her authorized representative to the Department to ensure consistency of the requests with the herein criteria and standards, as well as the thrusts and policy directions of the DOH.
  • Moreover, the DBM may only proceed with the evaluation of the proposed creation of positions in the hospital concerned, provided that its existing authorized manpower complement in units covered by the Phase II of the herein standards has already been filled by at least 80%.
• 4. The number and level of positions prescribed for each hospital category shall be the maximum that will be allowed for the various organizational units. However, hospitals may adopt a lesser number and lower levels of positions and/or merge different staff offices in the internal management and support units, depending on their financial capability.
• 5. Hospitals that qualify for the next higher category shall adopt the corresponding organizational structure and staffing pattern herein prescribed. However, the hospital management has the option to adopt a leaner organizational structure and staffing pattern by merging the prescribed organizational units or using lowerlevel positions. If the authorized bed capacity of ^a hospital falls between two of the specified bed capacities in the standard staffing pattern, the higher set of

• standards shall be applied if the number of beds is in excess of one-half of their difference.

• 6. Request for additional Medical Officers and Medical Specialists in the newly-created subspecialty of the Hospital and the optional staffing shall be evaluated based on the readiness of the facility to implement the said services.
  • Further, in case of additional medical doctors in view of new sub-specialty of a department, the formula provided under Annex A shall be used in determining the allowable additional number of Medical Officer and Medical Specialist positions.
• 7. Hospitals under other national government agencies such as the Department of National Defense (DND), Philippine National Police (PNP), Department of Justice (DOJ), State Universities and Colleges (SUCs), and Department of Local and Interior Government (DILG) shall adhere to this staffing standard.
• 8. The local government unit (LGU) owned and/or managed hospitals are encouraged to implement the revised staffing standards.
• 9. All filled positions that not part or excess of the revised staffing standards shall be marked as coterminous with the incumbent (CTI), to be abolished once vacated.
  • Further, unfilled excess items under units covered by the Phase II shall be offered for abolition to fund the creation of its proposed positions.
• 10. These standards shall be subject to regular review to ensure that the same remain responsive to the needs of the health facilities. The staffing standards may be reviewed or revised in portions or as a whole.

Staffing Standards for 200-900 Beds Level III Government Hospitals

Staffing Standards for 1000-1500 Beds Level III Government Hospitals

Annex A

Specific Formula for the Number of Authorized Medical Officer and Medical Specialists Positions per Department

A. Department of Pediatrics

B. Department of Internal Medicine

C. Department of General Surgery

D. Department of Obstetrics and Gynecology

E. Department of Anesthesiology

F. Department of Family and Community Medicine

Annex B

Tally of Positions of the Medical Service

^*Excluding Optional Nurse II/SG-16 Position/s in the Department of Physical Medicine and Rehabilitation

^*Excluding Optional Nurse II/SG-16 Position/s in the Department of Physical Medicine and Rehabilitation

^*Excluding Optional Nurse II/SG-16 Position/s in the Department of Physical Medicine and Rehabilitation

Annex C

Tally of Positions per Bed Capacity Summary of Phase I and II of the Revised Standards

^*Excluding Optional Positions