Department of Surgery

Department of Surgery

Nov 18, 2008

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Head, Corporate Planning Office

Manila Doctors Hospital

(One of three topics: Department of Surgery; OR; ER)

(Recommendation: Read first “Framework on Managing and Leading a Hospital Department”)

Short Course on Hospital Organization and Management of Selected Clinical, Ancillary, and Support Departments

Nov. 17 – 21, 2008

College of Public Health

University of the Philippines Manila

Department of Surgery

Let’s tackle first the Deparment of Surgery.

Let’s create a scenario to position ourselves.

Imagine you, a BOARD-CERTIFIED SURGEON, are going to be appointed Head of a Department of Surgery in a hospital (whether government or private).

Existing or new one?

Let’s use the scenario of an existing one as this is a more common situation.

What are initial and eventual things you have to do as the newly appointed head of an existing department of surgery?

First two requirements before you assume officially the chairmanship of the department of surgery

Make sure you have an official appointment paper to be the chair of the department of surgery before you start doing anything. (Chief of Hospital take note!)
Make sure you have an official job description as chair of the department of surgery before you start doing anything. (Chief of Hospital take note!)

The appointment paper gives you the authority. The job description spells out your duties and responsibilities with corresponding authority. The job description also serves as a basis of your performance evaluation.

Initial activities of a newly appointed chair

Initial quick assessment of the department of surgery

After getting your appointment paper together with a job description,

scan the department in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources – through observation and inspection to get a quick assessment of the status of the abovementioned essential elements needed in the management of the department (present or not; if present, needs improvement or not; if improvement needed, prioritize and strategize; resources – source and level of difficulty)

Initial resuscitative and corrective measures if needed / indicated

Based on your initial quick assessment, if there is something very important and urgent that needs to be resuscitated and corrected, do so as soon as possible.

Examples of important and urgent needs:

no staff to man the department

no resuscitative equipment in the department

no place to do surgical procedures and operations

Eventual activities

Detailed assessment of the department of surgery

When you have settled down as chair, usually in a month or two, do a more detailed assessment of the department again at least in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources. Other parameters may be used like culture, values, practices, work habits, etc. Identify the gaps and what needs to be changed or improved and then make a tentative plan on how to improve the present system, on how to manage the department, and on how to lead your staff.

Formulation and implementation of strategic and specific action plans

Formulate strategic and specific action plans with consultation and collaboration from your staff. Then gradually but surely and effectively and efficiently implement them through technical and coordinating teams. Don’t forget to include a system of evaluation of results of implementation of your strategic and specific action plans.

Essential things to consider for gap analysis, corrective actions, and for continual improvement

Authorized functions of a department of surgery

There must be a document stating the authorized functions of your department of surgery.

It must be complete and clear with general and specific functions and it must be authorized by a higher office (ideally by the Chief of Hospital).

This document on authorized functions will serve as a steering wheel or guide for everything you will do in the department. It describes the roles and responsibilities of your department in the context of the whole hospital.

It gives your department the authority to do what you should be doing. It will serve as a guide in determining what you need in your department to function properly and adequately such as in terms of structure, staffing, policies and procedures, programs, and resources. It will serve as a guide in determining what programs, projects, tasks, and activities you can do to accomplish your functions, both on a long term and short term basis. It will serve as a basis for evaluating your department’s performance, at the very least, whether you have been accomplishing your expected functions on a daily basis and annually.

The authorized functions contain at the very least the service functions of the department. They can include training and research functions.

The formulation of service functions of a department is guided by the current expectations on the specialty of the department by the health care industry and medical profession; vision-mission of the hospital; expectations of the community where the hospital is situated; and benchmarking and trends in the hospital industry both locally and internationally.

There is a need to specify scope of functions because of rapid changes in the medical specialties; because of overlapping of specializations nowadays (General Surgery – Otorhinolaryngology; Neurosurgery – Orthopedic Surgery; Internal Medicine – minimally invasive surgery; etc.); to avoid confusion among staff and patients and public also; and to facilitate integration, coordination, and collaboration within and among units (a challenge to chief hospital).

Whatever be the formulated authorized functions of a department, they must be officially authorized by a higher office.

Examples of authorized functions of a department of surgery –

General Function:

To provide quality health services to all patients needing management in the field of general surgery.

To provide proper medical service to all patients with surgical diseases who seek consultation and treatment in the hospital.

To provide quality health services to all patients needing management in the field of surgery (general surgery, colorectal surgery, pediatric surgery, urologic surgery, neurosurgery, plastic and reconstructive surgery, thoracocardiovascular surgery, and orthopedic surgery).

Specific Functions:

1. To provide quality health promotion and disease prevention program in the field of surgery to clients in need of such service.

2. To provide quality diagnostic and therapeutic procedures to all patients with surgical problems.

3. To provide quality pre-operative, intra-operative, and post-operative surgical care to all patients in need of such health care service.

4. To provide quality rehabilitative health programs in the field of surgery to all clients in need of such service.

1. To examine all patients with a possible surgical diseases and after which, to make a rational and accurate diagnosis.

2. To provide treatment to all patients with surgical diseases.

3. To provide training in surgery.

4. To promote research in surgery.

(Side NOTES)

Examples of Authorized Functions of Other Clinical Departments

Department of Orthopedic Surgery

To provide quality health services to all patients needing management in the field of orthopedic surgery.

Department of Otorhinolaryngology

To provide quality health services to all patients needing management in the field of otorhinolarynology.

Department of Obstetrics-Gynecology

To provide quality health services to all patients needing management in the field of obstetrics and gynecology.

Department of Internal Medicine

To provide quality health services to all patients needing management in the field of internal medicine (adult medicine).

Department of Pediatrics

To provide quality health services to all patients needing management in the field of pediatrics (pediatric medicine).

Specific Functions:

1. To provide quality health promotion and disease prevention program in the field of pediatrics to clients in need of such service.

2. To provide quality diagnostic and therapeutic procedures to all pediatric patients in need of such service.

3. To provide quality treatment to all pediatric patients in need of such service.

4. To provide quality rehabilitative health programs in the field of pediatrics to all clients in need of such service.

Structural or physical requirements of a department of surgery

Based on the authorized functions and other ancillary functions of the department of surgery, such as governance, training and research, determine the structure or physical requirements.

Structural or physical requirements based on the usual authorized and expected service functions of a department of surgery

The chief clients of a department of surgery are patients with potential or actual surgical disorders and who usually need to undergo a surgical procedure or operation as part of their treatment. The operations may be done on an outpatient or inpatient basis. The consultations may be on an emergency or elective basis. Some patients need confinement in the hospital. Most patients need to be provided with a program for health promotion, disease prevention, and rehabilitation.

Thus, on the basis of the abovementioned needs of the chief clients of a department of surgery and the corresponding services that should be provided, at the very least, the following structures or physical facilities must be present:

1. Operating rooms

1.1 For ambulatory surgeries

1.2 For inpatient surgeries

2. Surgical patient beds, wards, and rooms

3. Consultation rooms in

3.1 Outpatient department

3.2 Emergency room

[Note: These abovementioned physical facilities are usually NOT under the direct management of a department of surgery. They are usually under the management of a nurse from the nursing service. Integration, coordination, and collaboration between the department of surgery and the nursing service as well as other clinical departments which are also using the facilities are important for an effective and efficient management of these areas.]

There are several issues to consider when establishing or making available the above structures and physical facilities required by a department of surgery. These are, namely:

· Location within the hospital (lay-out and functional flow within the hospital)

· Quantity of consultation, examining, operating, and confinement beds and rooms

· Size

· Design

· Equipment requirement

How to resolve the issues? How to decide?

Resolution of the above issues will be dependent on the following general determining factors:

· government regulations (particularly the licensing requirements of DOH Bureau of Health Facilities and Services) [http://www.doh.gov.ph]

· quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as International Organization for Standardization or ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

· usual and anticipated increase in patient load (cost-benefit considerations)

· needs and expectations of the community

· integration, coordination and collaboration with other units in the hospital for efficient use of physical resources – ER, OR, OPD and wards and floors being used by several departments

· allowance for expansion (space availability)

· value-added, vision-mission, and benchmarking considerations (sustainability purpose)

· Location within the hospital (lay-out and functional flow within the hospital)

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

Outer Zone	ER OPD
Second Zone
Inner Zone	Wards / Floors
Deep Zone	OR
Service Zone

DOH Guidelines:

19. Zoning: The different areas of a hospital shall be grouped according to zones as follows:

19.1 Outer Zone – areas that are immediately accessible to the public: emergency service, outpatient service, and administrative service. They shall be located near the entrance of the hospital.

19.2 Second Zone – areas that receive workload from the outer zone: laboratory, pharmacy, and radiology. They shall be located near the outer zone.

19.3 Inner Zone – areas that provide nursing care and management of patients: nursing service. They shall be located in private areas but accessible to guests.

19.4 Deep Zone – areas that require asepsis to perform the prescribed services: surgical service, delivery service, nursery, and intensive care. They shall be segregated from the public areas but accessible to the outer, second and inner zones.

19.5 Service Zone – areas that provide support to hospital activities: dietary service, housekeeping service, maintenance and motorpool service, and mortuary. They shall be located in areas away from normal traffic.

20 Function: The different areas of a hospital shall be functionally related with each other.

20.1 The emergency service shall be located in the ground floor to ensure immediate access. A separate entrance to the emergency room shall be provided.

20.2 The administrative service, particularly admitting office and business office, shall be located near the main entrance of the hospital. Offices for hospital management can be located in private areas.

20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement.

20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement. The nursery shall be separate but

immediately accessible from the delivery room.

20.5 The nursing service shall be segregated from public areas. The nurse station shall be located to permit visual observation of patients. Nurse stations shall be provided in all inpatient units of the hospital with a ratio of at least one (1) nurse station for every thirty-five (35) beds. Rooms and wards shall be of sufficient size to allow for work flow and patient movement. Toilets shall be immediately accessible from rooms and wards.

Accessibility to patients and to interfacing patient care units is the main and initial guidepost for determining the location of the operating rooms, surgical wards and rooms, surgical outpatient department, and surgical emergncy room. The physical location of the unit structure per se within the hospital complex is the initial determinant of accessibility. The other determinants for location of the unit structures include sterility zoning, privacy zoning, traffic zoning, and inter-relationship with other units in the hospital.

Aside from actual physical location, directional signages, elevators, and connecting bridges, ramps and tunnels can be used to promote accessibility.

· Quantity of consultation, examining, operating, and confinement beds and rooms

Quantity of beds and rooms is primarily influenced by cost-benefit considerations, that is, usual and anticipated increase in patient load vis-à-vis revenues and expenses. The availability of spaces is also a determining factor.

· Size

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

There must be ADEQUATE SPACE to allow patients, personnel, beds, stretchers, and wheelchairs to move freely and safely around patient bed and room areas. The quantity of consultation, examining, operating, and confinement beds and rooms required as well as equipment requirements also determine size.

· Design

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

Whatever be the design, foremost it must promote FUNCTIONAL FLOW of patients and staff, one that will promote effectiveness and efficiency in achieving the service functions of the units. It must create a healthy and esthetic atmosphere and environment for patients, public, and staff.

Structural or physical requirements based on other ancillary functions of a department of surgery, such as governance, training, and research

• Chairman’s office

• Conference room

• Library

• Computer system, IT, with Internet access

Governance:

An office for the chair and his administrative team is needed, complete with computer system, communication system, record management system, and other basic necessities.

For level 3 and 4 hospitals, DOH requires the presence of an office for the head of the department of surgery.

Training:

It is recommended to have a dedicated conference room for the department that can be used for multiple purposes, such as training, business meetings, study room, and library. If a dedicated conference room is not possible or practical, then a shared conference room (with other clinical departmetns) will suffice.

Research:

It is recommended to have a department library with facilities for information technology with Internet access and research.

For level 4 hospitals with accredited residency training program in surgery, a library and computer facilities are required by the Philippine Society of General Surgeons (PSGS), dedicated to the department or shared.

Equipment and material requirements based on the usual authorized and expected service functions of a department of surgery

Surgery is a branch of medicine that is commonly associated with the use of instruments in the management of patients, both for diagnosis and for treatment. Thus, surgery is equated to operations.

Note, however, surgeons also prescribe medicines and do other basic routines being done by generalist physicians and non-surgeons, such as interviewing and performing physical examination to come out with a clinical diagnosis, auscultating with the use of stethoscope, doing a rectal examination with gloved fingers, etc. Surgeons are NOT just barbers, craftsmen, and mechanics. They are physician-surgeons!

Thus, the equipment and material requirements of a department of surgery can be categorized into non-operative and operative. Non-operative ones are those categorized as non-operative or non-surgical supplies, instruments, and equipment, such as drugs, intravenous fluids, thermometers, nebulizers, etc. being used by patients of the department outside of or during, to support an operative procedure. Operative ones are those used in an operation, such as surgical supplies (gauze, drains, plasters; etc.); surgical instruments (knives, clamps needle holders, etc.); and surgical equipment (lights, suction machines, electrocautery machines; etc.).

Note: Although the department of surgery can determine their requirements, the equipment, instruments, materials and suppies are usually NOT directly acquired by it and are NOT stored in its office but in the service areas (operating rooms, emergency room, outpatient department, nurses stations), pharmacy, and central supply and stock rooms.

There are several issues to consider in the management of equipment and material requirements of a department of surgery. These are, namely:

· Who determines the equipment and material requirements of a department of surgery (what and how much to store)?

· Who gives the supply?

· Who does the inventory?

· Who regulates the supply (quality, safety, and durability considerations)?

· Who determines the equipment and material requirements of a department of surgery (what and how much to store)?

The DOH

The department of surgery

The nurses in charge of the service areas of the department of surgery

The pharmacy

The central supply and stockroom

DOH

See minimum licensing requirements for equipment and instrument of a hospital (Level 1 to 4) in the ER, OR-RR, OPD, Nurses Stations [http://www.doh.gov.ph]

The surgeons

The surgeons are the primary users or, more specifically, the prescribers of what and when to use the equipment and materials for their patients. Thus, heads of the nursing service areas, pharmacy, central supply, and stockrooms should consult the surgeons. If not, there will be wastage due to unused equipment and supplies.

The nurses in charge of the service areas of the department of surgery

The pharmacy

The central supply and stockroom

The heads of the nursing service areas, pharmacy, central supply and stockrooms can also determine what and how much to store for use by the department of surgery but this should be done in coordination with, if not authorization from department of surgery administration.

Based on the inventory and usage data, they can determine what and how much to store.

· Who gives the supply?

The hospital management and at times, higher office, especially in government hospitals.

· Who does the inventory?

The nursing service areas, pharmacy, central supply and stockrooms and even a higher office, such as an auditing office or finance department.

· Who regulates the supply (quality, safety and durability considerations)?

Approval of requests by surgeons and the service areas has to pass through a body or office which will study the requests for acquisition.

Surgeons may request sophisticated and expensive equipment, instruments, and materials for their use. Decision for approval, aside from the logistical considerations, should be guided by government regulations, quality standards requirements, cost-benefit considerations, value-added, vision-mission, and benchmarking considerations; and financial viability. (Surgeons should promote returns on investment on equipment requested.)

Equipment should have preventive maintenance and calibration at planned intervals to ensure accuracy and safety in their use and longer life span.

EQUIPMENT/INSTRUMENT

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

4.1. All equipment and instruments necessary for the safe and effective provision of services are available and are properly maintained.

4.1.1. Records of equipment are maintained and updated regularly.

4.1.2. A preventive maintenance program ensures that all

equipment are maintained and/or calibrated to an appropriate

standard or specification.

4.1.3. There is a plan in place for essential equipment replacement.

4.1.4. Personnel are competent when using equipment in line with

manufacturer’s instruction/operational manual.

4.1.5. Operational manuals of all equipment and instruments are

available for reference and guidance.

In the mangement of equipment, be guided by the following:

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

Quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

Staff requirements of a department of surgery

For an effective functioning of a department of surgery, at least the following kinds of staff are needed:

1. Surgical specialists

2. Anesthesiologists (needed for a painless operation)

3. Nurses and nursing attendants

Note: Anesthesiologists, nurses, and nursing attendants are not under the jurisdiction of the department of surgery. However, they are important members of the surgical team. Thus, integration, cooperation, and collaboration among these different staffs must come into play for an effective functioning of the department of surgery.

Staff requirements of the service areas of a department of surgery:

These will NOT be elaborated here. They will be discussed in the sessions on emergency room, operating room, outpatient department, and nursing services.

Suffice it to say,

1. Quality of surgical services in the service areas will suffer if the staff requirements in the latter are NOT satisfied.

2. Quality of surgical services will be better if there is integration, cooperation, and collaboration among different professionals working with the department of surgery in the different service areas.

General determining factors on staff requirements of a department of surgery

The basic issues are qualification (competency) and quantity.

Resolution of the above issues will be dependent on the following general determining factors:

· government regulations (particularly the licensing process of DOH Bureau of Health Facilities and Services)

· quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI)

· usual and anticipated increase in patient load (cost-benefit considerations)

· needs and expectations of the community

· integration, coordination and collaboration with other units in the hospital for efficient use of human resources

· value-added, vision-mission, and benchmarking considerations

Basic staff requirements based on DOH licensure for hospitals:

See licensing requirements of DOH Bureau of Health Facilities and Services on personnel [http://www.doh.gov.ph]

3. Personnel

The health facility appoints and allocates personnel who are suitably qualified, skilled and/or experienced to provide the service and meet patient needs.

3.1.1. Each personnel is qualified, skilled and/or experienced to

assume the responsibilities, authority, accountability and

functions of the position.

3.1.2. Professional qualifications are validated, including evidence

of professional registration/license, where applicable, prior to

employment.

3.1.3. An organized medical and nursing staff shall be responsible

for the quality of patient care and for the ethical conduct and

professional practices of its members.

In fulfilling the staff requirements, be guided by the:

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

Department of Labor and Employment (DOLE) requirements

Quantity of Staff

DOH has the following prescriptions:

For Physicians:

100 beds and below = 8

Every additional 50 beds = additional 3

The physician must not go on continuous duty for more than forty-eight (48) hours.

For Nurses and Nursing Attendants:

Supervising Nurse

50 beds and below = 1;

51 –100 beds = 2;

101 – 150 beds = 3

151 beds and above = 4

Supervising Nurse (Critical Care Units)= 2

Head Nurse = 1:15 Staff Nurses

Staff Nurse = 1:12 beds at any time

Staff Nurse (Critical Care Units = 1:3 Critical Care Unit beds at any time

Nursing Attendant/ Midwife = 1:24 beds at any time

Nursing Attendant/ Midwife (Critical Care Units = 1:3 Critical Care Unit beds at any time

For every three (3) Nurses or Nursing Attendants/Midwives, there must be one (1) reliever.

Critical Care Units include all Intensive Care Units (ICUs) and Post-Anesthesia Care Unit (PACU)/Recovery Room (RR).

Staff requirements of a department of surgery per se

Structurally and minimally speaking, the department of surgery usually consists of a chairman’s office and a conference room. Its service areas are the operating rooms, outpatient departments, wards and floors, and emergency room which are NOT under its direct jurisdiction.

Human resource or workforce wise and minimally speaking, the department of surgery usually consists of “consultants.” At times, if present, “residents.” At times, if present, “interns” or rotating medical students. At times, if present, office clerks.

Strictly speaking, the primary workforce of a department of surgery in a hospital setting should be the full-pledged, board-certified surgical specialists, the so-called consultants, who are accepted and considered as official staff of the department. In reality, however, in the Philippines and globally, the primary workforce consists of the “residents.” These are physicians who are pursuing further training to become surgeons.

Staff requirements of a department of surgery with accredited training program

Depending on its capability, a department of surgery can have an accredited residency or fellowship program. Surgical residents and surgical fellows are board-certified physician who are in a training program to become surgeons and super-specialist surgeons.

A fellowship program comes after a residency program. The fellowship is a furtherance of training, usually in more specialized field than what was acquired in the residency program.

University hospitals in the Philippines such as the Philippine General Hospital usually have both surgical residency and fellowship program. In general, however, hospitals both government and private, have surgical residency training, usually a general surgery residency training program.

The staff requirements for hospitals with and without accredited training program differ in terms of the accreditation bodies’ prescription of qualifications and number of trainers.

DOH has the following prescriptions for a level 4 and level 3 hospital accreditation:

For Physicians in Clinical Service (surgery and others):

The Department Head must be Diplomate/Fellow of a Specialty/ Subspecialty Society.

Consultant Physicians are must be Diplomates/Fellows of a Specialty/Subspecialty Society.

Philippine Society of General Surgery (PSGS) has the following requirements for hospitals with accredited residency training program in general surgery:

Consultant Staff

A minimum of three (3) PSGS and/or GS PCS Fellows who actively participate in the residency training program is required for eight (8) or fewer surgical residents.

An additional PSGS and/or GS-PCS Fellow must be added for every 2 additional residents. They must have appointments from the institution.

Only consultants who are PSGS and/or PCS Fellows or PBS Diplomates should be involved in the training of residents.

In the presence of an accredited residency training program in a department of surgery, the “residents” in the program automatically become part of the workforce of the department.

Having residents in a department of surgery is usually a welcome thing to both the department administration and the hospital administration. It is seen as more 24/7 manpower with the least expense on the part of the hospital administration, especially private. The residents usually receive “honoraria” for their on-the-job training.

A hospital can also have an accredited training program for medical “interns” (the pre-board medical graduates). Again, having interns in a hospital and a department is a welcome thing to the hospital, department, and to the residents as well. It means more 24/7 manpower and more helping hands particularly to the residents. Depending on the hospital, some would give “incentives,” particularly the private hospitals, some none, particularly the government hospitals.

Note: there is a limit to the number of residents and interns a hospital or department can have (depending on the case load / training materials). This number is controlled by the accrediting specialty society (PSGS) and Association of Philippine Medical Schools (APMC).

Note: In the presence of residents and interns, they usually become the frontliners and primary workforce in the hospital and department. Because of patient load and requirements of training, some residents and interns tend to go on continuous duty for more than 48 hours.

DOH prescription: The physician must NOT go on continuous duty for more than forty-eight (48) hours.

Consultant staff of department of surgery

Consultant staff or “consultants” of a department of surgery are usually full-pledged, board-certified surgical specialists who are accepted and considered as official staff of the department. This is in contrast to “residents” who are full-pledged physicians who are training in the surgical department to become surgical specialists.

Consultants are seen in the departments of surgery of both government and private hospitals, whether they have residency training programs or not.

Consultants in both government and private hospitals are expected at least to manage their patients and to supervise and teach residents and interns, if these are present.

Consultants in government hospitals are usually salaried with no stocks involved. Some have full-time items but majority, only part-time items. Some have permanent items; some with temporary items. In government hospitals with private wards, consultants have the privilege to have private practice as a result of their being accepted and appointed as regular staff of the hospital.

Consultants in private hospitals are usually non-salaried staff given the privilege to practice medicine and surgery in the hospital. They are usually categorized as active and courtesy or visiting consultants. Active consultants are usually stockholders of the corporation that owns the hospital. Active consultants usually have more privileges than courtesy or visiting consultants such as privilege to hold clinic in the hospital, to be decked in walk-in patients, and to be given hospitalization benefits.

Almost all of the consultants are part-timers in the sense that they can come and go to the hospital as they wish and as dictated by the need and scheduled clinic hours of their private practice.

Whether they be in private and government hospitals, consultants are considered the primary staff of the department whom the hospital administration rely for delivery of quality service and financial sustainability, with or without the presence of residents and interns.

In a private hospital setting, the hospital administration by granting the privilege to practice to the consultants expects them to bring in and attract paying patients to the hospital and to utilize its services. This is the primary and universal business development strategy in any hospital. This is the challenge given to the head of the department – how to promote his consultant staff to contribute actively to the business of the hospital or financial viability and sustainability. This is aside from making sure that the consultant staff are also fulfilling their other duties like providing quality patient care, supervision and teaching of residents and interns.

In a government hospital setting whose primary goal is to serve the indigent public, the hospital administration’s challenge to the head of the department is to ensure his consultant staff are actively promoting the delivery of quality patient care.

The challenge for the head of the department is how to manage his consultant staff to produce what are expected from them from the hospital administration as well as from the department administration’s point of view (considering their idiosyncrasies, variable philosophies and priorities, their time allotment and commitment to the hospital, their variable competency in teaching, etc.) Leadership and managership are crucial here.

There is a delicate balance between controlling and enticing them to contribute to the financial viability and sustainability of the hospital.

Control can include job descriptions and performance evaluations and monitoring of contributions.

Enticing them include promoting their satisfaction with the hospital and its administration in whatever way legally, ethically, and compassionately possible so that they will continue to contribute to the financial viability and sustainability of the hospital.

Policies and procedures in a department of surgery

Operations Manual

To provide order, to promote standardization, to facilitate communication, to promote effectiveness and efficiency, and to provide a guide to present and future staff, among other things, policies and procedures must be in place. These should be reviewed and revised periodically.

This is a requirement for licensing by DOH, accreditation by PhilHealth and other accrediting bodies like ISO and JCI.

There must be policies and procedures on

Governance

Service (Patient Management)

Clinical practice guidelines

Clinical pathways

Training

Research

These must be aligned with those of the hospital.

In patient management, clinical practice guidelines and clinical pathways are useful in standardization of procedures as well as in the promotion of efficiency.

Clinical practice guidelines – systematically developed statements, built on synthesis of evidence, which provide formal recommendations about appropriate and necessary care, intended to assist practitioner and patient to make decisions about appropriate health care for specific clinical circumstances.

Clinical pathway – an interdisciplinary plan of care that outlines the optimal sequencing and timing of interventions and expected outcomes for patients with a particular diagnosis, procedure or symptom.

The following are useful references in making policies and procedures:

PhilHealth Benchbook, Joint Commission International, and Investors in People Standards

Established clinical practice guidelines of the Philippine College of Surgeons and Philippine Society of General Surgeons

PhilHealth Benchbook [http://www.philhealth.gov.ph]

A reference manual originating from PhilHealth containing accreditation standards that will evaluate processes that hospitals and professionals use to provide health care and evaluate outcomes that occur as a result of health care provision. It is essentially a benchbook of quality health care that will be used as a yardstick against which the quality of care rendered by PhilHealth and its accredited health providers and professionals will be measured.

Seven groups of standards:

Patient Rights and Organizational Ethics

Patient Care

Leadership and Management

Human Resource Management

Information Management

Safe Practice and Environment

Performance Improvement

Joint Commission International Accreditation Standards for Hospital (JCI)

[http://www.jointcommissioninternational.org]

It is a reference manual produced by the Joint Commission International, an international arm of The Joint Commission (USA) containing accreditation standards on quality and patient safety.

Patient-centered Standards

Access to Care and Continuity of Care

Patient and Family Rights

Assessment of Patients

Care of Patients

Anesthesia and Surgical Care

Medication Management and Use

Patient and Family Education

Health Care Organization Management Standards

Quality Improvement and Patient Safety

Prevention and Control of Infections

Governance, Leadership, and Direction

Facility Management and Safety

Staff Qualifications and Education

Management of Communication and Information

Investors in People Standards [http://www.investorsinpeople.co.uk]

Accreditation standards on improving organizational performance through better planning, implementation and evaluation of learning and development programmes across the organization. It is essentially a framework for delivering organizational improvement through people.

Standards

Business strategy
Learning and development strategy
People management strategy
Leadership and management strategy
Management effectiveness
Recognition and rewards
Improvement and empowerment
Learning and development
Performance measurement
Continuous improvement

Programs of a department of surgery

Based on the authorized functions, programs and projects can be designed to achieve the functions and then continually improve the department.

General programs and projects consist of the following:

Programs on Governance

Programs on Improving Service

Programs on Teaching

Programs on Research

Examples of programs based on functions:

Functions	Parameters / indicators	Programs / Projects
To provide quality surgical service to all patients.	With structured cost-effective program in the management of patients With implementation of Project Cost-Effective Management (Health-Process-Evidence-based Clinical Practice Guidelines) With structured quality-monitored service program Recovery Rate – 90% Mortality Rate – 5% Morbidity Rate – 5% Customer Satisfaction Rating ≥ 85% Not more than 3 written and valid complaints per year	Project Excellent Service Project Cost-effective Management (Health-Process-Evidence-based Clinical Practice Guidelines) Project Customer Satisfaction
To provide quality training for its staff with the view of ensuring provision of quality service.	With structured quality-monitored training program for surgical residents Not more than 5% mortality rate per resident per year Not more than 5% morbidity rate per resident per year Less than 3 written and valid complaints per resident for 5 years Less than 3 written and valid complaints per consultant for 5 years	Project Excellent Education and Training Project Customer Satisfaction
To provide quality research among its staff with the goal of ensuring provision of quality service.	With structured quality-monitored research program Action researches with impact on quality service – at least one a year	Project Excellent Research (Project Action Research Program / Continuous Quality Improvement )
To conduct public health education on prevention of surgical disorders as well as on promotion and maintenance after treatment of surgical disorders.	With public health education on prevention of surgical disorders and on promotion and maintenance after treatment of surgical disorders At least 6 times a year	Project Public Health Education

Resources in a department of surgery

Resources include infrastructure, equipment, people and other logistics needed for the operations of the organization.

The assumption is always there is a limit to resources.

In a private hospital setting, resources come from revenues of operations of the department.

In a government hospital setting, resources come from allocated tax payment and are usually limited.

The head of the department should determine how much he needs based on his planned programs, where he can get them, and how to get them. This is the challenge to his leadership and managership.

Common problems and solutions in a department of surgery

Categories

Common Problems

Suggested Strategies

MAN

Consultants

Residents

Colleagues in other units

Chief of Hospital

Competencies

Number

Integration, coordination, collaboration

Leadership and managership

Investor in People Standards

Managing your boss

SYSTEM AND METHOD

Lack of systematization

Lack of standard procedures

Use DOH requirements

Use quality standards (PhilHealth Benchbook and JCI)

Policies and procedures

Clinical practice guidelines

Clinical pathways

MACHINE/EQUIPMENT

Lack of management system

Lack of calibration

Lack of preventive maintenance

Policies and procedures

MONEY

Other resources

Limited

Leadership

Innovativeness

TRENDS

Rapid changes - difficulty in coping

Knowledge management system (constant tracking and continual education)

Benchmarking

Innovativeness

Managership of the head of a department of surgery

Leadership of a head of a department of surgery

As a leader, you must lead and coach your staff in formulating the vision-mission statements, core values, quality policy, and quality objectives of your department.

The vision-mission statements, core values, quality policy, and quality objectives must be aligned with those of the hospital or cascaded from those of the hospital.

The formulation of the governance statements and objectives should be an outcome of collaborative activities of all the staff as much as possible in order to faciliitate accomplishment driven by sense of ownership and spirit of commitment.

Example of a vision statement of a department of surgery:

We envision our department of surgery to be

a model (or an excellent or an outstanding) department of surgery in the community (or in the Philippines) providing quality and safe services to patients with surgical disorders.

After formulating the governance statements of the department, as a leader and manager, you must lead and coach your staff in formulating a 3 to 5 years strategic plan and an annual management action plan. There must be monitoring and evaluation of the implementation of the plans at planned intervals, end of the year and at the end of your terms. It is only after getting the results of the evaluation can you and your chief of hospital really say whether you have been a good leader and a manager.