T H E S U R G E R Y D E P A R T M E N T

T H E S U R G E R Y D E P A R T M E N T

REYNALDO O. JOSON, MD, MHA, MHPEd, MS Surg

THE SURGERY DEPARTMENT

TABLE OF CONTENT

Introduction ..............................................................................................................	1
Objectives .................................................................................................................	1
Recommended Preparation .............................................................,..........................	1
I. Goal and Objectives ..................................................................................................	1
Review Questions I ..............................................................................................	2
II. The Physical Requirements .......................................................................................	2
Review Questions II .............................................................................................	5
III. The Personnel Requirements .....................................................................................	6
Review Questions III ............................................................................................	7
IV. Manual of Policies and Procedures ...........................................................................	8
Review Questions IV ............................................................................................	8
V. The Trends ...............................................................................................................	9
Review Questions V .............................................................................................	9
Answers to Review Questions ..........................................................................................	10
References .......................................................................................................................	12
Post-test ..........................................................................................................................	13
Answers to Post-test ........................................................................................................	16
Recommended Follow-up .................................................................................................	17
About the Author .............................................................................................................	17

PRIMARY INTENDED USERS: Students of Hospital Administration

ESTIMATED STUDY TIME: One hour

REYNALDO O. JOSON, MD, MHA, MHPEd, MS Surg

November, 1992

Updated, 1994; 1999; 2003

THE SURGERY DEPARTMENT

INTRODUCTION

With the advent of specialization, clinical medicine is now divided into various departments. Surgery is one of these clinical departments. In fact, it is one of the four major clinical medical departments, the others being the departments of internal medicine, pediatrics, and obstetrics and gynecology.

All modern general hospitals have and must have a surgery department. Thus, all students of hospital administration must be knowledgeable of the surgery department. They must know at least its objectives, its physical and personnel requirements, and how it should function.

OBJECTIVES

At the end of the program, the students should be able to:

1. Define the objectives of the surgery department.

2. Discuss the physical requirements of the surgery department in relation to its objectives.

3. Discuss the personnel requirements of the surgery department in relation to its objectives.

4. Explain the importance of a manual of policies and procedures in the surgery department.

5. Discuss the competencies required of the surgery department chairman.

6. Discuss the present trends in the management of a surgery department.

RECOMMENDED PREPARATION

No special preparation is needed for a study of this program. However, students who have been exposed to a surgery department of any hospital are expected to comprehend more readily the content of this program than those without any previous exposure.

I. GOAL AND OBJECTIVES

Diseases can generally be classified into surgical and nonsurgical. Surgical diseases are those needing surgical treatment.

All general hospitals will invariably be confronted with patients with surgical diseases. For this reason, all general hospitals should provide facilities and personnel to serve these patients with surgical diseases. This is the raison d' entre for the surgical department in a hospital.

The goal of the surgery department is to provide proper medical service to all patients with surgical diseases who seek consultation and treatment in the hospital.

The main objectives of the surgery department are the following:

1. To examine all patients with a possible surgical disease and afterwhich, to make a rational and accurate diagnosis.

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

Other objectives may be added, such as:

1. To provide training in surgery.

2. To promote research in surgery.

The "surgery department" is a broad term that originally encompasses all medical subspecialties that use surgery or an operation as their primary tool in treating diseases. Thus, historically, the surgery department includes general surgery, ophthalmology, otolaryngology, and obstetrics and gynecology. Nowadays, these four subspecialties are distinct departments by themselves with the latter three carrying the name of their respective subspecialty.

The term "surgery department" usually refers to the subspecialty of general surgery. General surgery is composed of various sub-subspecialties like head and neck, breast, abdominal, thoracocardiovascular, trauma, plastic and reconstructive, neurologic, urologic, and orthopedic surgery. Depending on how well-developed a sub-subspecialty is in a particular hospital, it may be a distinct department by itself or still be a section of the surgery department. For example, nowadays, in some hospitals in the Philippines, there is a distinct department of orthopedics.

In this program, the term "surgery department" will be used to refer to the subspecialty of general surgery and its sub-subspecialties.

REVIEW QUESTIONS I

1. Give the two components of the service objective of a surgery department.

2. Nowadays, what subspecialty in clinical medicine is being referred to when the term "surgery department" is used?

*Check answers with those on page 10.

II. THE PHYSICAL REQUIREMENTS

GENERAL CONSIDERATIONS

In order to meet its service objective, the surgery department must have at least the following:

1. Operating rooms

2. Surgical patient beds

3. Consultation rooms in the

3.1 Outpatient department

3.2 Emergency room

The location within the hospital, the quantity, the size, the design, and the equipment of the abovementioned physical requirements will be dependent on a lot of factors. Some of these are enumerated below:

1. Government regulations

2. Usual and anticipated increase in patient load

3. Needs and expectations of the community

4. Allowance for expansion

5. Cost-benefit considerations

In order to meet its training objective, the surgery department must have at least a conference room and a library. For its research objective, a library that is abundant in books and journals is helpful. In the Philippines, since it is expensive to subscribe and to maintain journals, a recommendation will be to utilize the INTERNET and the HERDIN of the Philippine Council for Health and Research Development. HERDIN stands for Health Research Development Information Network. Through the INTERNET and HERDIN, needed journal articles, both local and foreign, can be requested and secured with an email, a phone call or through a FAX communication.

THE OPERATING ROOM

The operating room is the place where diagnostic and therapeutic surgical procedures are performed.

Depending on the decision of the hospital administration, beside the hospital proper, the emergency room and the outpatient department may be equipped with an operating room. From hereon, in this program, the term "operating room" will refer to the one in the hospital proper.

The operating room may be located at the ground floor or at the upper floors. The most important consideration is that it must be accessible. It must not be very far from the emergency

room and from the surgical department. If an operating room is located at the upper floors, elevators or ramps will have to be provided for ready access.

The number of rooms inside the operating room proper will be dependent on a lot of factors, some of which have already been mentioned under "general considerations".

There is a general rule on the number of operating rooms required. The rule is one operating room for every 50 hospital beds. Thus, if the bed capacity of a hospital is 200, then, following the rule, four operating rooms are needed.

The ultimate basis in deciding how many rooms will be put up will be the cost-benefit considerations which relate the usual patient load of the surgical department to investment in spaces for the operating rooms.

In some hospitals, the department of ophthalmology, otolaryngology, and obstetrics and gynecology have their operating rooms located in places away from those of the surgical department. However, in most hospitals, there is only one operating room complex that houses in one floor or one area all the rooms assigned to the various surgical subspecialties. The latter set-up is more cost-beneficial because of the flexibility in the utilization of rooms and operating room personnel.

In a modern general hospital of about 200 beds or more, the following areas or rooms are usually designated in the operating room proper:

1. General surgical rooms

2. Urology room

3. Ophthalmology room

4. Endoscopy room

5. Emergency room

6. Minor operating room

7. Delivery room

8. Induction room

9. Recovery room

10. Scrubbing areas

11. Dark room

12. Storage room

13. Working areas

14. OR lounge

15. Anesthesiologists' room

16. Male dressing room

17. Female dressing room

18. Administrator's room

19. Conference room

The design of the operating room should be one that will best achieve effectiveness and efficiency. Another important consideration is that the design should try to achieve the sterility standards and requirements of the operating room. This refers specifically to the design to control the traffic flow, from the outside to the inside of the operating room, from the dirty zone to the cleaner one and then to the sterile areas.

The essential equipment and facilities needed by the operating room can be categorized into seven groups:

1. Anesthesizing equipment

2. Operating equipment

3. Supplies for anesthesia and operation

4. Monitoring devices

5. Drugs, parenteral fluids, and gases

6. Recovery room beds

REVIEW QUESTIONS II

1. What are the three essential physical requirements of the surgery department in order for it to meet its service objective?

2. What are the two essential physical requirements of the surgery department in order for it to meet its training objective?

3. If a surgery department in the Philippines does not have sufficient journals, where could its staff look for the journals they need for their research project?

4. What is the most important consideration in siting the operating room in the hospital proper?

5. What is the ultimate basis in the deciding how many rooms will be put up in the operating room proper?

6. Which is more cost-beneficial, several department operating rooms or one operating room complex? Why?

7. Give two important considerations in the planning of design of the operating room.

8. Enumerate five groups of essential equipment and facilities in the operating room.

*Check answers with those on page 10.

III. THE PERSONNEL REQUIREMENTS

GENERAL CONSIDERATIONS

In order to meet the service objective, the surgery department must have at least surgeons, nurses, and nursing aides. These personnel must be adequate in number and in competency to serve effectively and efficiently the surgical patients in the operating room, in the floors and wards, and in the consultation rooms, both in the outpatient department and in the emergency room.

Some of the factors that will affect the number of personnel in the surgery department will be the following:

1. Government regulations

2. Usual and anticipated increase in patient load

3. Needs and expectations of community

4. Cost-benefit considerations

For hospitals with a training program in general surgery, there must be adequate competent trainors. In the Philippines, the Philippine Society of General Surgeons is the accrediting agency for residency programs in general surgery. There must be a minimum of three general surgeons who are fellows of the Philippine College of Surgeons for a residency program in general surgery to be accredited. For the surgery department to be able to promote research, its staff must be research-oriented and must know how to do and to teach research.

THE OPERATING ROOM

The operating room must have surgeons, anesthesiologists, nurses, and nursing aides to be able to directly provide service to patients. These personnel are expected to be competent in their respective fields and responsibilities. At present, the minimum requirement for each type of personnel is a license to practice their profession. For the surgeons and anesthesiologists, a specialty-board certification is preferred, if not required.

The number of personnel required will ultimately be determined by cost-benefit considerations that relate primarily the usual as well as anticipated increase in patient load in the surgery department.

An operation usually needs an anesthesiologist, three surgeons (one surgeon and two assistants), two nurses (one scrub and one circulating) and one nursing aide.

If there are four operating rooms and operations are allowed to be performed simultaneously in each room, then the personnel required will be at least four anesthesiologists, four surgeons, eight surgical assistants, eight nurses, and four nursing aides. For the nurses and nursing aides, provisions will have to be made for the afternoon and evening shifts.

The administration of the operating room will be dependent on the set-up in a particular hospital. If the operating room is distinctly under a particular surgical subspecialty, then the operating room is administered by the clinical department concerned. If the operating room is a complex consisting of activities under various surgical subspecialties, then an operating room management team or committee should be formed. This team or committee should be composed of representatives from the various surgical subspecialties involved, the department of anesthesia, and the nursing service.

THE CHAIRMAN

Considering the objectives of the surgery department and the nature of activities and personnel involved, the chairman of the surgery department must have the following qualifications:

1. He must be a surgeon.

2. He must know administration or management.

3. He must know pedagogy.

4. He must know how to do research.

REVIEW QUESTIONS III

1. Name the three groups of essential personnel in the surgery department.

2. Name the four groups of essential personnel in the operating room.

3. How many general surgery fellows of the Philippine College of Surgeons are needed for a training program in general surgery to be accredited?

4. In an ideal set-up, enumerate the type of personnel and their corresponding number that are usually needed in the performance of a major operation.

5. What is the ultimate basis that will determine the number of personnel required in an operating room?

6. Usually, who are the members of the operating room management team or committee?

7. What are the competencies required of the chairman of the surgery department?

*Check answers with those on page 11.

IV. MANUAL OF POLICIES AND PROCEDURES

GENERAL CONSIDERATIONS

After the objectives have been formulated and after the physical and personnel requirements have been filled in, the next step is to run the department. To run the surgery department effectively and efficiently, a manual of policies and procedures is needed. The manual should guide the present and future staff. It should be reviewed and revised periodically.

The manual should contain policies and procedures in the various areas under the surgery department or in which the surgery department is involved. These areas are the operating rooms, the floors and wards where surgical patients are housed, and the surgical consultation rooms, both in the outpatient department as well as in the emergency room.

The manual should also contain policies and procedures on the attainment of the objectives of the surgery department , such as in terms of service, training, and research.

THE OPERATING ROOM

In the operating room, there must be available a manual of policies and procedures. The manual should contain specific policies and procedures, among other things, on the following:

1. Safety in the operating room, especially in terms of explosions and infections

2. Scheduling of cases

3. Operating room privileges

4. Records

5. Charging

6. Instruments and equipment

7. Traffic

REVIEW QUESTIONS IV

1. Explain the importance of a manual of policies and procedures in a surgery department.

2. Enumerate five major items that should be included in the manual of policies and procedures of an operating room.

*Check answers with those on page 11.

V. THE TRENDS

The present trends in the management of a surgery department consist of the following:

1. The objectives are not limited to service. Training and research are usually included because they contribute to perpetuation and quality of service.

2. All training programs must be accredited with the Philippine Society of General Surgeons.

Accredited training programs will attract trainees more than those non-accredited ones.

3. Only those surgeons certified by the Philippine Board of Surgery can now be accepted for active and permanent staff membership in hospitals.

4. An operating room complex is the trend and this is being managed by an operating room management team.

REVIEW QUESTION V

1. Enumerate three present trends in the management of a surgery department.

*Check answers with those on page 12.

ANSWERS TO REVIEW QUESTIONS

NOTE: ANSWERS STATED IN DIFFERENT WAYS BUT WITH ESSENTIALLY THE SAME CONTENT ARE ALSO CORRECT.

ANSWERS TO REVIEW QUESTIONS I

1.1. To examine all patients with a possible surgical disease and afterwhich, to make a logical and accurate diagnosis.

1.2 To provide treatment to all patients with surgical diseases.

2. General surgery.

ANSWERS TO REVIEW QUESTIONS II

1.1. Operating rooms

1.2. Surgical patient beds

1.3. Consultation rooms in the outpatient department and in the emergency room

2.1. Conference room

2.2. Library

3. INTERNET and/or the Philippine Council for Health and Research Development through its HERDIN

4. Accessibility to patients of the surgery department

5. Cost-benefit considerations

6. Operating room complex because of the flexibility in the utilization of rooms and personnel

7.1. Effectiveness and efficiency

7.2. Sterility standards and requirements

8.1. Equipment for anesthesia

8.2. Equipment for operation

8.3. Supplies for anesthesia

8.4. Supplies for operation

8.5. Monitoring devices

8.6. Drugs, parenteral fluids, gases

8.7. Recovery room beds

(*Any five of the above answers)

ANSWERS TO REVIEW QUESTIONS III

1.1. Surgeons

1.2. Nurses

1.3. Nursing aides

2.1. Surgeons

2.2. Anesthesiologists

2.3. Nurses

2.4. Nursing aides

3. Three

4.1. Anesthesiologist - 1

4.2. Surgeons - 3

Surgeon - 1

Surgical assistant - 2

4.3. Nurses - 2

Scrub nurse - 1

Circulating nurse - 1

4.4. Nursing aide - 1

5. Cost-benefit considerations

6.1. Representatives from the various surgical subspecialties

6.2. Representative from the department of anesthesia

6.3. Representative from the nursing service

7.1. Surgeon

7.2. Administrator

7.3. Teacher

7.4. Researcher

ANSWERS TO REVIEW QUESTIONS IV

1. A manual of policies and procedures facilitates the running of the surgery department. It contributes to effectiveness and efficiency. It guides the present and future staff.

2.1. Safety in the operating room

2.2. Scheduling of cases

2.3. Operating room privileges

2.4. Records

2.5. Charging

2.6. Instruments and equipment

2.7. Traffic

(*Any five of the above answers)

ANSWERS TO REVIEW QUESTION V

1.1. Objectives are usually three: service, training, and research.

1.2. All general surgery training programs must be accredited with the Philippine Society of General Surgeons.

1.3. Only surgeons certified by the Philippine Board of Surgery can now be accepted for active and permanent staff membership in hospitals.

1.4. An operating room complex is preferred over separate departmental operating rooms.

(*Any three of the above answers)

REFERENCES

1. Grant C: Hospital Management. New York: Churchill Livingston, 1973.

2. Joson RO: Manual for Surgical Interns. University of the Philippines College of Medicine, 1990.

3. Mac Eachern MT: Hospital Organization and Management. Chicago: Physician's Record Co., 1957.

4. O'Leary DS: Accreditation Manual for Hospital, 1987.

5. Rosenberg N: Surgical Services. In Owen JK (ed): Modern Concepts of Hospital Administration. Philadelphia: W.B. Saunders, Co., 1962.

THE SURGERY DEPARTMENT

POST-TEST

DIRECTIONS: Circle T if the statement is true and F if the statement is false.

T F 1. The presence of patients with surgical diseases is the raison d' entre for a surgery department in a hospital.

T F 2. The service objective of a surgery department is to diagnose and treat all patients with surgical diseases seeking consultation at the hospital.

T F 3. Training and research are invariably parts of the objectives of a surgery department because they contribute to the perpetuation and quality of service.

T F 4. Nowadays, the term "surgery department" refers to the subspecialty of general surgery and its sub-subspecialties.

T F 5. A surgery department must have operating rooms.

T F 6. A surgery department must have hospital beds for its patients.

T F 7. A surgery department must have consultation rooms at the outpatient department.

T F 8. To meet its research objective, a surgery department can utilize the service of INTERNET for its journal requirements.

T F 9. The most important factor to consider when planning for the location of the operating room is sterility.

T F 10. The operating room must not be very far from the emergency room.

T F 11. A rule to follow when computing for the number of operating rooms needed in a general hospital is 50 hospital beds to one operating room.

T F 12. The ultimate basis in deciding how many operating rooms to have is the cost-benefit considerations.

T F 13. The design of the operating room should take into consideration the sterility standards and requirements of the operating room.

T F 14. The minimum essential equipment needed in the operating room are those needed in giving anesthesia and in operating.

T F 15. The personnel of the surgery department consist of surgeons, anesthesiologists, nurses, and nursing aides.

T F 16. The personnel of the operating room consist of surgeons, anesthesiologists, nurses, and nursing aides.

T F 17. For a general surgery training program to be accredited with the Philippine Society of General Surgeons, three general surgery fellows of the College are needed.

T F 18. The number of personnel required in the operating room will ultimately be determined by cost-benefit considerations.

T F 19. An operating room complex is more cost-beneficial than various separate departmental operating rooms.

T F 20. To run the surgical department and the operating room effectively and efficiently, a manual of policies and procedures is needed.

DIRECTIONS: Place a "T" on the line before a factor which will have to be considered when planning for the physical requirements of the surgery department and operating room. Place an "X" on those items not required.

_____ 21. Government regulations

_____ 22. Usual patient load

_____ 23. Anticipated patient load

_____ 24. Needs of the community

_____ 25. Expectations of the community

_____ 26. Sterility

_____ 27. Cost-benefit considerations

_____ 28. Wish of owners

_____ 29. Available spaces

_____ 30. Trends in medicine

DIRECTIONS: Place a "T" on the essential equipment and facilities required by an operating room. Place an "X" on items not required.

_____ 31. Equipment for anesthesia

_____ 32. Equipment for operation

_____ 33. Supplies for anesthesia

_____ 34. Supplies for operation

_____ 35. Monitoring devices

_____ 36. Drugs

_____ 37. Gases

_____ 38. Parenteral fluids

_____ 39. X-ray machines

_____ 40. Beds

DIRECTIONS: Place a "T" on the line before a competency which is required of a chairman of a surgery department. Place an "X" for those not required.

_____ 41. Certified surgeon

_____ 42. Administrator

_____ 43. Teacher

_____ 44. Researcher

_____ 45. Lawyer

_____ 46. Businessman

DIRECTIONS: Place a number on the blank representing the number of personnel required during the performance of a major operation.

_____ 47. Nurses

_____ 48. Surgical assistants

_____ 49. Nursing aides

_____ 50. Anesthesiologists

THE SURGERY DEPARTMENT

ANSWERS TO POST-TEST

1. T 11. T

2. T 12. T

3. T 13. T

4. T 14. T

5. T 15. F

6. T 16. T

7. T 17. T

8. T 18. T

9. F 19. T

10. T 20. T

21. T 26. T

22. T 27. T

23. T 28. T

24. T 29. T

25. T 30. T

31. T 36. T

32. T 37. T

33. T 38. T

34. T 39. X

35. T 40. T

41. T 44. T

42. T 45. X

43. T 46. X

47. (2) 49. (1)

48. (2) 50. (1)

RECOMMENDED FOLLOW-UP

After finishing this program, the students of hospital administration are encouraged to do the following for further training and mastery of the subject matter:

1. Study, analyze, and critique an existing surgery department in terms of the following:

1.1 Objectives

1.2 Physical facilities

1.3 Personnel

2. Study, analyze, and critique an existing operating room in terms of the following:

2.1 Location

2.2 Size and number

2.3 Design

2.4 Equipment and facilities

2.5 Personnel

3. Study and analyze the manual of policies and procedures of an existing surgery department and an operating room.

ABOUT THE AUTHOR

DR. REYNALDO O. JOSON obtained his Doctor of Medicine degree from the University of the Philippines College of Medicine (UPCM) in 1974. He finished his General Surgery Residency Training Program at the Philippine General Hospital (PGH) in 1981. He is a Fellow of the Philippine College of Surgeons and a Diplomate of the Philippine Board of Surgery.

In 1991, Dr. Joson obtained a Master in Hospital Administration (MHA) from the University of the Philippines College of Public Health (UPCPH). Since 1989 up to the present, he is the Assistant Medical Director of the Manila Doctors Hospital (MDH). He is also the chair of the Quality Assurance Committee of MDH (1998 up to present). He was the former director of the MDH Emergency Room (1991-1993) and Operating Room (1990-1993).

Beside MHA, Dr. Joson is also a holder of Master of Health Profession Education (MHPEd) and Master of Science (MSc) in General Surgery.

He was formerly the chief of Division of Head and Neck, Breast, Soft Tissue, and Esophageal Surgery of the Department of Surgery of the PGH; a professor of the UPCM; a facilitator in the UPCPH; and an affiliate professor of the UP Faculty Health Sciences (UP Manila School of Distance Education).

From 2001 up to present, he has been the chairman of the Department of Surgery of Ospital ng Maynila Medical Center.

Updated, 1994; 1999;2003