Department of Surgery - HA202 - 2023

Organization and Management of a Department of Surgery
Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg
2023

Course Number and Title: HA 202
(Organization and Management of the Different
Departments and Services of a Hospital)
Course Description:
The course deals with the major concepts, principles,
and considerations in the management of various
hospital services and departments.

Prescribed Learning Outcomes:
After studying this topic, you should be able to:
1. Understand the philosophy, objectives, structure, staffing,
policies, systems, and methods in running the Department
of Surgery of a hospital.
2. Understand the roles and relationships of different
components of the department of surgery.
3. Describe the responsibilities of hospital managers in
directing and coordinating the department of surgery.
4. Understand the challenges that might be encountered in
the department of surgery and to recommend solutions
thereto.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
A Department Design and Development Framework
Regular Performance Evaluation and Continual Improvement Program
Administrative Design and Development Program
Architectural Design / Engineering / Construction
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Learning objectives:
1. Understand the philosophy, objectives,
structure, staffing, policies, systems, and
methods in running the Department of Surgery
of a hospital.
2. Understand the roles and relationships of
different components of the department of
surgery.
3. Describe the responsibilities of hospital
managers in directing and coordinating the
department of surgery.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Department of Surgery Design and Development Framework
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
One of the various
medical specialty
departments
Providing
medical-surgical
services

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
HOSPITAL =
Supersystem
DEPARTMENT OF
SURGERY =
Subsystem
OTHER DEPARTMENTS
= Co-subsystems

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Surgery Department Design and Development Framework
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
A Surgery Department Design and Development Framework
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
The administrative design and
development program should be
aligned and integrated with the
whole hospital ‘s…………… as well
as interfacing units’ ………….!
SYSTEMS PERSPECTIVE or
SYSTEMS THINKING!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
There must be a competent
HEAD!
Competencies expected of a head:
Unit Technical Requirements
/ Competency (The Specialty
– SURGERY)
Hospital Teamship
Managership
Leadership
SYSTEMS APPROACH /
THINKING

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
JOB DESCRIPTIONS
JOB SPECIFICATIONS
PERFORMANCE
EVALUATION SYSTEM

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
There must be a
document stating
authorized FUNCTIONS of
the department.
It must be complete and
clear with general and
specific functions and it
must be authorized by a
higher office.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
• Serve as compass or
guide;
• Describe roles and
responsibilities of unit
in context of whole
hospital;
• Give unit authority to
do what it should be
doing;

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
• Serve as guide in
determining what are
needed in unit to
function properly and
adequately such as in
terms of structure,
staffing, policies and
procedures, programs,
and resources;

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
• Serve as guide in
determining what
programs, projects,
tasks, and activities the
head and staff can do to
accomplish their unit’s
functions, both on long
term and short term
basis;

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
• Serve as basis for
evaluating unit’s
performance at the very
least, whether it is
accomplishing its
expected functions on a
daily basis and annually;
and
• Serve as basis for the
name of the unit.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Example:
General Function:
To provide medical services to
all patients with surgical
conditions and diseases who
seek consultation and treatment
in the hospital.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Example:
Specific Functions:
1. To examine all patients with a
possible surgical conditions and
diseases and afterwhich, to make
a rational and accurate diagnosis.
2. To provide treatment to all patients
with surgical conditions and
diseases.
3. To provide training in surgery.
4 To promote research in surgery.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Example:
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 and safe diagnostic
and therapeutic procedures to all patients
with surgical problems.
3. To provide quality and safe 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.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
There must be a
document stating
authorized
SERVICES of the
department.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Formulated
“functions” determine
the “services” to be
offered to clients –
physicians and
patients.
“Services” offered
and “functions”
authorized must be
congruent with each
other.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Example:
Based on authorized functions -
Services to offer:
• Diagnostic program
• Therapeutic program
• Pre-operative, intra-
operative, and post-
operative surgical care
program

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Example:
Based on authorized functions -
Services to offer:
• Health promotion and
disease prevention
program
• Diagnostic program
• Therapeutic program
• Pre-operative, intra-
operative, and post-
operative surgical care
program
• Rehabilitative health
program

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Ultimate goals:
Performance excellence
Client engagement (returning loyal
patient-clients)
Quality and safe health care
services
Cost-efficient / valued-based
services
Maximal utilization of services
Financial viability and
sustainability

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Value-based services
Value created and appreciated by
patient- and physician-clients for
services rendered
Good health care delivery
outcomes (good results)
Quality and safe services
Reasonable costs and expenses

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
There must be a document stating
ultimate GOALS of the
DEPARTMENT -
aligned and integrated with
HOSPITAL’s goals.
Financial viability and
sustainability of HOSPITAL!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Physical structure of surgery
department refers to a
geographical space or area in
the hospital, constructed to
receive patient- and
physician-clients requesting
for services and to house the
staff who will perform the
functions of the department.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Physical structure needs of
surgery department in terms
of functions and services:
1. Operating rooms
2. Surgical patient beds /
floors
3. Consultation rooms in
3.1 Outpatient
department / clinics
3.2 Emergency room
4. Department
administrative office/s

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Physical structure needs of
surgery department in terms
of functions and services:
1. Operating rooms
2. Surgical patient beds
3.1 Outpatient
3.2 Emergency room
4. Department
Surgery department
leaders must be
involved in design
and development.
As they have impact
on its functions and
services.
These departments
and services are
usually handled by
different managers!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
SERVICE REQUIREMENT
as dictated by authorized
functions is the first
determinant of
the PHYSICAL
STRUCTURE of the
department.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Other determinants of
PHYSICAL STRUCTURE:
• statutory and regulatory
requirements;
• DOH Licensing
Requirements (DOH
Guidelines in the Planning
and Design of a Hospital and
Other Health Facilities and
Safe Hospital Initiative –
structural, non-structural,
and functional indicators)
• Building Code
• Fire Code
• local government
requirements

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
PHYSICAL STRUCTURE:
• SPECIALTY requirements
particularly on training and
research
• human resource program
• equipment and material
program
• data / documents / records
program
• budget program
• risk management program
• business development
program

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
PHYSICAL STRUCTURE:
• quality standards
• community
expectations
• efficiency
• case load
• owners’ wants

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
•Compliant with DOH licensing and structural
requirements– particularly on location and size
•Accessibility – with clear signage
•Adequate size (not cramped for staff and client
movement)
•Adequate lighting
•Adequate ventilation
•Aesthetics – attractive, with a welcoming, friendly
and therapeutic environment
•Provision for privacy as needed
•Comfortable waiting areas

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
These will be dictated by the
DOH licensing and structural
requirements and the physical
structure requirements.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Staff
MDs - Surgical Consultants,
Fellows, Residents, Interns,
etc.
Providing medical-surgical
services
on a salaried and/or non-
salaried basis

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Specialists in:
• General Surgery
• Pediatric Surgery
• Urology
• Thoracocardiovascular
Surgery
• Plastic and
Reconstructive Surgery
• Neurosurgery

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
JOB DESCRIPTIONS
JOB SPECIFICATIONS
PERFORMANCE
EVALUATION SYSTEM
Adequate in number
and in competency!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
In consideration of the key
functions and services of the
department, statutory and
regulatory requirements, and
other objectives like
business development, risk
management, and IT-enabled
system ,
adequacy of equipment and
materials needed to facilitate
an effective and efficient
functioning of the unit.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Adequacy of equipment and
material program in the
following service areas:
1. Operating rooms
floors
3.1 Outpatient
3.2 Emergency room
4. Department

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Presence of management
system of the equipment and
material program
- Preventive maintenance
- Calibration of precision
biomedical equipment

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
In consideration of the key
functions and services of the unit,
statutory and regulatory
requirements, and other
objectives like business
development, risk management,
and IT-enabled system ,
ADEQUACY and ACCURACY of
data, documents, and
records needed to facilitate
an effective and efficient
functioning of the unit.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Adequacy and accuracy of
data, documents and records
program in the following
service areas:
1. Operating rooms
floors
3.1 Outpatient department
/ clinics
3.2 Emergency room
4. Department
Patient records
Governance and
Operations
Manual
Department
statistics
Others

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Presence of a structured
and comprehensive
program that will develop
the business of unit to
make it viable and
sustainable!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Objectives:
•To project future income and expenses of
the unit which are reflected in a document
(budget).
•To use projected future income and
expenses of the unit (budget) as guide for
day-to-day performance and financial
evaluation at planned intervals.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Risk management program is a planned and
systematic process / program to reduce
and/or eliminate the probability of a “risk”
that usually results in injuries, losses, and
legal suits.
(may also include risk with potential positive effect –
improving business and client engagement.)

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Use of computing technology, such as
hardware, software, networking, and
Internet
•to promote efficiency in performance of
functions and accomplishment of services ;
•to manage information of unit – getting,
storing, protecting, processing,
transmitting, and later retrieving as
necessary;

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Use of computing technology, such as
hardware, software, networking, and
Internet
•to create interconnection with other units in
hospital for timely communication,
coordination and collaboration in
accomplishment of services of unit;
•to communicate with the patient- and
physician-clients both in and out of hospital.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Policies and
Procedures (PP)
/ CPGs / CPaths
to provide order;
to promote
standardization;
to facilitate
communication;

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
to promote
effectiveness
and efficiency;
and
to provide a guide
to present and
future staff

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
PPs
must be aligned
with policies
and procedures
of the hospital!
should be
reviewed and
revised
periodically!

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
f
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.
CPGs
Acute Appendicitis
Breast Cancer
Management
Gallbladder Stone
Management
Others

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Performance
Excellence
Client
Engagement
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
CPaths
Acute Appendicitis
For Operation
Elective
Cholecystectomy
Others
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.

Whole
Hospital
Concepts
and Design
Whole
Hospital
Governance
Policies
Procedures
Whole
Hospital
Operations
Policies
Procedures
Interfacing
Units
Operations
Policies
Procedures
Functions
(authorized)
Services
(authorized)
Leadership
IT-enabled System
DOH
Licensing
& Structural
Requirements
Policies &
Procedures /
Clinical
Practice
Guidelines/
Clinical
Pathways
Risk
Management
Program
Physical
Structure
(Location,
space)
Human
Resource
Program
Equipment
/ Material
Program
Data /
Documents /
Records
Program
Business
Development
Program
Budget
Program
Goals
Client
Engagement
Performance
Excellence
Quality and
Safe Health
Care
Services
Cost-
efficient /
Value-based
Services
Maximal
Utilization
of Services
Appraising extent of accomplishment
of the unit in its authorized functions
and business plans at planned
intervals (quarterly, biannually, and
annual).
To determine areas of improvement
and to act on them.

• Common CHALLENGES encountered in governance of the
department together with their suggested strategic
solutions.
Categories Common Problems Suggested
Strategies
• Man
• System and
Method
• Machine /
Equipment
• Money / Other
Resources
• Trends in Surgery

• Common CHALLENGES
Strategies
MAN
Consultants
Residents
Colleagues in other
units
Chief of Hospital /
bosses
Subordinates
Competencies
Quantity
Alignment
Coordination
Collaboration
Integration
Personality
Leadership and
managership skills
Managing your boss
Use of a multisectoral /
multi-professional
committee
membership

Categories Common Problems Suggested Strategies
SYSTEM AND
METHOD
Lack of
systematization
Lack of standardized
procedures
Use DOH licensure
requirements
Use quality standards
(PhilHealth
Benchbook, JCI, ACI)
Policies and
procedures
Clinical practice
guidelines
Clinical pathways

Strategies
MACHINE /
EQUIPMENT
Lack of
management
system
Lack of calibration
Lack of preventive
maintenance
Policies and
procedures
MONEY
Other resources
Limited Leadership
Innovativeness

Categories Common
Problems
Suggested Strategies
TRENDS
in SURGERY
Rapid changes -
difficulty in coping
Knowledge
management system
(constant tracking and
continual education)
Benchmarking
Innovativeness

Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg
2023

Department of Surgery - HA202 - 2023

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Editor's Notes