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Organization and Management of a Department of Surgery - ROJoson Reynaldo Joson
The document discusses the organization and management of a hospital department of surgery. It outlines the course description, learning objectives, and framework for designing and developing a surgery department. The administrative design and development program for the surgery department should be aligned and integrated with the systems and policies of the whole hospital as well as interfacing units using a systems perspective.
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Management of a Clinical Medical Department with Focus on Department of Surgery - UP-CHP HA 201
Organization and Management of Different Departments and Services of the Hospital - February 8, 2018
Systems Approach to Hospital Operations - Department of SurgeryReynaldo Joson
The document outlines a framework for developing and managing a department of surgery within a hospital system. It describes 22 essential elements that must be aligned and integrated for effective department design and operations. These include leadership, functions and services authorized by the department, compliance with whole-hospital and other departmental policies and procedures, and service outputs that are cost-efficient and provide value to patients. The framework is intended to guide departments in establishing governance structures and policies to ensure operations are coordinated with the overall hospital system.
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This document outlines guidelines for improving the management of healthcare institutions. It discusses the need to create an enabling framework of supportive policies, laws, and resources. It also emphasizes clarifying the mandates and principles that will guide the institution. The document recommends conducting a strategic planning process that involves stakeholders in developing a vision, mission, SWOT analysis, and strategic action plan. It stresses the importance of strategic change management and capacity development to successfully implement the strategic plan through training, workshops, and developing new management roles and responsibilities. Monitoring and evaluation is also highlighted as important for tracking performance indicators outlined in the strategic plan.
This document provides a summary of Carolyn Isaacson's background and experience. She has over 23 years of experience in healthcare, including leadership roles as Director of Nursing and Manager of Clinical Services. Currently, she is the Director of Quality and Compliance Management at Altus ACE, where she is building the infrastructure for quality and compliance. Previously she held national roles at UnitedHealthcare managing clinical adherence programs. She has extensive experience in quality monitoring, ensuring regulatory compliance, and training and developing staff.
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The document presents a framework for managing hospital operations across multiple departments systematically. It proposes taking a systems approach that views the hospital as a whole system and ensures alignment and integration of departmental plans, processes and evaluations to support overall hospital goals. The framework includes 22 elements that must be aligned and integrated for each department. It then illustrates this framework using the Department of Surgery, mapping its functions, structure, equipment, staffing, policies, programs, resources, problems and solutions to the 22 framework elements. The goal is to facilitate leadership, organization, management, integration and collaboration across hospital departments.
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DNP-835A: Patient Outcomes and Sustainable Change
ASSIGNMENT 2:
Please see the ATTACHED Quality and Sustainability Paper: Part 1
Quality and Sustainability Paper: Part 2
Assessment Description
The purpose of this assignment is to determine what is needed to promote successful implementation and sustainability of a quality or safety program for your selected health care entity/issue.
General Guidelines:
Use the following information to ensure successful completion of the assignment:
· This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
· Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
· This assignment requires that you support your position by referencing six to eight scholarly resources. At least three of your supporting references must be from scholarly sources other than the assigned readings.
· You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
· Learners will submit this assignment using the assignment dropbox in the digital classroom. In addition, learners must upload this deliverable to the Learner Dissertation Page (LDP) in the DNP PI Workspace for later use.
Directions:
Write a paper (2,000-2,500 words) that provides the following:
1. Incorporate all necessary revisions and corrections suggested by your instructor for Part 1. Synthesize the different elements of Part 1 and Part 2 into one paper using transitions to connect ideas and concepts.
2. Evaluate current evidenced-based quality and/or safety program designs that can be implemented to improve the quality and/or safety outcomes for your selected quality and/safety issue at your identified health care entity. Based on this evaluation, propose an evidence-based quality and/or safety program to address your selected issue from Part 1. Explain how your proposed design will better improve the outcomes for the selected quality and/or safety issue as compared to the program currently in place at the health care entity.
3. Identify potential obstacles (such as economics or ethical issues) that may hinder the implementation of the proposed quality and/or safety program and suggest ways to overcome these.
4. Identify stakeholders within the selected health care entity with whom you may need to collaborate and discuss the role of each stakeholder in the implementation of the proposed program. In the identification of stakeholders, also include specific groups and leaders that are needed.
5. Identify a change management theory you will use to support the implementation of your quality and/or safety program. Provide evidence that supports the use of this theory within the program you designed.
6. Discuss the expected outcomes of the implementation of your proposed quality and/or saf.
This document provides an agenda and overview for a project kick-off meeting between FreemanWhite, a healthcare consulting firm, and Abbott Northwestern Hospital to define the scope of studying and planning improvements to the hospital's emergency department. The objectives are to analyze current and projected patient volumes, workflow, and identify areas for improved operations. Over two days, the FreemanWhite team will tour the existing emergency department, gather data, map current patient flows, discuss opportunities with ancillary departments, and identify best practices to develop recommendations and concept plans for the emergency department's long-term facility needs.
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Christine Egan has over 15 years of experience in healthcare IT, specializing in pharmacy systems and electronic health records. She has extensive experience implementing, customizing, and supporting Cerner applications including PharmNet, CPOE, and medication administration. Her background includes roles as a consultant, analyst, and project manager where she has led teams and managed complex clinical implementations.
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This document outlines the learning objectives and content for an instructional module on strategic planning concepts, principles, and processes for hospitals. It will be part of a strategic planning management system and associated with other hospital exercises. The module aims to provide board members, executives, managers, and other key hospital staff an understanding of strategic planning fundamentals. Topics will include the definition and purpose of strategic planning, types of plans at the hospital, business unit, and program levels, and the steps involved in strategic planning, implementation, and evaluation.
Quality improvement across our healthcare system - Mirek Skrypak.pptxlibrary66
This document discusses quality improvement in healthcare. It defines quality improvement as giving staff the skills and resources to solve issues affecting care quality. It outlines Donabedian's structure-process-outcome model for quality improvement and describes how the organization will use clinical audits and the model for improvement to engage staff. The document proposes a strategy for training staff in quality improvement over the next 3 years and establishes partnerships and an evaluation plan to support continuous quality improvement across the system.
The document discusses the DIY Information Technology Strategic Plan for an organization. It provides an overview of typical strategic planning costs and recommends doing strategic planning internally to save money. It then covers why strategic planning is important, what different strategy models look like, and the strategic planning process. Examples of strategic plans and frameworks are presented. The document emphasizes that the strategic plan should focus on tying projects and investments to the overall vision and goals of the organization.
The elements of the development plan
Elements of the quality plan
Development and quality plans for small and for internal projects
Software development risks a
The document discusses the need for healthcare project management training and the benefits it provides. It notes that recent US legislation and industry trends have led to an increased number of healthcare projects. Good project management is required to implement projects successfully and achieve goals like improved quality and reduced costs. However, healthcare workers often lack project management skills since they are more familiar with operational versus project work. The document advocates for training clinical leaders in project management principles and provides suggestions for developing effective training programs.
The document provides an overview of the Joint Commission International (JCI) accreditation process for hospitals. It describes what accreditation is, the benefits of accreditation, and the accreditation timeline. The standards are organized around important hospital functions and apply to the entire organization as well as individual departments. There are sections that address requirements for maintaining accreditation, patient-centered functions, organizational functions that support patient care, and how standards, intents and measurable elements are used in the accreditation and survey process.
The document provides an overview of the Joint Commission International (JCI) accreditation process for hospitals. It describes what accreditation is, its benefits, and timeline. The standards are organized around important hospital functions and patient care. During an on-site survey, surveyors use various methods like document review, interviews, patient tracers, and facility tours to evaluate hospitals' compliance with JCI standards. Scoring guidelines are provided to assess standards as fully met, partially met, not met, or not applicable.
The Clinical Decision Support Consortium aims to advance clinical decision support through several research projects. The Consortium will assess, define, demonstrate, and evaluate best practices for clinical decision support across multiple healthcare settings and electronic health record platforms. Several research teams will focus on knowledge management, clinical guideline translation, decision support content development and delivery, and evaluating demonstrations of decision support. The goal is to improve healthcare quality by facilitating widespread use of evidence-based clinical decision support.
Managing a major hospital website redesignShawn Gross
What's it like to lead a 200-year old academic medical center through a three+ year institution-wide website redesign initiative?
Slides cover planning, implementation and measuring success of the new website for Massachusetts General Hospital in Boston.
The new massgeneral.org has received top health care marketing awards, including recognition from organizations such as MITX, AIGA and WebAwards; and most importantly, continues to receive positive feedback from its patient and health care professional constituents.
The document outlines a postgraduate certificate in moving and handling (M&H) at Auckland University of Technology (AUT). Musculoskeletal disorders are a major cause of disability and work-related illness, especially in healthcare. The certificate aims to upskill healthcare workers in ergonomics, risk assessment, and evidence-based M&H practices. It consists of three papers taught over 15 months to align M&H in New Zealand with international standards. An evaluation will assess how the certificate improves M&H practices and reduces workplace injuries in healthcare organizations.
Hosconnn Consultancy Services Pvt Ltd is a company that provides comprehensive healthcare solutions including management consulting, architecture, interior design, and turnkey project management. They have experience working in healthcare facilities across India and internationally. Their services include feasibility studies, project management, design and construction of new healthcare facilities, and operational consulting for existing facilities.
Hosconnn Consultancy Services Pvt Ltd is a company that provides comprehensive healthcare solutions through management consulting, architecture, interior design, and turnkey project management. It was founded to help healthcare organizations achieve their goals through understanding the variables in the healthcare field. The company adopts an integrated approach, drawing on expertise across various services to provide cost-effective and innovative solutions for clients. Services include conceptualizing, planning, designing, and implementing healthcare projects from start to finish.
The document provides a summary of Dr. Ahmed Kassem Ghoneem's qualifications and experience in healthcare quality management. It lists his education and certifications in fields including management, healthcare utilization, data analysis, and quality management. It then describes his work experience in quality management roles for various hospitals in Saudi Arabia and Egypt from 2008 to present. Finally, it outlines his core skills and achievements in areas such as quality improvement, accreditation, clinical guidelines, data analysis, and leading quality projects.
05 integrated management system telkom 2016 penanganan bencana - tanggap da...wisnu wardhana, i nyoman
1) The document outlines standards and procedures for conducting exercises and testing of Telkom's business continuity plans. It discusses defining the scope, participants, objectives, scenarios, and communications for exercises.
2) Exercises and tests should be conducted regularly based on predefined schedules and should involve top management. They assess the feasibility and effectiveness of continuity plans, identify areas for improvement, and confirm the organization's ability to respond to incidents.
3) The results of exercises are documented and used to update plans and strategies. Lessons learned are incorporated to ensure continuous improvement of the business continuity management system.
DNP-835A Patient Outcomes and Sustainable ChangeASSIGNMENT 2.docxpauline234567
DNP-835A: Patient Outcomes and Sustainable Change
ASSIGNMENT 2:
Please see the ATTACHED Quality and Sustainability Paper: Part 1
Quality and Sustainability Paper: Part 2
Assessment Description
The purpose of this assignment is to determine what is needed to promote successful implementation and sustainability of a quality or safety program for your selected health care entity/issue.
General Guidelines:
Use the following information to ensure successful completion of the assignment:
· This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
· Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
· This assignment requires that you support your position by referencing six to eight scholarly resources. At least three of your supporting references must be from scholarly sources other than the assigned readings.
· You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
· Learners will submit this assignment using the assignment dropbox in the digital classroom. In addition, learners must upload this deliverable to the Learner Dissertation Page (LDP) in the DNP PI Workspace for later use.
Directions:
Write a paper (2,000-2,500 words) that provides the following:
1. Incorporate all necessary revisions and corrections suggested by your instructor for Part 1. Synthesize the different elements of Part 1 and Part 2 into one paper using transitions to connect ideas and concepts.
2. Evaluate current evidenced-based quality and/or safety program designs that can be implemented to improve the quality and/or safety outcomes for your selected quality and/safety issue at your identified health care entity. Based on this evaluation, propose an evidence-based quality and/or safety program to address your selected issue from Part 1. Explain how your proposed design will better improve the outcomes for the selected quality and/or safety issue as compared to the program currently in place at the health care entity.
3. Identify potential obstacles (such as economics or ethical issues) that may hinder the implementation of the proposed quality and/or safety program and suggest ways to overcome these.
4. Identify stakeholders within the selected health care entity with whom you may need to collaborate and discuss the role of each stakeholder in the implementation of the proposed program. In the identification of stakeholders, also include specific groups and leaders that are needed.
5. Identify a change management theory you will use to support the implementation of your quality and/or safety program. Provide evidence that supports the use of this theory within the program you designed.
6. Discuss the expected outcomes of the implementation of your proposed quality and/or saf.
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Kenneth Kruk's story of transforming challenges into opportunities by leading successful medical record transitions and bridging scientific knowledge gaps during COVID-19.
Trauma Outpatient Center is a comprehensive facility dedicated to addressing mental health challenges and providing medication-assisted treatment. We offer a diverse range of services aimed at assisting individuals in overcoming addiction, mental health disorders, and related obstacles. Our team consists of seasoned professionals who are both experienced and compassionate, committed to delivering the highest standard of care to our clients. By utilizing evidence-based treatment methods, we strive to help our clients achieve their goals and lead healthier, more fulfilling lives.
Our mission is to provide a safe and supportive environment where our clients can receive the highest quality of care. We are dedicated to assisting our clients in reaching their objectives and improving their overall well-being. We prioritize our clients' needs and individualize treatment plans to ensure they receive tailored care. Our approach is rooted in evidence-based practices proven effective in treating addiction and mental health disorders.
Healthy Eating Habits:
Understanding Nutrition Labels: Teaches how to read and interpret food labels, focusing on serving sizes, calorie intake, and nutrients to limit or include.
Tips for Healthy Eating: Offers practical advice such as incorporating a variety of foods, practicing moderation, staying hydrated, and eating mindfully.
Benefits of Regular Exercise:
Physical Benefits: Discusses how exercise aids in weight management, muscle and bone health, cardiovascular health, and flexibility.
Mental Benefits: Explains the psychological advantages, including stress reduction, improved mood, and better sleep.
Tips for Staying Active:
Encourages consistency, variety in exercises, setting realistic goals, and finding enjoyable activities to maintain motivation.
Maintaining a Balanced Lifestyle:
Integrating Nutrition and Exercise: Suggests meal planning and incorporating physical activity into daily routines.
Monitoring Progress: Recommends tracking food intake and exercise, regular health check-ups, and provides tips for achieving balance, such as getting sufficient sleep, managing stress, and staying socially active.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
Let's Talk About It: Breast Cancer (What is Mindset and Does it Really Matter?)bkling
Your mindset is the way you make sense of the world around you. This lens influences the way you think, the way you feel, and how you might behave in certain situations. Let's talk about mindset myths that can get us into trouble and ways to cultivate a mindset to support your cancer survivorship in authentic ways. Let’s Talk About It!
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Gemma Wean- Nutritional solution for Artemiasmuskaan0008
GEMMA Wean is a high end larval co-feeding and weaning diet aimed at Artemia optimisation and is fortified with a high level of proteins and phospholipids. GEMMA Wean provides the early weaned juveniles with dedicated fish nutrition and is an ideal follow on from GEMMA Micro or Artemia.
GEMMA Wean has an optimised nutritional balance and physical quality so that it flows more freely and spreads readily on the water surface. The balance of phospholipid classes to- gether with the production technology based on a low temperature extrusion process improve the physical aspect of the pellets while still retaining the high phospholipid content.
GEMMA Wean is available in 0.1mm, 0.2mm and 0.3mm. There is also a 0.5mm micro-pellet, GEMMA Wean Diamond, which covers the early nursery stage from post-weaning to pre-growing.
Michigan HealthTech Market Map 2024. Includes 7 categories: Policy Makers, Academic Innovation Centers, Digital Health Providers, Healthcare Providers, Payers / Insurance, Device Companies, Life Science Companies, Innovation Accelerators. Developed by the Michigan-Israel Business Accelerator
This particular slides consist of- what is Pneumothorax,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is a summary of Pneumothorax:
Pneumothorax, also known as a collapsed lung, is a condition that occurs when air leaks into the space between the lung and chest wall. This air buildup puts pressure on the lung, preventing it from expanding fully when you breathe. A pneumothorax can cause a complete or partial collapse of the lung.
2. 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.
Organization and Management of a Department of Surgery
3. 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.
Organization and Management of a Department of Surgery
4. 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
5. 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
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.
6. 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
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
7. 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
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
One of the various
medical specialty
departments
Providing
medical-surgical
services
8. 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
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
HOSPITAL =
Supersystem
DEPARTMENT OF
SURGERY =
Subsystem
OTHER DEPARTMENTS
= Co-subsystems
9. 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
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
10. 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
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
11. 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
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
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!
12. 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
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
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
13. 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
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
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
14. 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
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
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.
15. 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
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
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;
16. 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
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
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;
17. 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
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
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;
18. 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
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
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.
19. 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
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
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.
20. 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
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
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.
21. 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
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
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.
22. 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
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
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.
23. 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
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
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.
24. 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
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
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
25. 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
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
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
26. 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
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
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
27. 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
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
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
28. 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
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
There must be a document stating
ultimate GOALS of the
DEPARTMENT -
aligned and integrated with
HOSPITAL’s goals.
Financial viability and
sustainability of HOSPITAL!
29. 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
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
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.
30. 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
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
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
31. 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
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
Physical structure needs of
surgery department in terms
of functions and services:
1. Operating rooms
2. Surgical patient beds
3. Consultation rooms in
3.1 Outpatient
department / clinics
3.2 Emergency room
4. Department
administrative office/s
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!
32. 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
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
SERVICE REQUIREMENT
as dictated by authorized
functions is the first
determinant of
the PHYSICAL
STRUCTURE of the
department.
33. 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
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
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
34. 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
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
Other determinants of
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
35. 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
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
Other determinants of
PHYSICAL STRUCTURE:
• quality standards
• community
expectations
• efficiency
• case load
• owners’ wants
36. 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
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
•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
37. 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
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
These will be dictated by the
DOH licensing and structural
requirements and the physical
structure requirements.
38. 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
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
Staff
MDs - Surgical Consultants,
Fellows, Residents, Interns,
etc.
Providing medical-surgical
services
on a salaried and/or non-
salaried basis
39. 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
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
Specialists in:
• General Surgery
• Pediatric Surgery
• Urology
• Thoracocardiovascular
Surgery
• Plastic and
Reconstructive Surgery
• Neurosurgery
40. 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
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
JOB DESCRIPTIONS
JOB SPECIFICATIONS
PERFORMANCE
EVALUATION SYSTEM
Adequate in number
and in competency!
41. 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
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
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.
42. 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
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
Adequacy of equipment and
material program in the
following service areas:
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
43. 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
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
Presence of management
system of the equipment and
material program
- Preventive maintenance
- Calibration of precision
biomedical equipment
44. 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
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
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.
45. 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
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
Adequacy and accuracy of
data, documents and records
program in the following
service areas:
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
Patient records
Governance and
Operations
Manual
Department
statistics
Others
46. 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
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
Presence of a structured
and comprehensive
program that will develop
the business of unit to
make it viable and
sustainable!
47. 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
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
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.
48. 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
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
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.)
49. 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
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
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;
50. 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
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
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.
51. 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
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
Policies and
Procedures (PP)
/ CPGs / CPaths
to provide order;
to promote
standardization;
to facilitate
communication;
52. 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
to promote
effectiveness
and efficiency;
and
to provide a guide
to present and
future staff
53. 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
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
PPs
must be aligned
with policies
and procedures
of the hospital!
should be
reviewed and
revised
periodically!
54. 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
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
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
55. 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
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
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.
56. 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
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
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.
57. 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
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.
58. Prescribed Learning Outcomes:
• 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
Organization and Management of a Department of Surgery
59. Prescribed Learning Outcomes:
• Common CHALLENGES
Categories Common Problems Suggested
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
Organization and Management of a Department of Surgery
60. Prescribed Learning Outcomes:
• Common CHALLENGES
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
Organization and Management of a Department of Surgery
61. Prescribed Learning Outcomes:
• Common CHALLENGES
Categories Common Problems Suggested
Strategies
MACHINE /
EQUIPMENT
Lack of
management
system
Lack of calibration
Lack of preventive
maintenance
Policies and
procedures
MONEY
Other resources
Limited Leadership
Innovativeness
Organization and Management of a Department of Surgery
62. Prescribed Learning Outcomes:
• Common CHALLENGES
Categories Common
Problems
Suggested Strategies
TRENDS
in SURGERY
Rapid changes -
difficulty in coping
Knowledge
management system
(constant tracking and
continual education)
Benchmarking
Innovativeness
Organization and Management of a Department of Surgery
63. 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.
Organization and Management of a Department of Surgery
64. 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
65. Prescribed Learning Outcomes:
• 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
Organization and Management of a Department of Surgery
66. Reynaldo O. Joson, MD, MHA, MHPEd, MScSurg
2023
Organization and Management of a Department of Surgery
Editor's Notes
Good day. I am Dr. Reynaldo Ong Joson.
I was asked to give a lecture with this title: Organization and Management of a Department of Surgery for HA 202 – with a time limit of 45 minutes and
With the following prescribed learning outcomes or 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.
4. Understand the challenges that might be encountered in the department of surgery and to recommend solutions thereto.
I will use this generic department design and development framework which is essentially an administrative design and development program to tackle
learning objectives 1 to 3.
I said this framework is generic and is applicable to all kinds of departments in the hospital. As such, this is applicable to a department of surgery.
The department of surgery is one of the various medical specialty departments providing medical-surgical services to patient-clients of the hospital.
The department of surgery is one of the subsystems within the hospital (which is the supersystem). The other departments are co-subsystems.
Using the framework, this slide shows the essential and basic components of a department of surgery which must be present to facilitate accomplishment of its authorized functions and services and achievement of its goals. See the various boxes with the following labels:
Leadership
Authorized functions
Authorized services
Goals
Architectural design / engineering / construction
Physical structure
DOH licensing and structural requirements
Policies and procedures
Risk management system
Human resource program
Equipment / material program
Data / documents / records program
Business development program
Budget Program
IT-enabled system
Regular performance evaluation and continual improvement program
All of these components must be present, aligned and integrated with each other in order to achieve performance excellence for the department.
The arrows indicate the need for alignment and integration of all parts of the department.
On the extreme left of the slide, one sees the need for alignment and integration with the whole hospital as well as the other departments in the hospital.
This slide illustrates the supersystem (which is the hospital), subsystem (which is a particular department), and co-subsystem (which is an interfacing department).
Again, all the arrows indicate the need for alignment and integration of all parts of the subsystem (the department) with the supersystem (the hospital) and co-systems (the interfacing departments).
Let me repeat, the administrative design and development program should be aligned and integrated with the whole hospital‘s concepts and design, governance policies and procedures, operations policies and procedures as well as the interfacing units’ operations policies and procedures!
In other words, there must be a SYSTEMS PERSPECTIVE or SYSTEMS THINKING!
Leadership
there must be a competent head with at least the following competencies: unit technical requirements / competency on the specialty of the department (in other words, the head must be a surgeon); hospital teamship (team player); managership and leadership with systems approach and thinking in management.
There must be documents that contain the job descriptions, job specifications and performance evaluation system of the leaders and managers.
Functions
There must be a document stating the 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.
The authorized functions serve as compass or guide; describe roles and responsibilities of the department in the context of the whole hospital; give it authority to do what it should be doing
Serve as guide in determining what are needed in the unit to function properly and adequately such as in terms of structure, staffing, policies and procedures, programs, and resources;
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;
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.
Example:
General Function:
To provide medical services to all patients with surgical conditions and diseases who seek consultation and treatment in the hospital.
Example of list of 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.
Another example of list of specific functions:
To provide quality health promotion and disease prevention program in the field of surgery to clients in need of such service.
To provide quality and safe diagnostic and therapeutic procedures to all patients with surgical problems.
To provide quality and safe pre-operative, intra-operative, and post-operative surgical care to all patients in need of such health care service.
To provide quality rehabilitative health programs in the field of surgery to all clients in need of such service.
Services
There must be a document stating authorized SERVICES of the department.
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.
Example of list of services based on authorized functions:
Diagnostic program
Therapeutic program
Pre-operative, intra-operative, and post-operative surgical care program
Another example;
Health promotion and disease prevention program
Diagnostic program
Therapeutic program
Pre-operative, intra-operative, and post-operative surgical care program
Rehabilitative health program
There must be a document stating the goals of the department, which are usually the following: Performance excellence; Client engagement (returning loyal patient-clients); Quality and safe health care services; Cost-efficient / valued-based services;
Maximal utilization of services; ultimately resulting to financial viability and sustainability
Value-based services means value created and appreciated by patient-and physician-clients for services rendered as a result of good outcomes and results in quality and safe services and associated with reasonable costs and expenses.
There must be a document stating the ultimate goals of the department which must be aligned and integrated with the goals of the hospital.
All the department’s goals should eventually be contributing to financial viability and sustainability of the hospital.
Physical structure
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.
Physical structure
Physical structure needs of surgery department as dictated by functions and services include the following: operating rooms; surgical patient beds or floors; consultation rooms in outpatient department or clinics and emergency room; and department administrative office or offices.
The surgeons or department leaders must be involved particularly in the design and development of the operating rooms; surgical patient beds, consultation rooms in the outpatient department / clinics and emergency rooms as they have impact on its authorized functions and services. These departments and services are usually managed by different groups of managers.
The department leaders must take note of this:
SERVICE REQUIREMENT as dictated by authorized functions is the first determinant of the PHYSICAL STRUCTURE of the department.
The department leaders must also take note of the other requirements and 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
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
quality standards
community expectations
efficiency
case load
owners’ wants
The physical structure of the department service areas must be compliant with DOH licensing and structural requirements particularly on location and size. In particular, they must comply with the following: 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; and Comfortable waiting areas
Architectural Design / Engineering / Construction
These will be dictated by the DOH licensing and structural requirements and the physical structure requirements.
Human Resource Program or StaffThese consist of MDs - Surgical Consultants, Fellows, Residents, Interns, etc. providing medical-surgical services on a salaried and/or non-salaried basis
The specialists usually consist of consultants in general surgery; pediatric surgery; urology; thoracocardiovascular surgery; plastic and reconstructive surgery; neurosurgery; and other subspecialties.
There must be a document showing job descriptions, job specifications and performance evaluation system of human resource in the department.
There must be documentation of adequacy in number and in competency.
Equipment / Material Program
There must be a document showing adequacy of equipment and materials needed to facilitate an effective and efficient functioning of the unit 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.
There must be a document showing adequacy of equipment and materials in the following services areas: operating rooms; surgical patient beds or floors; consultation rooms in the outpatient department / clinics and emergency rooms; and department administrative offices.
There must be documents showing presence of a management system of equipment and material program which includes among other things, preventive maintenance and calibration especially of precision biomedical equipment
Data / Documents / Records Program
There must be documents showing adequacy and accuracy of data, documents and records needed to facilitate an effective and efficient functioning of the unit 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.
Data / Documents / Records Program
There must be documents showing adequacy and accuracy of data, documents and records needed following services areas: operating rooms; surgical patient beds or floors; consultation rooms in the outpatient department / clinics and emergency rooms; and department administrative offices. Examples are patient records, governance and operations manual, department statistics, etc.
Business Development Program
There must be a document showing the presence of a structured and comprehensive program that will develop the business of the unit to make it viable and sustainable.
Budget Program
There must be a document showing a budget that project future income and expenses of the unit and the budget is being used as a guide for day-to-day performance and financial evaluation at planned intervals.
Risk Management Program
There must be a document showing a risk management program - which 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.
The program may also include risk with potential positive effect – improving business and client engagement.
IT-enabled system
There must be a document showing the use of IT
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;
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.
Policies and Procedures / Clinical Practice Guidelines / Clinical Pathways
There must be documented Policies and Procedures / Clinical Practice Guidelines / Clinical Pathways that serve 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 aligned with policies and procedures of the hospital.
They should be reviewed and revised periodically!
Clinical practice guidelines and clinical pathways are akin to policies and procedures but focus on patient management.
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.
Examples of titles of CPGs are CPG on Acute Appendicitis; Breast Cancer Management; Gallbladder Stone Management; etc.
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.
Examples of titles of CPaths are CPaths on Acute Appendicitis for Operation; Elective Cholecystectomy; etc.
Regular Performance Evaluation and Continual Improvement Program
There must be a document that shows a program to appraise extent of accomplishment of the unit in its authorized functions and business plans at planned intervals (quarterly, biannually, and annual) and
To determine areas of improvement and to act on them.
At this point, I like to say that I have covered the learning objectives 1 to 3 using the department design and development framework – philosophy, objectives, structure, staffing, polices, systems and methods in running a department of surgery; roles and relationships of the different components of a department of surgery; and lastly, responsibilities of hospital managers in directing and coordinating the department of surgery. Haven’t I?
Let’s now go to the last learning objective: common challenges encountered in governance of a department of surgery together with their suggested strategic solutions.
The challenges can be in at least 5 categories:
Man
System and Method
Machine and Equipment
Money and other Resources
Trends in Surgery
Under the MAN categories are
The consultants
The residents
Colleagues in other units
Chief of Hospital and other bosses
Subordinates
The common problems are:
Competencies
Quantity
Alignment, Coordination, Collaboration and Integration
Personality
Suggested strategies consist of
Leadership and menagership skills
Managing your boss (manage his persoanality – adjust accordingly to his / her mind set and mood)
Use of multisectoral - multiprofessional committee membership to engage everybody into alignment, coordination, collaboraiton and integration
Under the System and Method Category –
Common problems are:
Lack of systematization in doing things
Lack of standardized procedures
Suggested strategies:
Use DOH licensure requirements as guide
Use quality standards as guide such as PhilHealth Benchbook, Joint Commission International, Accreditation Canada International
Establish policies and procedures, clinical practice guidelines and clinical pathways
Under the Machine / Equipment Category –
Common problems are:
Lack of management sytem
Lack of calibration and preventive maintenance of machine and equipment
Suggested strategies
Policies and procedures
Under the Money and Other resources category –
Limited resources is always a problem
Suggested strategies:
Leadership and Innovativeness on how to get money
Under the Trends in Surgery Category
The most common problem is the rapid changes in trends which oftentimes are difficult to cope
Suggested strategies are:
Knowledge management system – constant tracking and continual education
Benchmarking
Innovativeness
I like to end my lecture by flashing again the topics that I have covered.
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.
My parting advicesRemember and use this framework – it is generic; it is applicable to all departments; and it is comprehensive. It facilitates learning, planning and governance of a department.
Just put in the details, the contents in each box and compile them into an operations manual.
Remember this starting table with the five categories (Man, System and Method, Machine and Equipment, Money and Trends) and recall the common problems under each category and my suggested strategies. You can add more as needed based on your settings and circumstances, particularly on the strategies. WITH THIS, I conclude my lecture.
I really hope you have acquired the prescribed learning outcomes through my presentation.
Thank you for your kind attention.