DEPARTMENT OF MEDICINE
DEPARTMENT POLICIES
Vision:

To render consistently high quality standards of medical services with highest degree
of professionalism, competence, compassion and ethics
Mission:

To exercise the best clinical judgment at all times, keeping in mind the principle of
patient-centered care and holistic management

To render cost- effective medical management that serves the patient’s best interest

To treat colleagues and staff ( medical and nonmedical) with courtesy, respect and high
degree of professionalism.

To be a teamplayer to co-workers, in addressing the needs of the patient, helping out
my colleagues or mentoring other staff in order to improve hospital services

To actively engage in continuing medical education activities, conventions and
workshops that will further enhance one’s clinical knowledge, skills and competency as
physician
I.
Active Consultant Staff
1.1 Holder of shares of stocks of at least 10 shares (10 shares = 1 block)
1.2 Have started or completed the payment of Privilege to Practice fee amounting
to P150,000. ( May be payable in 15 months term but must have all post dated
checks submitted to the hospital.)
1.3 Graduate of Internal Medicine residency training program in an accredited
training hospital and preferably a Diplomate and/or Fellow. Some subspecialties
such as Neurology, Dermatology and Rehabilitation Medicine which do not
require completion of a full Internal Medicine Residency Program as
prerequisite for their subspecialty, should be graduates of respective residency
training program of medical practice by accredited training institutions and
preferably a Diplomate and / or Fellow of their respective professional
societies.
1.4 Application approved by the Credentials Committee, upon recommendation of
the Department Head.
1.5 Exemplifies professional and ethical demeanour at all times. Reported unethical
and unprofessional behaviors are subject to investigation and appropriate
corrective action by the Department’s Peer Review Committee. If not resolved
within the department, the case shall be referred to the Ethics Committee .
1.6 Required to attend conferences , at least one conference a year.
II.
Visiting Consultants
2.1 Graduate of Internal Medicine residency training program in an accredited
training hospital and preferably a Diplomate and/or Fellow. Some subspecialties
such as Neurology, Dermatology and Rehabilitation Medicine, etc. which do
not require completion of a full Internal Medicine Residency Program as
prerequisite for their subspecialty , should be graduates of respective residency
training program of accredited training institutions and preferably a Diplomate
and / or Fellow of their respective professional societies.
2.2 Accreditation is valid for 2 years, after which, the consultant may apply for
reaccreditation. The approval of reaccreditation will primarily depend on
continuing need for the subspecialty applied, with high probability of approval
if number of active consultants at that time in said subspecialty is not enough to
meet the hospital’s needs.
2.3 Required to admit at least four (4) patients a year
2.4 Required to attend conferences of at least one conference a year, if possible as
a co-presenter of an interesting case.
III.
Responsibilities of Visiting Consultants:
3.1 Shall be allowed to admit private patients subject to the rules and regulations of
the Department and the Hospital
3.2 Shall adhere to the “closed referral” system. The visiting consultant may refer
his private patient only to members of the Active Consultant Staff.
3.3 Shall avail of the department and hospital facilities in the management of
patient subject to the rules and regulations of the department and the hospital
3.4 Shall be subjected to disciplinary action under the Department’s Peer Review
Committee for unprofessional and unethical demeanour. If not resolved within
the department, the case shall be referred to the Ethics Committee upon
recommendation by the Department Head.
IV.
Position/Function of the Active Consultant Staff
4.1 Department Head – appointed by the President and will serve a term of two
years.
4.1.1 Must be Diplomate and/ or Fellow of Internal Medicine of the
Philippine College of Physicians
4.1.2 Actively practicing Internal Medicine
4.1.3 Must have administrative capabilities and leadership potential
4.1.4 Involved in Continuing Medical Education activities
4.1.5 Shall develop policies that would enhance the performance of the
Department.
4.1.6 Shall prepare the budget for the Department
4.1.7 Shall be accountable to the Board
4.2 Section Head
4.2.1 Must be Diplomate and/ or Fellow of Internal Medicine of the
Philippine College of Physicians and Diplomate of the subspecialty
section. In case there is lack of available diplomates in a subspecialty,
a board-eligible consultant may be appointed as section head.
4.2.2 Shall plan and implement programs that would enhance the
performance of the subsection.
4.2.3 Shall conduct studies and research with the cooperation of the
department staff, in the fulfilment of the hospital’s vision on
continuing medical education and research.
V.
Referral System
5.1 The department shall adopt a “closed” referral system for all patients.
5.2 “Closed” referral system means interdepartmental or intersubspecialty referral
is exclusively among the active medical staff of the hospital
5.3 Referrals of patients to nonstockholder medical practitioners may be allowed
only for specialties or subspecialties not available in the hospital. These
specialists should be accredited visiting consultants of the hospital.
VI.
Decking Privileges
6.1 The privilege to be decked on house and OPD cases is exclusively for medical
stockholders who are members of the active consultant staff. Exception are
those who waived their rights to be decked.
6.2 Clear-cut Acute Cerebrovascular Accident (CVA) cases will be directly decked to
to Neurology subspecialty, as they will not join the grand decking.
6.3 For emergency cases, the decked consultant is given 30 minutes to
acknowledge the notification. Failure to respond within allotted time period
automatically transfers the patient to next consultant on deck. After two failed
acknowledgments, the Department Head will be called to handle the case.
6.4 For extreme emergency cases, any consultant available may be called upon.
6.5 House case patients should be seen by the Attending Physician 16 hours from
the time of patient’s admission. Otherwise, the patient will be transferred to
the next consultant on deck.
VII.
Clinic Privileges
7.1 Only members of the active medical staff shall have the privilege of holding
clinics at the OPD rooms
7.2 All consultants holding clinic should abide by the OPD guidelines set by the
hospital.
VIII. Professional fees
8.1 Professional fees for house cases shall be in accordance with the rates prepared
by the Department and approved by the Board of Directors.
8.2 All consultants are enjoined to make their professional fees reasonable and
affordable.
IX.
Attendance in Staff Meetings and Functions
9.1 All consultant staff of the Department are required to attend all department
functions and activities
9.2 A minimum of 51% attendance in all department-sponsored functions and
meetings is required for each year. Short of this requirement, a member is
suspended from housecase rotation for three (3) months. This is regardless
whether the absence is excused or not.
9.3 A minimal fee of one hundred pesos (P100) shall be imposed from members
with unexcused absences.
9.4 A member unable to attend meetings and functions shall inform the Secretary
of the Department Head at least 4 days prior to the activity.
X.
Other Responsibilities of the Consultants
10.1
All consultants shall actively participate or involve themselves in the
teaching functions of the department.
10.2
They shall attend to their assigned conferences and committees
10.3
All consultants actively practicing shall be guided by the Medical and
Dental Policies Governing the use of the Emergency Room, Wards and OPD
Doctors’ Clinics.
XI.
Amendments
11.1
Amendments to these policies could be made by a majority vote of the
active consultant staff in the Department of Medicine. Approval of the Board of
Directors is needed for the amendment’s effectivity.
Revisions made on thefollowing;
1. Department and section head terms : 2 years instead of 1 year because 1 year is too short
to make an impact and implement working policies. (Dr. Dacumos)
2. Section on Training officer not applicable at the moment as it is a nonteaching hospital.
3.