PSGS

2023 GUIDELINES for ACCREDITATION

OF

RESIDENCY TRAINING PROGRAMS

IN

GENERAL SURGERY
 PREFACE

Five years have elapsed since we first drafted the Accreditation Manual.
Many revisions and updates have been made on a regular basis to keep up with
the fast changing and evolving teaching and learning environment for our
residents. More importantly, they were made to be able to serve efficiently our
patients who are in essence the most important purpose of training surgeons.

Like its previous editions, this 2023 Manual is an objective means of assessing
the quality of Residency Training in General Surgery in the Philippines. Aside
from the minimum requirements needed to be granted accreditation, the manual
recognizes the essential aspect of patient safety thru the PSGS Surgical
Curriculum.

It is our vision that our graduates are globally competitive in the field of
surgery and align the programs towards ASEAN integration thus the shift to
Outcome-based Curriculum. We made the number of index cases more efficient
by making the cases required more realistic such as in gastric surgeries, pancreatic
surgeries and esophagus and head and neck surgeries. The integration of the
minimal access surgery and the simulation into the accreditation requirements as
well as taking the initiative towards surgical endoscopy will give our graduates a
more competitive stance in the region.

The manual supports the Mission-Vision of the Philippine Society of General

Surgeons as it monitors the implementation of a standardized instructional plan
in general surgery.
 VISION - MISSION STATEMENT

VISION
To be an organization of General Surgeons with
global expertise.

MISSION
(Promote. Provide. Deliver.)

Promote General Surgery as a premier and distinct specialty.

Provide excellence through innovation in surgical training,

education and research.

Deliver world-class, safe, compassionate and holistic service

to the community.
 TABLE of CONTENTS

INTRODUCTION 1

ACCREDITATION OF TRAINING PROGRAMs in GENERAL SURGERY 2

2.1. APPLICANTS for Accreditation 2

2.1.1. Institutions considered as a NEW Applicant GS-Residency Training Program

2.2. Application Process for Accreditation of Training Programs 2

2.2.1. Submission of documentary requirements for accreditation
2.2.2. Preliminary evaluation of submitted documents
2.2.3. PSGS Board decision regarding Accreditation visit
2.2.4. PSGS Committee on Accreditation visit of a qualified applicant training
program
2.2.5. The PSGS Board of Directors (Post-Visit) decision on the application for accreditation

MINIMUM REQUIREMENTS FOR ACCREDITATION IN GENERAL SURGERY 7

3.1. REQUIRED HOSPITAL FACILITIES & SERVICES 7

3.1.1. Department of Health accredited hospital with a minimum of 150 beds
3.1.2. All major clinical departments must be present and preferably accredited
3.1.3. Outpatient Facilities
3.1.4. Emergency Rooms, Operating Rooms, Recovery Room and Critical Care Facilities,
Minimally Invasive Surgery Facilities
3.1.5. Laboratory Services
3.1.5.1. Facilities for hematologic, serologic, biochemical and microbiological
examinations
3.1.5.2. Blood bank
3.1.5.3. Histopathology
3.1.6. Other Facilities/Services:
3.1.6.1. Radiologic facilities
3.1.6.2. Ultrasonography
3.1.6.3. Endoscopic Facility
3.1.7. Facilities available within the immediate vicinity of the hospital
3.1.7.1. CT Scan
3.1.7.2. Mammography
3.1.7.3. MRI
3.1.7.4. ERCP
3.2. TRAINING FACILITIES, MEDICAL LIBRARY AND INFORMATION TECHNOLOGY
FACILITIES WITH SUBSCRIBED AND FUNCTIONING INTERNET ACCESS 8
3.2.1. Textbooks
3.2.2. Surgical Journals
3.2.2.1. PJSS
3.2.2.2. Foreign Surgical Journals
3.2.2.3. E-journals
 3.2.3. PSGS Assessment and Surveillance (ASSURE) Online Database of Surgical Procedures
3.2.4. Functioning Hospital Tumor Board
3.2.5. Quality Assurance Board or Committee
3.2.6. Ethics Review Board
3.2.7. Required Skills Training Facility/Laboratory for Residents

3.3. STRUCTURED GENERAL SURGICAL RESIDENCY TRAINING PROGRAM

REQUIREMENTS 9

3.3.1. Policy on Commitment and Resident – Supervision

3.3.2. Qualified Training Staff

3.3.2.1. Department Chairperson
3.3.2.2. Residency Training Officer
3.3.2.3. Consultant Staff

3.3.3. Resident Staff

3.3.3.1. Basic Qualifications/Requirements of applicants for Residency Training
3.3.3.2. The Resident Complement
3.3.3.3. Lateral Entry Residents
3.3.3.4. Residents and the Program Factor

3.3.4. The Case Material

3.3.4.1. Program’s case load (volume and variety of cases) requirement
3.3.4.2. PROCEDURE as a RESIDENT’S CASE: Resident as “THE SURGEON”

3.3.5. Documentation of case material or cases handled

3.3.5.1. PSGS Prescribed Resident’s Logbook
3.3.5.2. PSGS Assessment and Surveillance Database

3.3.6. Residency program duration and structured rotation

3.3.6.1. Duration of training
3.3.6.2. Structured Rotation

3.3.7. Residents Evaluation

3.3.7.1. The Internal Evaluation Residents
3.3.7.2. The External Evaluation of Residents

3.3.8. Teaching and Learning Activitities

3.3.8.1. Minimum number of conferences per year

3.3.9. Documentation of the Teaching and Learning Activities

3.3.9.1. All teaching and learning activities
3.3.9.2. MIS/Laboratory Trainer Exercises

3.3.10. The Annual Report of the General Surgery Residency Training Program
 3.4. THE ANNUAL ACCREDITATION FEE 25

3.5. EVALUATION OF GRADUATES OF THE TRAINING PROGRAM 26

CONDUCT OF VISITS 27
4.1. When should an accredited training program be visited? 27
4.2. What to evaluate during a VISIT? 27
4.2.1. The CONTEXT within which the Program is being operated
4.2.2. The Training Resources (INPUT)
4.2.3. Implementation of the Training Program (PROCESS)
4.2.4. Resident performance at different levels of training
4.2.5. Promotion System
4.2.6. The PRODUCTS of the Program
4.3. Scheduling of a visit 29
4.4. Who will VISIT? 30
4.5. Expectations During a VISIT 30
4.5.1. Expectations of the Visiting Team
4.5.2. Expectations of the Hospital

LEVELS OF ACCREDITATION OF TRAINING PROGRAMS and PERIOD OF VALIDITY 33

5.1. LEVEL I – CONDITIONAL ACCREDITATION 33
5.2. LEVEL II – FULL ACCREDITATION 34
5.3. WARNING Status 35
5.4. SUSPENSION of Accreditation 36
5.5. TERMINATED Status / TERMINATION of Accreditation 37

MEMORANDUM OF AGREEMENT forming or supporting a Training Program

(CONSORTIUM, AFFILIATION, LINKAGE) 38
6.1. GUIDELINES AND REQUIREMENTS FOR CONSORTIUM 38
6.2. GUIDELINES FOR LINKAGE AND AFFILIATION 40
6.3. OTHER MOA LIMITATIONS AND REQUIREMENTS 41

Guidelines infractions that may lead to one level downgrade of Current

Accreditation Status
43
APPEAL on PSGS BOD DECISIONS regarding Accreditation Status 45
8.1. PSGS BOARD DECISIONS NOT SUBJECT TO APPEAL 45
8.2. Appeals to the PSGS Board of Directors must be in writing 45

STEPS TO AMEND THE REQUIREMENTS AND PROCEDURES OF ACCREDITATION 46

Implementing Rules and Regulations for Interim Accreditation on General Surgery Residency
Training Program 47
10.1 General Principles 47
10.2 Basic Requirements 48
10.3 Procedures and Policies of Application and Accreditation 49
10.4 Phase specific process, requirements and expected outcomes of “Interim Accreditation” 49
10.4.1 Phase I
10.4.2 Phase II
10.4.3 Phase III
10.4.4 Phase IV
10.5 Provisions for retention and re-visit 55

APPENDICES 57
11.1. Appendix 1 – FORMS 58
11.1.1 PSGS Form 2023-1: Application for Accreditation in General Surgery
11.1.2. PSGS Form 2023-2: General Surgery Accreditation Information Sheet
11.2. Appendix 2 – ANNUAL REPORT TABLE OF CONTENTS 65
11.3.Appendix 3 – 2023 Content and FORMAT: PSGS ANNUAL REPORT 66
11.3.1. PSGS Table 2023-I: Signature page
11.3.2. PSGS Table 2023-II: Breakdown of Operations
11.3.3. PSGS Table 2023-III: Tabulation of Operations
(14 Main Categories and Specific Operations)
11.3.4. PSGS Table 2023-IVa: Tabulated Summary of Program’s Census
11.3.5. PSGS Table 2023-IVb: Resident’s Tabulated Census for OUTSIDE Rotation
11.3.6. PSGS Table 2023-Va: PROGRAM STRUCTURE
11.3.7. PSGS Table 2023-Vb: Tabulated Names of Residents/ respective year level/
Annual Report Year Appointment dates/ divided according to year level and
schedule of rotators for the year.
11.3.8. PSGS Table 2023-Vc: Tabulations of Residents- New appointments/
Resigned/New Lateral Entry Residents/Terminated/& Rotators from
another institution
11.3.9. PSGS Table 2023-Vd1: Tabulation of Resident’s CERES and PBS-RITE results
(including the year’s MPL)
11.3.10. PSGS Table 2023-Vd2: Tabulation of Evaluation and Assessment Tools and
Schedule
 11.3.11. PSGS Table 2023-Ve: List of Graduates of the program and their status
11.3.12. PSGS Table 2023-VI: Listing of Year’s CONFERENCES and Activities
11.3.13. Roster of Consultants for the Annual Report Year
11.3.14. Training Committee Members for the Annual Report Year
11.3.15. PSGS Table 2017-Vg: 3-Year (past 2 years prior to and the annual report)
TABULATED CUMULATIVE OPERATION SUMMARY (including Index
Cases)
11.3.16. List of Hospital’s Existing and New Facilities, Equipments, Clinical Departments
and Committees for the Annual Report Year

11.4. Appendix-4 – PSGS Committee on Accreditation Rubric System for Evaluation of the 90
Programs

11.5. Appendix 5 - Guidelines and Criteria for Eligibility to take the Certifying
Examinations in General Surgery 105

11.5. GLOSSARY 108

11.6. PSGS Definition of General Surgery 111

 INTRODUCTION

General surgery training in the Philippines developed from the invaluable and progressive efforts
of our predecessors who have had the vision of an excellent and world class society of practicing
surgeons. An accrediting body, therefore, was created to ensure the delivery of the highest quality of
surgical care through a structured residency program with a standard curriculum. Thus, the
competence of those undergoing training in General Surgery in the different training institutions
nationwide is ensured.

The joint PCS Specialties Accreditation Committee was formed in 1976 with Dr. Alfredo T.
Ramirez as chair. It included all the chairs of the surgical specialty Boards and Presidents of the
surgical specialty societies. In 1977, eight hospitals received full accreditation and 26 had partial
accreditation. In 1995, the surgical curriculum for General Surgery was converted into competency-
based education curriculum. It was during this time that objectives, competencies, content, rotation,
teaching-learning activities, and resources were defined. The standardized evaluation system for
residents was introduced with rating scales using clinical competence, psychomotor skills and attitudes
as parameters to determine the accreditation status of the training institution.

The Accreditation Committee worked cooperatively with the Committee on Surgical Training
(CST), Philippine Association of Training Officers in Surgery (PATOS) and Philippine Board of
Surgery (PBS).

In 1999, the moratorium for the residency training programs applying for accreditation was lifted
through Board Resolution 99-005. The implementation of the Surgical curriculum and Standardized
Evaluation began. It was also at this time that the Philippine Society of General Surgeons was
established specifically during the Midyear Convention in Subic. PCS then gradually handed over its
task of accrediting General Surgery training programs to PSGS until May 4, 2002 when full devolution
was made at the signing of the Memorandum of Agreement.

After a series of workshops and public fora, it has been agreed upon that there will be a standard
5-year training program in General Surgery. All institutions desirous of receiving full accreditation
must comply with the minimum requirement prescribed.

The PSGS Accreditation Committee is composed of 25 members, all Fellows of the PSGS.

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 ACCREDITATION OF TRAINING PROGRAMS IN GENERAL SURGERY

2.1. Applicants for Accreditation

2.1.1. Institutions considered as New Applicants for GS-Residency Training Program

• Non-accredited Department of Surgery residency training program
• Previously PSGS-accredited Residency Training Program that was terminated but still
wishes to have the program re-accredited after a minimum period of one (1) year from
the date of termination of accreditation
• Non-accredited residency training program wishing to become PSGS-accredited as a
consortium either with another non-accredited program or with a currently PSGS-
accredited single institution or consortium training program. In the latter situation, the
existing PSGS-accredited single institution or consortium training program shall lose
its accredited status and shall be considered as a NEW applicant that will become a
NEW consortium.

• NOTE •

The PSGS Board of Directors must have been informed in writing, by the prospective
applicant training program, of their intention to apply for PSGS accreditation at the latest two (2)
years prior to the intended filing of their application. In the case of a consortium between two or
more non-accredited training programs, the notarized Memorandum of Agreement between the
involved institutions must have also been submitted for review and approval by the PSGS Board
of Directors at least 2 years before the intended date of application for accreditation.

All institutions wishing to apply for PSGS accreditation are advised to review the current
guidelines for PSGS Accreditation of General Surgery Training Programs for their guidance and
compliance.

2.2. Application Process for Accreditation

2.2.1. Submission of documentary requirements for accreditation:

a. Duly accomplished application form (Appendix 1-Forms, PSGS Form 2023-1:

Application for Accreditation in General Surgery)
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 b. Letter of application signed by the Department of Surgery Chairperson with the
written approval of the Hospital Medical Director or Chief of Hospital addressed to
the PSGS President thru the Committee on Accreditation stating the following:
(Appendix 1-Forms, PSGS Form 2023-2: General Surgery Accreditation Information
Sheet)
i. Mission-Vision of the Institution and the Department of Surgery
ii. Reason why the department is applying for PSGS accreditation
c. Signed written commitment to comply with ALL the rules and regulations on
accreditation set forth by the Society, to implement the Standardized Surgical
Curriculum for General Surgery, to actively participate and support all society and
chapter activities and projects, and to abide by the decision of the PSGS Board of
Directors (Appendix 1-Forms, PSGS Form 2023-2: General Surgery Accreditation
Information Sheet)
d. Annual reports covering the 2 years immediately prior to the date of application
(Please refer to Appendix 2- Annual Report Table of Contents) that shows satisfactory
compliance with the minimum annual PSGS case load requirements for accreditation
during each of the 2 years (excludes Graduate Evaluation & List of Graduates)
e. For institutions applying for accreditation as a consortium, a copy of the duly
notarized Memorandum of Agreement forming the consortium together with the
PSGS Board of Directors’ written approval of the MOA entered into at least 2 years
before the intended year of application
f. Payment of application processing fee amounting to PhP 30,000 or as determined by
the Board of Directors for the initial and preliminary evaluation of the submitted
documents. This fee is separate from the fee for an actual accreditation visit
amounting to PhP 70,000 or as determined by the PSGS Board of Directors.

2.2.2. Preliminary Evaluation of Submitted Documents

Upon payment of the required fee of PhP 30,000.00, a preliminary evaluation of the
submitted documents shall be done by the Committee on Accreditation to determine its
completeness.

A program must have the required hospital facilities and services, an organized
Department of Surgery, qualified training staff and resident complement, adequate
number and variety of case material to support the training of the resident complement, a
structured training program and resident rotation, properly documented teaching-learning
activities, documented internal evaluation of residents, documented external evaluation of
all residents (PSGS CERES-written examinations and PBS RITE ) during the two (2) years
immediately prior to the application for accreditation as well as other requirements that
may be deemed necessary by the Committee on Accreditation and the PSGS Board of
Directors.

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2.2.3. PSGS Board Decision Regarding Accreditation Visit

Based upon the evaluation and recommendation of the Committee on Accreditation and as
concurred with by the PSGS Board of Directors, applicant training programs that
satisfactorily comply with the minimum requirements for accreditation and are deemed
qualified for a visit shall be informed of the favorable decision. The Committee on
Accreditation shall then schedule an accreditation visit, at the earliest, one month after the
PSGS Board approval for the accreditation visit and upon full payment of the PhP 70,000.00
accreditation visit fee to fully evaluate the Applicant Training Program.

Prior to the Visit by the Committee on Accreditation, an Orientation/Briefing MUST be

scheduled with the Committee on Surgical Training by the training staff of the applicant
program. The department chairperson, training program director or training officer, and the
members of the training committee MUST be present during the aforementioned
orientation.

If an applicant training program fails to comply with the minimum requirements for
accreditation after the evaluation by the Committee on Accreditation and therefore is
deemed not yet qualified for an accreditation visit, the PSGS Board of Directors upon the
recommendation of the Committee on Accreditation shall likewise duly notify the applicant
training program of its decision. The training institution shall also be informed of their
deficiencies for their future reference should they wish to re-apply for accreditation after a
minimum period of one (1) year from the date of denial of their application for an
accreditation visit by the PSGS Board of Directors.

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 • NOTE •
Approved ('QUALIFIED’) or Disapproved ('Non-QUALIFIED’) Applicant Training
Program for an ACCREDITATION VISIT

Following the preliminary evaluation of the written documentary requirements submitted by

the applicant training program and upon the recommendation of the Committee on
Accreditation, the PSGS Board of Directors shall decide if an accreditation visit of the
Applicant Training Program is APPROVED or DISAPPROVED.

An APPROVED or 'QUALIFIED' Application for Accreditation only means that the

applicant program qualifies for an accreditation visit. The PSGS Board of Directors shall
schedule an accreditation visit upon the recommendation of the Committee on Accreditation.
The visit shall be conducted to fully assess the applicant training program and does not
guarantee that the visited training program shall be granted Level I accreditation.

A DISAPPROVED or 'NON-QUALIFIED' Application for Accreditation only means that

the applicant program did not qualify for an accreditation visit because there are still
significant deficiencies that will likely lead to the non-granting of PSGS accreditation based
on the assessment of the written documents submitted to the Committee on Accreditation and
as sustained by the PSGS Board of Directors. Disapproved programs may re-apply and go
thru the same procedure of application after a minimum period of one (1) year from the date
of denial of their application for an accreditation visit by the PSGS Board of Directors.

2.2.4. PSGS Committee on Accreditation Visit of a Qualified Applicant Training

Program

A team composed of at least 3 members of the Committee on Accreditation shall visit the
applicant training program. The yearly requirements for continued accreditation of general
surgery residency training programs shall be used to evaluate the qualification of the
applying institution or consortium.

The visiting team shall report its findings and assessment to the Committee on
Accreditation for discussion and committee approval. The committee thereafter submits
its recommendations to the PSGS Board of Directors.

The PSGS Board of Directors shall decide based on the recommendation of the Committee
on Accreditation and will notify the applicant training program of its decision immediately
after the board meeting held for that purpose.

2.2.5. PSGS Board Decision on Application for Accreditation

5
A successful applicant training program or consortium shall be granted a LEVEL 1
(Conditional Status) accreditation status that shall be valid for 2 years from the time it is
granted unless deficiencies are noted before the end of the 2-year period. The training
program shall also be given a certificate attesting to their Level 1 accreditation by the
PSGS.

A visited training program that does not satisfy the minimum requirements for initial Level
1 accreditation based on the evaluation and recommendation of the Committee on
Accreditation and as sustained by the Board of Directors shall be duly notified of the
decision. The applicant training program shall be informed of the findings of the visiting
team for their future reference should they wish to re-apply for accreditation after a
minimum period of one (1) year from the date of denial of their application for
accreditation by the PSGS Board of Directors.

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 Minimum Requirements for Accreditation in General Surgery

3.1. Required Hospital Facilities and Services

3.1.1. It must be at least a Department of Health Level 2 accredited hospital. For consortia
programs, EACH member hospital MUST be a DOH Level 2 or higher accredited
hospital.

3.1.2. All major clinical departments such as Internal Medicine, Obstetrics & Gynecology,
Pediatrics, and Anesthesiology MUST be present and preferably accredited by their
respective specialty societies.

3.1.3. Outpatient Facilities including a properly equipped minor Operating Room.

3.1.4. Emergency Room, Operating Room, Recovery Room, Critical Care Facility (preferably a
Surgical ICU but may be an ICU shared with other specialty services), and Minimally-
Invasive Surgery Facilities

3.1.5. Laboratory Services:

3.1.5.1. Facilities for hematologic, serologic, biochemical, and microbiological
examinations
3.1.5.2. Blood Bank
3.1.5.3 Histopathology:
3.1.5.3.1 Submission of all specimens to a pathologist for documentation
and/or histopathologic analysis.
3.1.5.3.2. Facility and capability to perform frozen section must be present
in the hospital or within the immediate vicinity so that results
will be available within approximate one (1) hour.
3.1.5.3.3. Facilities for fine needle aspiration cytology (FNAC) and core
needle biopsy must be present.
3.1.5.3.4. Provisions for Breast Panel (Estrogen and Progesterone assay,
Her-2-neu assay)

3.1.6. Other Facilities/Services:

3.1.6.1. Radiologic Facilities
3.1.6.1.1. Plain x-rays: chest, abdomen, KUB
3.1.6.1.2. Contrast x-rays: Upper GI, Barium Enema, IVP
3.1.6.1.3. Intra-operative cholangiography
3.1.6.2. Ultrasonography
3.1.6.3. Endoscopic Facility
7
 3.1.6.3.1. Upper & Lower GI endoscopy
3.1.6.3.2. Choledochoscopy
3.1.6.3.2. ERCP

3.1.7. Facilities that should be available within the immediate vicinity of the hospital, if not
available in the hospital
3.1.7.1. CT Scan
3.1.7.2. Mammography
3.1.7.3. MRI
3.1.7.4 ERCP

3.2. Training Facilities, Medical Library and Information Technology facilities with subscribed
and functioning internet access

3.2.1. Textbooks
3.2.1.1. Principles of Surgery
3.2.1.2. Atlas of Operative Techniques
3.2.1.3. Surgical Anatomy
3.2.1.4. Physiology
3.2.1.5. Pathology
3.2.1.6. Surgical Oncology
3.2.1.7. Trauma and Critical Care
3.2.1.8. Training Resource Manual in Minimal Access Surgery
3.2.1.9. All PSGS published and prescribed reference materials
3.2.1.10. Digital Libraries and E-books for Surgery

3.2.2. Surgical Journals

3.2.2.1. Philippine Journal of Surgical Specialties
3.2.2.2. Foreign Surgical Journals
3.2.2.3. E-journals Access

3.2.3. PSGS Assessment and Surveillance (ASSURE) Online Database of surgical procedures

3.2.4. Functioning Hospital or Department Tumor Board

3.2.5. Quality Assurance and Patient Safety Board or Committee

3.2.6. Ethics Review Board

3.2.7. Required skills training facility/laboratory for residents

3.2.7.1. Trainer Box
8
 3.2.7.2. Logbook to document exercises performed by each resident stating the date
and time of performance and the time to completion of the task/ exercise (e.g.
hand tying and suturing exercises, minimal access surgery drills and exercises)

3.3. Structured General Surgical Residency Training Program Requirements

3.3.1. Policy on Commitment & Resident-Supervision

Since the training program provides both patient care and accredited training of residents,
it is incumbent upon the Qualified Training Staff to demonstrate their commitment to the
training program. There must be a sustained and appropriate resident-supervision on
patient evaluation/care, management decisions, and performance of surgical procedures
as the trainee acquires the skills and maturity to be capable of practicing independently.
As emphasized in the Standardized Outcome-based Surgical Curriculum in General
Surgery, these attributes are fundamental to the provision of excellent patient care and the
training of future board-certified general surgeons. The Qualified Training Staff has the
obligation to follow-through with resident supervision and to provide guidance during the
pre-operative, intra-operative & post-operative assessment and management of all their
surgical patients. Such duties and commitment are not confined nor limited to the
supervision and oversight functions done during conferences or actual surgery.

Determination of the degree of supervision is generally left to the discretion of the qualified
training staff within the context of the levels of responsibility assigned to the individual
resident involved. This determination is a function of the experience and competence of
the resident and the complexity of the specific case.

3.3.2. Qualified Training Staff

3.3.2.1. Department Chairperson

- Has administrative authority over the Department of Surgery.
- In the case of a consortium, there must only be one (1) Chairperson for the
training program although there may be separate Department of Surgery
chairpersons per member hospital. The chairperson of the consortium
program may either be the concurrent chairperson of a member hospital’s
Department of Surgery or another individual mutually agreed upon and
designated by the consultant staff of the member hospitals
- Highly recommended to be a General Surgeon who is a Diplomate of the
Philippine Board of Surgery and a Fellow in good standing of the
Philippine Society of General Surgeons and the Philippine College of

9
 Surgeons to help ensure the comprehensive crafting of policies relevant to
General Surgery as a distinct specialty.
- He/She is the Chairperson in ONLY one (1) PSGS-Accredited Residency
Training Program at any given time.

3.3.2.2. Residency Training Officer

- Has authority over the residents' surgical training program and functions
as the Head of the GS-Residency Training Program Committee that is
composed of consultant staff members
- In the case of a consortium, there should be one (1) Program Director or
Over-all Training Officer for the program, and one (1) Assistant Training
Officer per member hospital. The Program Director or Over-all Training
Officer may either be the concurrent Assistant Training Officer of one of
the member hospitals or another individual mutually agreed upon and
designated by the consultant staff of the member.
- MUST be a PSGS Fellow in good standing who has been actively
practicing general surgery for at least five (5) years at the time of his/her
appointment
- MUST be a Philippine Association of Training Officers in Surgery
(PATOS) member in good standing at the time of his/her appointment.
- He/She is highly encouraged to complete the competency-based
curriculum of PATOS or at least modules 101A, 101B and 102.
- He or She is the training officer in ONLY one (1) PSGS-Accredited
Residency Training Program at any given time.

3.3.2.3. Consultant Staff

All consultants involved in the training of residents must have written

appointments from the institution.

Only consultants who are PSGS Fellows in good standing or PCS Fellows of
other PCS Surgical Specialty Societies in good standing may be involved in
the training of general surgery residents. All general surgical operations
included in the list of case requirements for accreditation must be supervised
by PSGS Fellows in good standing while the rotation of residents in other
specialties must be supervised by their respective board-certified specialists.
Only cases supervised by these qualified trainers in good standing may be used
for accreditation and board-eligibility purposes.

A minimum of five (5) PSGS Fellows in good standing who actively

participate in the residency training program is required for every ten (10) or
fewer surgical residents. One (1) additional PSGS Fellow in good standing
MUST be added for every three (3) additional residents. Failure to comply
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 with the 5 PSGS Fellows in good-standing for every 10-or-fewer-residents ratio
shall be a basis for the downgrading of the institution's accreditation status by
one level.

All PSGS fellows in the consultant staff of an accredited training program are
required to maintain their good standing as part of the requirements for
accreditation. A program's accreditation status shall not be affected if the
minimum required trainer in good standing to resident-ratio is maintained. All
the service and pay cases under the supervision of a consultant staff, NOT in
good-standing with PSGS and/or PCS, shall however NOT be credited as case
material of the training program for accreditation or board eligibility purposes.

All consultants appointed or assigned as members of the program’s Training

Committee should attend the competency based curriculum of PATOS.

3.3.3. Resident Staff

3.3.3.1. Basic Qualifications/Requirements of applicants for Residency Training

A. Must have taken the PSGS National Surgical Aptitude Test (NSAT) which
has a validity of 3 years from the time of examination

B. Must be duly licensed to practice medicine in the Philippines by the

Professional Regulatory Commission

C. Foreign Medical Graduates (FMG) must have been granted a written

permission or temporary license by the Professional Regulatory
Commission to undergo General Surgery Training in the Philippines. If
the foreign medical graduate is a graduate of a foreign medical school, a
current license to practice medicine from their country of origin
notarized/certified valid by their Department of Foreign Affairs or
equivalent agency must be submitted together with the Philippine PRC
temporary license.

3.3.3.2. The Resident Complement

A single institution training program MUST have a FULL resident

complement of at least FIVE (5) residents at any given time distributed with at
least one (1) 1st year level resident/JUNIOR level Resident, one (1) 2nd or 3rd
year level resident/INTERMEDIATE level resident, and one (1) 4th or 5th
year level resident/SENIOR level resident.

11
 A single institution applying for PSGS Accreditation of their Residency
Training Program must have a MINIMUM of ONE (1) FULL resident
complement as defined.

A consortium applying for PSGS Accreditation of their Residency Training

Program must have a FULL resident complement of at least SIX (6) residents
at any given time distributed so that there is a MINIMUM of three (3) residents
PER INSTITUTION with at least ONE (1) 4th or 5th year level resident per
institution at the time of application. Therefore, there must be at least ONE
(1) senior (4th or 5th year level) resident, ONE (1) intermediate level resident,
and ONE (1) junior level resident in each of the institutions in the consortium
at any given time.

THERE MUST BE NO LATERAL ENTRY RESIDENTS INTO THE

APPLICANT TRAINING PROGRAM during the two (2) years immediately
preceding their application for accreditation.

Upon being granted Level 1 accreditation, all the residents in the applicant
training program however shall start their accredited residency training levels
one (1) year level lower than their residency levels immediately prior to their
accreditation, i.e., upon accreditation, a 5th -year resident will start as a 4th -
year resident; similarly, a 4th -year resident will start as a 3rd -year resident; a
3rd -year resident as a 2nd -year resident; and, a 2nd -year resident as a 1st -
year resident. The 1st -year resident shall remain as a 1st -year resident.

The PSGS Board of Directors thru the Committee on Accreditation must be

immediately informed in writing by the Department Chairperson and the
Training Officer if there is an INCOMPLETE resident complement in their
Training Program. Failure to inform the PSGS of the incomplete resident
complement within one (1) month of its occurrence will result in automatic
suspension of accreditation which may not be appealed. An existing accredited
training program that informed the PSGS of the INCOMPLETE resident
complement within the prescribed period shall be given ONE YEAR from the
time it was incurred to correct the deficiency in order avoid the downgrading
of their accreditation status by one level.

3.3.3.3. Lateral Entry Resident

This refers to a resident who wishes to transfer from a PSGS-accredited

residency training program to another PSGS-accredited training program.

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Requirements for The Lateral Entry Resident & The Accepting Training Program:

A transferring resident is required to submit to the PSGS Board of Directors thru the PSGS Committee
on Accreditation and to the accredited training program being applied to the following duly signed
and notarized letters of recommendation from EACH of the following individuals:

- the department chairperson stating and attesting to the exact tenure of training of the resident
in their institution, the number of SATISFACTORILY COMPLETED years of accredited
residency training and the reason for the resident's resignation, non-reappointment or
termination

- the residency training officer stating and attesting to the exact tenure of training of the resident
in their institution, the number of SATISFACTORILY COMPLETED years of accredited
residency training and the reason for the resident's resignation, non-reappointment, or
termination

- the Medical Director or the Chief of Clinics from the institution of origin attesting to the exact
tenure of training of the resident in their institution, the number of SATISFACTORILY
COMPLETED years of accredited residency training

Upon acceptance of the lateral entry resident to another PSGS accredited training program, the
transferring resident shall resume his accredited residency training as an in-coming appointee on the
same year-level as the last satisfactorily completed year level in the previous institution with an
appointment, i.e., a newly appointed or mid-4th -year-level resident, who had satisfactorily completed
3 years of training in a PSGS-accredited training program; and, who is transferring to another
accredited training program (Lateral Entry), may be accepted as a 3rd year level resident upon his
transfer to another accredited training program. The highest residency year-level appointment that
may be given, by an accepting training program, to any in-coming, new appointee, lateral entry
resident will be the same as the transferring resident's last documented & completed year-level
appointment at the program of origin.

The accepting training program must formally verify in writing with the institution-of-origin the
authenticity and veracity of the letters of recommendation and the documents submitted by the
transferring resident.

The accepting training program must likewise formally verify in writing with the PSGS Board of
Directors thru the Committee on Accreditation that the certified completed years of residency training
in the initial institution of the transferring resident is covered by the period of accredited training.

The accepting training program is required to inform in writing the PSGS Board of Directors thru the
Committee on Accreditation within one month from the date of initial appointment that a transferring
resident has been accepted as a lateral entry into the training program. The committee must be

13
informed of the exact date of the appointment and the year level that the transferring resident was
accepted into.

Failure to comply with the aforementioned procedure for accepting lateral entry residents will result
to a downgrading of the accepting training program's accreditation status by one level.

3.3.3.4. RESIDENTS and the PROGRAM FACTOR

The program factor is used to compute the CASE LOAD REQUIREMENT

of a PSGS-accredited residency training program during a given year, and is
based on the resident complement of the program for that particular year.

The following residents shall be included in the determination of the program factor:

- All resident trainees who have regular appointments to the training program and who are part
of the RESIDENT COMPLEMENT.

- All Foreign Medical Graduates who are not Filipino citizens and not qualified to take the
Philippine Medical licensure examination but who by special arrangement (government-to-
government, government-to-institution, institution-to-institution, ASEAN agreement, etc.)
are allowed to undergo the structured sequence and duration of the training program in a
PSGS accredited training institution. The "Foreign Rotator" however is required to submit
the following documents to the PSGS Board of Directors thru the Committee on
Accreditation:

a. Proof that the rotator carries an ASEAN passport

b. Valid passport and visa if the foreign rotator is a citizen of a non- ASEAN country

c. Notarized certified true copy of license to practice medicine in the country of origin issued
by the rotator's government or consulate

The following residents shall NOT be included in the determination of the program factor:

- A resident who has been duly certified by the Medical Director and pre-identified by their
specialties to undergo further training in a specialty other than General Surgery in the SAME
INSTITUTION after completing the pre-requisite rotation in General Surgery. The resident
will be given yearly appointments for only a portion (1-4 years) of the full duration of the GS-
Residency Program and shall be considered as a 'STRAIGHT ROTATOR'. This intention
must be clearly stipulated in their appointment papers from other specialties such as Urology,
TCVS, Neurosurgery, Plastic and Reconstructive Surgery, and Pediatric Surgery, etc. A

14
 certified true copy of the rotator’s appointment papers must be submitted every year to the
PSGS Committee on Accreditation for verification.

- Although the cases that these rotators shall handle as 'SURGEON' shall be included in the
declared and tabulated-reporting of the host program's case material for the calendar year, a
separate listing of cases they handled must be included in the annual report of the institution.

- Residents from a PSGS-accredited training program who rotate in another PSGS accredited
training program on the strength of the memorandum of agreement for affiliation or linkage
between the two institutions as approved by the PSGS Board of Directors. (The MOA must
stipulate the category of procedures for which the resident will be rotating. The outside
rotation shall be limited to a maximum of two (2) categories of operations. These residents
will be considered as “OUTSIDE ROTATORS”.

Computation of Program Factor

- Include all eligible residents for the Annual Report Year (January 1 – December 31)
- Determine the number of months each resident is considered appointed for the year
- All residents who have completed 12 months for the Annual Report Year will be counted as
one (1)
- For residents who have NOT completed 12 months of residency for the Annual Report
Year, they will be counted as follows:
- ≤ 3 months = 0.25
- 3 months plus 1 day – 6 months = 0.5
- 6 months plus 1 day – 9 months = 0.75
- 9 months plus 1 day –12 months = 1
- the equivalent count per resident for the year shall be added and the sum will be divided by
five (5) to get the program factor

- Example: Resident A (January 1 to December 31) – 12 months = 1

Resident B (January 1 to December 31) – 12 months = 1
Resident C (January 1 to December 31) – 12 months = 1
Resident D (January 1 to November 30) – 11 months = 1
Resident E (January 1 to October 31) – 10 months = 1
Resident F (January 1 to March 31) – 3 months = 0.25
Resident G (January 1 to Feb 28) - 2 months = 0.25
Resident H (July 1 to December 31) – 6 months = 0.5
Resident I (August 1 to December 31) – 5 months = 0.5
Resident J (January 1 – July 31) – 7 months = 0.75
Resident K (May 1- December 31) - 8 months = 0.75
Total count for residents = 8
Program Factor = 8 / 5 = 1.6
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 3.3.4. The CASE MATERIAL

3.3.4.1. Program's Case Load (Volume and Variety of cases) Requirement.

A minimum volume and variety of surgical operations is required, as listed in PSGS TABLE 2023-III
Table of Operations, to ensure that all residents acquire mastery and proficiency in the pre-operative,
intra-operative and post-operative management of surgical cases that shall translate to high quality
surgical patient care. The 14 Main Case CATEGORIES OF OPERATIONS and the specific INDEX
CASES in certain Main Categories required annually for a training program are enumerated below.

CATEGORY I. HEAD AND NECK (20)

Index: Thyroidectomy – 10; Parotidectomy – 1; Neck Dissection – 1

CATEGORY II. BREAST (10)

Index: Modified Radical Mastectomy – 5; Any mastectomy/lumpectomy with SLNB/ALND - 1

CATEGORY III. ESOPHAGUS, STOMACH, DUODENUM (excision/resection/repair and

diaphragmatic hernia repair) (5)
Index: Gastric Resection of any variety- 1

CATEGORY IV. SMALL AND LARGE BOWEL SURGERY (25)

Index: Bowel Resection with or without anastomosis – 10; Adhesiolysis – 2

CATEGORY V. RECTAL SURGERY (2)

Index: either LAR or APR – 1

CATEGORY VI. ANAL SURGERY (10)

CATEGORY VII. APPENDECTOMY (ADULT or PEDIATRIC, OPEN or LAPAROSCOPIC,

COMPLICATED or UNCOMPLICATED) (20)

CATEGORY VIII. HEPATOBILIARY, GALL-BLADDER, PANCREAS, LIVER (30) Index:

Cholecystectomy (open or laparoscopic) – 10; CBDE – 2; Biliary Enteric Anastomosis - 1

CATEGORY IX. THORACOSTOMY (FOR TRAUMA OR NON-TRAUMA) (5)

CATEGORY X. TRAUMA (Operative and Non-Operative) (8)—

Index: Abdominal/Thoracic/Neck Exploration/ Major Vessel Injury -4

CATEGORY XI. VASCULAR ACCESS (cutdown, IJ/subclavian/IVAD) (5)

CATEGORY XII. ABDOMINAL WALL HERNIA (OPEN OR LAPAROSCOPIC) (15)

CATEGORY XIII. SKIN AND SOFT-TISSUE TUMOR SURGERY {benign ≥ 5 cm; malignant (any
size); debridement including burns and diabetic foot} (5)

CATEGORY XIV. OTHER SPECIALTY SURGERY (10) -

{Urology; Thoracic and Vascular Surgery; Plastic & Reconstructive Surgery; Pediatric
Surgery (other than AP & Abdominal Wall Hernia), Neurosurgery; Orthopedics}

16
Only cases properly supervised by PSGS Fellows in good standing or board-certified specialists of their
respective specialty societies shall be credited to the training institution as case material for
accreditation purposes and by the resident to fulfill diplomate board-eligibility requirements.

The annual Case Load Requirement of a training program with a Program Factor of 1 (for every 5
FULL resident complement) is 170 cases. The cases must be of sufficient variety and distributed in
proportion to the main categories of operations. The Index Case Requirement pertains to specifically
identified procedures with a fixed volume requirement that a training program must handle annually.
The number of index cases required for a training program for a particular year is a fixed number that
shall not be affected by the number of residents in the program (Program Factor). Taking as an
example main Category II BREAST index case, MRM is 5; a Training Program is required to handle
annually specifically a minimum of 5 MRM index cases regardless of its number of residents and its
program factor.

A MAXIMUM of thirty-five per cent (35%) per main category of operation of all the PRIVATE cases
of PSGS Fellows in good standing in the accredited training program regardless of whether the
resident performed the procedure or merely assisted the Qualified Training Staff shall be automatically
credited to fulfill the program's case load requirement. There will be no need to claim any cases as
resident performed or assisted for accreditation purposes.

There must be a reasonable quality instruction, commitment to the training program, and active
involvement of the qualified training staff as evidenced by regular supervision of residents and
presence in the operating room to maintain continuing and appropriate resident supervision. A
MINIMUM of twenty per cent (20 %) per main category of operations of the training program's
annual case load requirement, except for trauma cases, must be service cases. All trauma cases can
be claimed by the residents. All operations performed as service cases in the training program shall
be credited as a resident-performed case.

For Rectal Surgery, a fixed number of two (2) cases is required for the entire year and will not be
affected by the program factor with an Index case requirement of one (1) low anterior resection or
abdominoperineal resection.

In cases of multiple surgeries in one (1) patient, the program can claim each surgery to different
categories as long as each surgical procedure can stand on its own, i.e. one surgery can be performed
regardless of the other procedure/s. For example, cholecystectomy (open/laparoscopic) with inguinal
herniorrhaphy, sigmoid loop colostomy with debridement of sacral ulcer, bilateral inguinal
herniorrhaphy. An exemption to this rule would be a total thyroidectomy or parotidectomy with
modified radical neck dissection. Although neck dissection is part of the cancer surgery for
thyroid/parotid malignancy thus neck dissection alone cannot stand on its own without the primary
thyroid/parotic cancer surgery, however, since neck dissection is an index case and not often
performed by GS residents, therefore each surgery can be claimed separately as two (2) cases.

17
One (1) case of any mastectomy procedure (partial mastectomy, lumpectomy, quadrantectomy, total
mastectomy) WITH SLNB (sentinel lymph node biopsy) or axillary dissection is required as an index
case for the Breast Category.

In the Trauma Category, both operative and non-operative cases can be claimed by the program. For
non-operative trauma cases to be claimed, all the pertinent diagnostics, step by step management as
recorded in the patient’s chart/record, and daily progress reports should be prepared and made
available by the program for the PSGS Committee on Accreditation, if they so require.

Cases handled by a rotating resident during an outside rotation supported by a Memorandum of

Agreement specifying the category of operations for which the resident is rotating and duly approved
by the PSGS Board of Directors shall be credited as part of a rotating resident's training program's
case material to fulfill the rotating resident's institution case load requirements if there is proper host-
institution certified documentation. These cases, although reported, must however be listed separately
and bracketed [ ] in the list of cases [under Total Cases Handled PSGS TABLE 2023-III Table of
Operations] of the host training program and shall not be credited to the census of the host program.

Since the rotator is a resident from another PSGS-accredited residency training program thru an
affiliation or linkage, the listing of the cases handled by resident rotators must be included in the
annual reports of both the rotating resident's training program & the host institution in a separate table
similar to the senior residents' census. It must indicate the inclusive dates of the rotating resident's
outside rotation, the patient's initial, age, sex, and hospital number, preoperative diagnosis, procedure
and date of procedure, post-operative diagnosis, histopathology, and the outcome of the case (refer to
PSGS TABLE 2023-IVc Resident's Tabulated Census for OUTSIDE Rotation). Each procedure listed
must be countersigned by the service consultant in-charge or the residency training officer of the host
institution to ensure the veracity of the submitted information and for cross-referencing in order to
avoid double-reporting of cases.

Surgical procedures performed by rotating residents that are NOT WITHIN THE SCOPE of the
Memorandum of Agreement for the rotation shall NOT BE CONSIDERED as case material of the
rotating resident's training program to fulfill their case load requirements for accreditation and
diplomate board-eligibility.

Cases performed during Surgical Outreach Programs OUTSIDE OF THE BASE HOSPITAL/ S may
be credited as residents' cases for accreditation of the training program up to a maximum of twenty
per cent (20%) of the total number of cases required per main category of operation provided there is
adequate pre-operative care, post-operative care and direct supervision of the residents during the
performance of the operative procedure by a member of the qualified training staff. The
histopathology report (where appropriate) should also be available for verification. In addition, all
cases performed by residents in this Surgical Outreach Program Outside of the Base Hospital can be
claimed for PBS eligibility.

Example: If the required number of major head and neck cases is 40 and the required number of
hernia cases is 30 (i.e. if there are 10 residents in a 5-year program or program factor of 2, and the
18
residents performed 50 thyroid surgeries and 20 hernia cases in surgical missions outside the base
hospital for the calendar year, only 8 thyroidectomies (20% of 40 required thyroidectomy cases) and
only 6 herniorrhaphies (20% of 30 required herniorrhaphy cases) may be credited for accreditation
purposes of the training program.

There is no limitation in the number of service cases that may be credited to a training program for
accreditation purposes when these procedures are done as IN-HOUSE OR IN-BASE HOSPITAL
Surgical Missions.

Only cases done under the supervision of PSGS fellows in good standing shall be credited to fulfill
General Surgical case load requirements for accreditation as listed. All other cases supervised by PCS
fellows in good standing of other PCS specialties shall be credited as specialty procedures.

In case of suspension of accreditation of a training program, only cases done at the mother institution
during the period of suspension may be credited to satisfy the case requirements for re-accreditation
because OUTSIDE ROTATION OF RESIDENTS DURING THE PERIOD OF SUSPENSION
SHALL NOT BE ALLOWED. Although the cases performed in the mother institution during the
period of suspension shall be credited to the training program for accreditation purposes, these cases
may NOT be claimed by the residents to fulfill their case requirements for diplomate board-eligibility.

3.3.4.2. PROCEDURE as a RESIDENT'S CASE: Resident as 'THE SURGEON'

The resident is considered as "THE SURGEON" of a case in the following

situations:
- Operations wherein the qualified training staff scrubs-in on the case, assists
and allows the resident to perform most of the surgical procedure inclusive
of the vital and more important parts of the operation.
- Cases wherein the resident does the operation 'independently' (The
qualified trainer does not scrub-in on the case but has had pre-operative
discussion of the case and is available for intra-operative consultation).

3.3.5. Documentation of case material or cases handled

The cases handled by the program must be documented in the department's tabulated
case material (PSGS TABLE 2023-III Table of Operations) and tabulated summary of
program’s census (PSGS Table 2023-IVa) of the annual report, conference reports,
hospital database and operating room logbooks.

3.3.5.1. PSGS Prescribed Resident's Logbook

The officially-prescribed PSGS logbook must be filled up regularly and

conscientiously to prevent the backlog of cases and to assure uniformity of
reporting. The individual resident's entries in the logbook must be regularly
19
 checked at least quarterly by the residency training officer of the program and
attested to as accurate and true by periodically affixing his/her signature.

All service cases performed by residents during their rotations in other

institutions thru the strength of a PSGS-approved MOA for affiliation or
linkage must be authenticated and individually attested to as accurate by the
residency training officer or duly appointed authority (i.e., consultant in-
charge) of the host institution. The same list of operations performed by the
rotating resident must be attached to the individual resident's logbook and
reported in the annual reports of both the host and the affiliated institution for
cross-referencing.

Only cases done by residents under the direct supervision of a member of the
qualified training staff may be included in the residents' logbooks and annual
report.

3.3.5.2. PSGS Assessment and Surveillance Online Database

All residents are required to log-in their cases into the PSGS ASSURE Online
Database beginning January 2017. The Committee on Accreditation will
utilize the database in its review of the accredited institutions annual reports
and for accreditation visits. Only the entries in the database shall be considered
official.

3.3.6. Residency Program Duration & Structured Rotation

3.3.6.1. Duration of Training

The required duration of General Surgery Residency Training is sixty (60)

months.

A resident may be promoted, suspended, retained in a year-level, or expelled

based on the results of the periodic evaluation and the promotion policy of the
training program. Suspension or retention in a year level will prolong the
sanctioned resident's residency-training for the same duration as the penalty in
order to satisfy the 60-month required period of accredited residency training.
The program is highly encouraged to ensure that all residents have completed
the required duration of residency training and number of cases among other
things.

20
 Suspension of a training program's accreditation shall prolong the duration of
all the residents' training in order to satisfy the minimum requirement of 60
months of accredited training for a GS resident to qualify for graduation.

3.3.6.2. Structured Rotation

Since the minimum duration of regular residency training in a PSGS-

accredited residency training program is sixty (60) months, the rotation in
General Surgery must be at least forty-eight (48) months while the specialty
rotations should be a maximum of twelve (12) months.

The first and last years of residency training must be spent in General Surgery
at the mother institution. Therefore, rotations to affiliate or linked institutions
are NOT ALLOWED during the first and fifth years of residency training.

First year residents must not be assigned to man the Emergency Room.

Only intermediate level (2nd and 3rd year) residents are allowed to rotate in
other specialty services. Flexibility is allowed in other specialty rotations to
provide adequate exposure by assisting or performing surgical procedures in
the following specialties: Thoracic & Cardiovascular Surgery, Orthopedics,
Urology, Neurosurgery, Pediatric Surgery, Plastic Reconstructive & Aesthetic
Surgery. The duration and sequence of specialty exposure will be the
program's prerogative, but not exceeding 12 months per resident. A rotation
in Pathology is optional.

Only 4th year Residents are allowed to go on outside rotation for general
surgical procedures unless a special exemption is granted by the Board of
Directors on a case-to-case basis.

The outside rotation to other institutions must not exceed six (6) months per
resident per year and must be covered by a duly notarized Memorandum of
Agreement approved by the PSGS Board of Directors specifically stating the
purpose of the rotation and the specific operative categories for which the
resident is rotating for.

Per PSGS Board of Directors approved MOA, the outside rotation of residents
to comply with case load requirements of an accredited training program shall
be limited to a MAXIMUM OF 2 MAIN CATEGORIES of operations only.

Residents in an individual training program may be allowed to rotate outside

of the training program to a non-GS-accredited training program for the sole
purpose of additional exposure (e.g., SICU, etc.) for a maximum of 3 months
but NOT to perform operations in order to comply with the accreditation case
21
 load requirements of the training program and/or for individual’s board
eligibility purpose. Therefore, these cases may not be claimed either for a
training program’s accreditation purposes nor for an individual resident’s
board-eligibility. This rotation shall be subject to the written approval of the
Board of Directors upon the recommendation of the Committee on
Accreditation.

Although residents in a consortium are not allowed to rotate outside of the

training program in order to perform operations to comply with accreditation
case load requirements, an outside rotation to a non-GS accredited training
program for the sole purpose of additional exposure (e.g., SICU, etc.) for a
maximum of 3 months and not to accrue cases for accreditation purposes may
be allowed subject to the written approval of the Board of Directors upon the
recommendation of the Committee on Accreditation.

Consortia training programs are however allowed to accept resident rotators

from other PSGS-accredited residency training programs.

3.3.7. Resident Evaluation

The evaluation of residents should be properly documented and must have provisions for
feedback. This must be part of the bases for resident promotion that must be utilized by
the training program. The program must create and implement criteria and guidelines for
resident evaluation, promotion, sanctioning/reprimand and termination/expulsion, and
these criteria/guidelines must be available to the Committee on Accreditation when
deemed necessary.

3.3.7.1. Internal Evaluation of Residents

- must be implemented in accordance with the prescribed evaluation system
(See Standardized Surgical Curriculum for General Surgery) and must be done
at least once a year
- Written examinations must be given periodically and at least twice a year
with the competencies and the questions of the exam appropriate for each
resident’s year level (junior, intermediate, senior).
- Structured oral examination appropriate for each resident’s year level
given at least once a year, separate and distinct from the evaluation of
residents during their oral presentations during conferences
- Properly documented written evaluation of the resident's oral
presentations during conferences, case presentations, etc.
- PSGS MIS HOL Certification
- Complete and accurate documents and inserts of the resident’s portfolio
- Interesting paper case presentation and an IRB approved research paper as
appropriate for the resident’s year level
22
 - Regular and periodic feedback regarding their progress and standing must
be given to the residents with appropriate written acknowledgment by the
resident

3.3.7.2. External Evaluation of Residents

- PSGS-CERES Written Examination, PBS-RITE, etc.

All residents in PSGS-accredited General Surgery residency training programs

including straight rotators in General Surgery during their initial years of
training are required to take the Comprehensive External Resident’s
Evaluation System (CERES) written examination administered yearly by the
PSGS and the Residents’ In-Training Examination (RITE) administered by
the Philippine Board of Surgery. And any other external evaluation
examination mandated by the Board of Directors of the Philippine Society of
General Surgeons must also be complied with.

3.3.8. Teaching and Learning Activities

These activities include, but are not limited to, conferences, case presentations, grand
rounds, teaching rounds, journal clubs, seminars, and post-graduate courses.

3.3.8.1. Minimum number of conferences per year

Total
Morbidity and Mortality 6
Audit and Census 6
Pre-op & Post-op/ Case Presentation / Grand Rounds 24
Journal Club 4
Tumor Conferences 4
Quality Assurance and Patient Safety Conference 1

The training program should have a detailed discussion of one particular case during each
of the required six (6) morbidity and mortality conferences for the year.

To improve the quality and safety of healthcare delivery to our patients and welfare of
residents, the training programs are required to hold at least one (1) quality assurance and
patient safety conference every year which should include but not limited to providing a
forum to discuss and apply most recent knowledge pertaining to quality and safety
initiatives in the field of surgery.

3.3.9. Documentation of Activities

3.3.9.1. All teaching and learning activities

23
 The proceedings during all conferences must be properly documented in a
specific logbook for each type of conference. (i.e., M&M LOGBOOK, Pre-
op/Post-Op/Case Presentation LOGBOOK/ Census LOGBOOK, etc.) The
conferences must be arranged in chronological order and all the major issues
discussed must be properly noted.

The following entries/inclusions and attachments must be included in the

logbook:
- Date and time of the conference, venue and attendance list (active GS
consultants) that includes the name, position, and signature or picture (for
virtual conferences) of the attendees;
- Name and position of the presenter, the topic for discussion and a copy of
the topic protocol
- Copy of the visual aid presentation and the proceedings of the discussion
(minutes of the conference) including the consensus, lessons,
recommendations and conclusions reached for every case in the
conference

3.3.9.2. MIS/Laboratory Trainer Exercises properly documented in specific exercise

LOGBOOKS with the following entries:
- Residents' name/date/ time done
- Type of exercise done
- Duration of exercise to completion
- Signature of the consultant who supervised the resident

3.3.10. ANNUAL REPORT of the General Surgery Residency Training Program

The annual report is a collated documentation of the training program's activities and
census of cases for a particular year in compliance with the 2023 Standardized Outcome-
Based Curriculum in General Surgery.

3.3.10.1. Four (4) copies of the annual report must be submitted book-bound and one
(1) electronic copy; duly certified to be true and accurate by affixing the
signatures of both the Department Chairperson & the Residency Training
Officer/Program Director; and, duly signed by the Hospital Medical
Director. The Annual Report must be submitted to the PSGS on or before
February 28th of each year. For Interim Accredited Programs, the submission
of the Annual Report to the PSGS is on or before January 31st of each year
(please refer to Implementing Rules and Regulations for Interim Accreditation for GS
Residency Training Program, section 10 of the Accreditation Manual).

3.3.10.2. NO REVISIONS to the annual report shall be allowed once it has been
submitted to and accepted by the PSGS.

24
 3.3.10.3. All the contents of the annual report must be verifiable through pertinent
documents.

3.3.10.4. Submission of the annual report after February 28th but on or before March
31st of the calendar year will be considered late submission and shall
automatically result to a downgrading of the training program's current
accreditation status by one level. For Interim Accredited Programs, submission
of the Annual Report after January 31st but on or before February 28th of the
calendar year will be considered late submission, and shall automatically
result to a downgrading of the interim program’s current phase.

3.3.10.5. Failure to submit the annual report by March 31st of the calendar year shall
be considered as non-submission and will automatically result to the
SUSPENSION of the training program regardless of the program's prior
accreditation status. For Interim Accredited Programs, failure to submit after
February 28 of the Annual Report will automatically result to the program’s
SUSPENSION.

3.3.10.6. The annual report must follow the prescribed format and contain all the
required information and documents (Please refer to Appendix 2 - Annual
Report Table of Contents & Appendix 3 - PSGS Annual Report Format).

3.4 . Annual Accreditation Fee

3.4.1. For accredited training programs, the prescribed annual accreditation fee must be settled
on or before February 28th of each calendar year. For Interim Accredited Programs,
settlement of the prescribed annual accreditation fee will be on or before January 31st of
each calendar year.

3.4.2. For accredited training programs, payment of the accreditation fee after February 28th
but on or before March 31st of the current year shall be considered LATE PAYMENT
and will incur a 30 % SURCHARGE. For Interim Accredited Programs, a 30% surcharge
will be applied if payment of the accreditation fee will be made after January 31st but on
or before February 28th of the current year.

3.4.3. For accredited training programs, failure to pay the accreditation fee by March 31st of
the current year shall automatically result to a DOWNGRADING of the program's
current accreditation status BY ONE LEVEL. For Interim Accredited Programs, failure to
pay the prescribed accreditation fee by February 28th of the current year will result in an

25
 automatic downgrading of the program’s current interim phase level by one level.
automatically downgrade the program’s current interim phase level.

3.4.4 The annual accreditation fee is PhP 25,000 or as decided by the PSGS Board of Directors,
whichever amount is higher.

3.5. Evaluation of Graduates of the Training Program

The list of all graduates of the training program from the time of its initial accreditation and their
current status (diplomate/non-diplomate/fellow) must be included in the annual report
submitted to the PSGS.

All eligible graduates of PSGS-accredited Residency Training Programs must take the Philippine
Board of Surgery Diplomate Certifying Examinations. At least fifty percent (50%) of the training
program's graduates during the last five (5) years must pass both the written and oral
examinations of the Philippine Board of Surgery. Failure to comply with this minimum passing
rate MAY result to a downgrading of the program's current accreditation status by one level.

Graduates of training programs undergoing non-GS fellowship training and who will
subsequently be practicing specialties other than general surgery in the Philippines and those who
will practice surgery outside the Philippines shall NOT be included in this requirement provided
proper documentation has been submitted to the PSGS Committee on Diplomate Board
Eligibility and Committee on Accreditation.

26
 Conduct of Visits

4.1. When should an accredited training program be visited?

4.1.1. Upon the recommendation of the Committee on Accreditation and with the concurrence
of the PSGS Board of Directors that the applicant training program is qualified for an
accreditation visit

4.1.2. Within three to six (3-6) months before the expiration of a training program's accreditation

4.1.3. After a minimum period of six (6) months but within one (1) year after a training program
is warned pending the submission of a written request for a re-visit by the training program
to the PSGS Board of Directors thru the Committee on Accreditation. If a warned training
program fails to request for a re-visit within one (1) year from the date of effectivity of the
warning, the program shall be automatically suspended by default.
4.1.4. After a minimum period of six (6) months but within one (1) year after a training program
is suspended. The suspended program must submit a written request for a revisit to the
PSGS Board of Directors thru the Committee on Accreditation to schedule the visit after
the six (6) month period of suspension. If a suspended training program fails to request for
a re-visit within one (1) year from the date of effectivity of the suspension, the program
shall be automatically terminated by default.
4.1.5. Upon the recommendation of the Committee on Accreditation and as approved by the
PSGS Board of Directors, a program may be visited regardless of the training program's
current accreditation status at any time that significant deficiencies are identified in the
submitted annual report or the program is non-compliant to any of the regulations
stipulated in this manual

4.2. What to evaluate during a VISIT

4.2.1. The CONTEXT within which the Program is being implemented:

4.2.1.1. Administrative support for the program to maintain the high quality of residency
training
4.2.1.1.1 Bed allotment for service cases
4.2.1.1.2 Facilities for service cases including OR and OPD

27
 4.2.1.1.3 Salary of residents including government-mandated benefits such as
Phil health, GSIS/SSS, PAG-IBIG, hazard pay, board and lodging allowance
for residents in outside rotation.
4.2.1.1.4 Official appointment for trainers
4.2.1.1.5 Budget allotted for research, registration fees for convention and
workshops
4.2.1.2. Properly documented selection process for residents including the National
Surgical Aptitude Test (NSAT)
4.2.1.3. Adherence to the stated vision and mission of the PSGS, the institution, and the
Department of Surgery
4.2.1.4. Commitment of the program, consultant staff, and residents to comply
with all the PSGS guidelines for accreditation and the Standardized Outcome-
based Curriculum in General Surgery
4.2.1.4.1 Compulsory attendance of Department Chairperson, Training Officer
and Residency Training Committee in PCS/PSGS sponsored
consultative meetings on updates on accreditation guidelines, surgical
curriculum and other similar activities
4.2.1.4.2 Creation of innovative measures to upgrade, improve, maintain the
PSGS training standards
4.2.1.5. Commitment of the qualified training staff to maintain continuing and appropriate
resident supervision
4.2.1.6. Active participation and compliance with all PSGS mandated activities and
programs
4.2.1.6.1 Attendance in PSGS and PCS annual conventions and chapter
activities
4.2.1.6.2 In-house training workshops, seminars, webinars and the like

4.2.2. Training Resources (INPUT)

4.2.2.1. Hospital Facilities and Services
4.2.2.2. Residency Training Program
4.2.2.3. Clinical Materials

4.2.3. Implementation of the Training Program (PROCESS)

4.2.3.1. The rotation, structure, duration and evaluation of rotations
4.2.3.2. The teaching-learning activities (conferences, rounds, skills training and
workshops)
4.2.3.3. The resident internal evaluation & feedback system
4.2.3.3.1. Methods used: - written examinations, oral examinations, oral
presentations, observational assessment of actual performance and
skills
4.2.3.3.2. Frequency

28
 4.2.3.3.3. Research output
4.2.3.3.4. Resident’s portfolio

4.2.4. Resident performance at different levels of training based on:

· Internal Evaluation
· External Evaluation
CERES (Written Evaluation)
CERES Practical Evaluation
▪ During the accreditation visit, the program must
schedule two (2) operative cases for observation and
evaluation of the conduct of the surgeries by the
visiting team.
▪ 1 major and 1 medium case must be prepared for
presentation by the program.
▪ The accreditation team reserves the right to select the
resident who will perform the operation during the visit
according to the year level competency.
Residency-in-service training examination

4.2.5. Promotion, Disciplinary Action, Suspension and Termination System:

The program must establish policies and procedures related to resident
promotion, disciplinary actions/sanctions, suspensions and terminations that has a set of
clear, fair, reasonable and equitably applicable set of criteria and procedures. This must
be written and communicated with the resident staff and shall be available for the
Committee on Accreditation during visits and as deemed necessary for evaluation.

4.2.6. The PRODUCTS of the Program

4.2.6.1. The graduates’ performance based on the passing percentage in the Philippine
Board of Surgery Diplomate Certifying Examinations for the preceding five (5)
years
4.2.6.2 Graduates who went into a non-GS subspecialty fellowship training and who
subsequently practiced a non-GS specialty, and those who are practicing or
living outside the Philippines will NOT be included in the evaluation.

4.3. Scheduling of a Visit

4.3.1. Training programs with Level I or II accreditation shall be notified of the scheduled visit
as decided by the Committee on Accreditation at least thirty (30) days prior to the
scheduled visit or as mutually agreed upon by the training program and the Committee on
Accreditation

29
 4.3.2. Training programs on warning status that will be visited after the minimum period of six
(6) months has elapsed from the time the program was warned shall be notified of the
scheduled visit to be done as decided by the Committee on Accreditation at least thirty
(30) days prior to the scheduled visit or as mutually agreed upon by the training program
and the Committee on Accreditation

4.3.3. Suspended training programs that wish to be visited after the minimum period of six (6)
months from the time of suspension must submit a written request for an accreditation
visit to the PSGS Board of Directors thru the Committee on Accreditation before that
period has elapsed. Thereafter, the requesting training program shall be notified of the
schedule of the visit as decided by the Committee on Accreditation at least thirty (30) days
prior to the scheduled visit or as mutually agreed upon by the training program and the
Committee on Accreditation.

4.3.4. Training programs applying for accreditation that are deemed qualified for an accreditation
visit shall be notified of the schedule as decided by the Committee on Accreditation at least
thirty (30) days prior to the scheduled visit or as mutually agreed upon by the training
program and the Committee on Accreditation.

4.3.5. Written requests for re-scheduling of the accreditation visit shall be entertained on a case-
to-case basis as recommended by the Committee on Accreditation and with the
concurrence of the PSGS Board of Directors. In case PSGS has already incurred expenses
for the scheduling and accommodation of the accreditation visit (plane ticket, hotel
reservations, transportation expenses), the program who would request for a change of
date of visit will reimburse PSGS for the incurred expenses.

4.4. Who will Visit?

4.4.1. The Visiting Team

4.4.1.1. A team of at least three (3) members of the Committee on Accreditation shall
conduct the accreditation visit
4.4.2. The PSGS Director - in - Charge and / or the Chair of the Committee on
Accreditation may join any visiting team.

4.5 . Expectations During a Visit?

4.5.1. Expectations of the Visiting Team

30
 4.5.1.1. Physical presence of the Department Chairperson, Training Officer, the Qualified
Training Staff and Residents-in-training is required.
4.5.1.2. The recently graduated residents should preferably be present and their logbooks
MUST be available for scrutiny and evaluation by the visiting team
4.5.1.3. All necessary documents including resident’s portfolios, Memoranda of
Agreement with other institutions (if applicable), department and personal
logbooks of residents and OR records (operative notes, procedures and
anesthesia records) should be available for inspection and verification.
4.5.1.4. Operating Room and all other necessary permits must be facilitated by the training
program to allow any member of the visiting accreditation team to enter the
operating room and other facilities of the hospital as necessary.

4.5.2. Expectations of the Hospital

4.5.2.1. The hospital shall be informed in writing by the PSGS Board of Directors
regarding the schedule of the accreditation visit at least thirty (30) days prior
to the scheduled visit or as mutually agreed upon by the training program and
the PSGS.
4.5.2.2. Systems and mechanics of the visit shall be followed and adhered to.
4.5.2.3. Visiting team dialogue with the training program consultant staff and residents.
4.5.2.3.1. An initial dialogue with the department officers, qualified training
staff and the residents will be conducted.
4.5.2.3.2. Visit interviews shall be done with the qualified training staff and
with the residents separately if deemed necessary upon the
discretion of the visiting accreditation team.
4.5.2.4. A post-visit, exit conference with the department officers, the qualified training
staff and the residents without divulging the assessment and recommendation
regarding the accreditation status of the visited training program.
4.5.2.5 Recommended program for the actual face to face or virtual visit
A. Opening Prayer (to be named by the program)
B. National Anthem
C. Welcome Remarks from the Training Institution (preferably by the
Chairman)
D. Recognition of key members of the training program
E. Live or pre-recorded message of the Medical Director/Administrator
F. Opening Conference and Introduction of members of the visiting team (to
be led by the team leader)
G. Presentation of Audio-Visual Presentation or Power point presentation by
the Training Institution
H. Open Forum
I. Actual Face to Face/Virtual Visit (conference rooms, physical inspection
of facilities, observation of surgery in the OR)

31
 1. Team member 1/Room 1 (names and function to be determined by
the visiting team).
2. Team member 2/Room 2 (names and function to be determined by
the visiting team).
3. Team member 3/Room 3 (names and function to be determined by
the visiting team).
(conference rooms, physical inspection of facilities, observation of
surgery in the OR)
J. Team Deliberation
K. Exit Conference
L. Closing Remarks (to be assigned by the program or training officer)
M. PSGS hymn

32
 Levels of Accreditation of Training
Programs & Period of Validity

5.1. Level I Accreditation

Residency programs that have been granted CONDITIONAL accreditation, for a period of two
(2) years, from the date of PSGS Board of Directors decision upon the recommendation of the
Committee on Accreditation. These programs have met ALL the minimum requirements for
conditional accreditation that include but not limited to:

a. Satisfied the minimum volume and variety of surgical operations required of the training
program based on the number of residents in the program. There must also be a reasonable
quality of instruction as evidenced by having at least twenty per cent (20 %) of the case
load requirement as service cases with the pre-operative, intra-operative and post-operative
management actively supervised by a member of the qualified training staff
b. Creditable performance in the PSGS CERES and PBS RITE written examinations over
the past 2 years as shown by a fifty per cent (50 %) passing rate for all residents
c. Properly documented clinical and teaching activities that are adequate in number and
variety
d. Active involvement of the qualified training staff as evidenced by regular supervision of
residents and presence of at least thirty per cent (30 %) of the qualified training staff during
surgical conferences
e. A visible research achievement observable over a reasonable period of time. This will
include having each resident submitting two (2) satisfactorily completed published or
unpublished research papers before their graduation
f. For training programs which have been accredited for the past 5 years, a creditable
performance in the Philippine Board of Surgery diplomate certifying examination over the
last 5 years. All eligible graduates must take the examination within five (5) years of
graduation. At least fifty percent (50 %) of the ELIGIBLE graduates must have passed
both the written and oral diplomate examinations during the immediately preceding 5-
year period.

This accreditation status may be granted to:

- newly accredited training programs, including a previously terminated program
(considered as NEW applicant) that has been re-accredited.
- Previously warned or suspended training programs that were found to have corrected all
deficiencies and have satisfied all the requirements for accreditation based on an

33
 accreditation visit. The upgrading of the accreditation status must have been favorably
endorsed by the Committee on Accreditation and concurred with by the PSGS Board
of Directors.

After re-assessment of the training program during the required accreditation visit two (2) years after
the granting of Level I accreditation, a program will either be upgraded to Level II accreditation after
satisfying ALL the requirements for this higher level or downgraded to a warning status if the program
is unable to satisfy ALL the minimum requirements for upgrading to a Level II accreditation.

A training program may be re-visited at any time during the 2 years of Level I accreditation if
significant deficiencies are noted in the review of the training program's annual report to verify the
deficiencies and errors noted with a corresponding fee of PhP 60,000. In addition, the program may
be visited at any time if any adverse reports regarding the training program come to the attention of
the Committee on Accreditation.

Should a training-program with Level I accreditation fail to satisfactorily comply with all the
requirements to maintain this level of accreditation upon confirmation after a visit by the Committee
on Accreditation and as concurred with by the PSGS Board of Directors, the accreditation status will
be downgraded to Warning status.

5.2. LEVEL II Accreditation

Residency programs that have been re-accredited and granted FULL accreditation for a period of five
(5) years from the date of PSGS Board of Directors decision upon the recommendation of the
Committee on Accreditation. These programs have met ALL the minimum requirements for a 5-year
residency program as stipulated in this manual and must have satisfied the following additional
criteria:

a. Satisfied the minimum volume and variety of surgical operations required of the training
program based on the number of residents in the program. There must also be a reasonable
quality of instruction as evidenced by having at least twenty per cent (20 %) of the case
load requirement as service cases with the pre-operative, intra-operative and post-operative
management actively supervised by a member of the qualified training staff
b. Creditable performance in the PSGS CERES and PBS RITE written examination over the
past 2 years as shown by a fifty per cent (50%) passing rate for all residents
c. Properly documented clinical and teaching activities that are adequate in number and
variety
d. Active involvement of the qualified training staff as evidenced by regular supervision of
residents and presence of at least thirty per cent (30 %) of the qualified training staff during
surgical conferences

34
 e. A visible research achievement observable over a reasonable period of time. This will
include having each resident submitting two (2) satisfactorily completed published or
unpublished research papers before their graduation
f. A creditable performance in the Philippine Board of Surgery Diplomate certifying
examination over the last 5 years. All eligible graduates must take the examination within
five (5) years of graduation. At least fifty percent (50 %) of the eligible graduates must have
passed both the written and oral diplomate examinations during the immediately
preceding 5-year period.

A training program may be re-visited at any time during the 5 years of Level II accreditation if
significant deficiencies are noted in the review of the training program's annual report to verify the
deficiencies and errors noted with a corresponding fee of PhP 60,000. In addition, the program may
be visited at any time if any adverse reports regarding the training program come to the attention of
the Committee on Accreditation.

Should a training program with Level II accreditation fail to satisfactorily comply with all the
requirements to maintain this level of accreditation upon confirmation after a visit by the Committee
on Accreditation and as concurred with by the PSGS Board of Directors, the accreditation status will
be downgraded to a warning status.

5.3. WARNING Status

5.3.1. Upon the recommendation of the Committee on Accreditation and with the concurrence
of the PSGS Board of Directors, a training program with a LEVEL I or II Accreditation
may be downgraded to a WARNING Status if there are ANY significant deficiencies
noted during a scheduled accreditation visit or any visit as deemed necessary by the
committee on accreditation.
5.3.2. The residency program is still deemed accredited during the duration of the WARNING
Status.
5.3.3. A program on WARNING Status is given a minimum period of six (6) months and to a
maximum period of twelve (12) months after the decision by the PSGS Board of Directors
to correct all deficiencies and to submit a written request for an accreditation re-visit. If a
WARNED training program fails to request for a re-visit within one (1) year from the date
of effectivity of the warning status, the program shall be automatically SUSPENDED by
default.
5.3.4. A program that will be visited due to a Warning status will be charged PhP 60,000 for re-
visit expenses.

35
5.4. SUSPENSION of Accreditation

5.4.1. The accreditation of a program will be SUSPENDED if it fails to significantly correct

deficiencies within one (1) year after the issuance of a warning; furthermore, even if the
original deficiencies are corrected but new deficiencies are noted during a subsequent visit,
the training program will also be SUSPENDED.

5.4.2. A training program will be SUSPENDED from FULL (LEVEL II) or CONDITIONAL
Accreditation (LEVEL I) without the benefit of a WARNING, in case it is determined
during an accreditation visit and based on objective evidence that there is intellectual
dishonesty (ex. falsification of records; unverifiable, nonexistent claimed case material,
failure to inform the PSGS of developments that may significantly affect the training
program, etc.) in any of the data given to the accreditation team or if the DOH license has
been downgraded to a level I or lower category.

5.4.3. NON-SUBMISSION of the Annual Report shall result in automatic SUSPENSION by

default. (Please refer to the items on submission of Annual Reports).

5.4.4. The period of SUSPENSION is for a minimum period of six months. The program is
strongly encouraged to correct all deficiencies, not to incur any new major deficiencies and
to submit a written request for a re-visit/re-evaluation before the end of the one-year
period. The SUSPENSION may be lifted after six months and within one year if all the
noted deficiencies have been corrected and all the accreditation requirements have been
fulfilled as determined during a requested revisit by the Committee on Accreditation.

5.4.5. If a requested 'VISIT' is done within the period of SUSPENSION and the accreditation
team finds new deficiencies or a failure by the training program to correct the previously
noted deficiencies, the program will be TERMINATED. A program is not accredited
during the period of suspension. Outside rotation of residents to other accredited training
programs specially to accrue cases to satisfy accreditation case load requirements is NOT
ALLOWED AND WILL NOT BE CREDITED during the period of suspension.
However, a suspended program will have to continue the functions of a training program
to satisfy the minimum requirements for accreditation if it intends to request for a re-visit
to lift the SUSPENSION and get LEVEL I accreditation in the future. During the period
of suspension of accreditation of a training program, only cases done at the mother
institution or consortium and during surgical missions either in-house or outside the
hospital may be credited to satisfy the case requirements for re-accreditation. The cases
done during the period of suspension may however not be claimed by the residents to fulfill
their diplomate board-eligibility case requirements.

36
 5.4.6 A program that will be visited due to a Suspension status will be charged PhP 60,000 for
re-visit expenses.

5.5. TERMINATED Status/ Termination of Accreditation

5.5.1. Termination of accreditation automatically results if a SUSPENDED program fails to

request for a re-visit within the one (1) year period of SUSPENSION.

5.5.2. TERMINATION of Accreditation also results if a suspended program fails to comply with
the PSGS requirements for accreditation after a requested visit for re-evaluation which
shows either a failure to correct the previous deficiencies or there are new deficiencies
incurred.

5.5.3. Terminated programs may apply for re-accreditation only after a period of one (1) year
from the date of termination of accreditation by the PSGS Board of Directors. The
program shall then be considered as a NEW Applicant Training Program. Should the
resident complement remain during the period of the TERMINATED STATUS until re-
accreditation, he will be considered a NEWLY accredited program resident complement
and downgrading of the resident year-level from the last satisfactorily completed year level
shall apply.

37
 MEMORANDUM OF AGREEMENT forming or supporting a
Training Program (CONSORTIUM, AFFILIATION, LINKAGE)

A written approval from the PSGS Board of Directors thru the Committee on Accreditation MUST
be obtained by the concerned institutions before any duly executed Memorandum of Agreement for
accreditation purposes may be officially implemented.

Two (2) up to a maximum of three (3) institutions may FORM one (1) Structured GS-Residency
Training Program called a CONSORTIUM TRAINING PROGRAM thru a Memorandum of Agreement
(MOA).

Hospitals that either have different Department of Health licenses to operate or do not have a single
owner or Board of Trustees shall be considered as two different institutions. Should these institutions
wish to seek PSGS accreditation, they may apply either as two (2) separate single institution training
programs or as a consortium.

At any point in time that a new institution is added to an existing accredited consortium or two
institutions that are individually accredited wish to form a consortium, they shall be considered as a
NEW APPLICANT for a CONSORTIUM. This will result in the loss of any existing accreditation of the
involved institutions. In case the new application is disapproved by the PSGS Board of Directors,
the existing program of the original institution or consortium will continue.

Late expansions of healthcare institutions into a 'conglomerate' or 'chain' of hospitals regardless of

whether the member institutions have the same proprietor, corporate owners or management board,
does not exceed 3 hospitals, or have the same Department of Surgery Staff, officers and residents, shall
be considered as a NEW APPLICANT for a CONSORTIUM should the conglomerate wish to apply
for PSGS accreditation. This will result in the loss of any existing accreditation of the involved
institutions.

6.1. Guidelines & Requirements for A Consortium

6.1.1 A consortium may be formed by two (2) up to a maximum of three (3) hospitals upon
compliance with ALL the following basic requirements:

a) each component hospital has a minimum of 100 beds and the hospitals are located in
geographic proximity to each other (within 30 kms. apart)

38
 b) each component hospital is at least a Level 2 DOH accreditation based on the 2017
DOH Classification

c) the consortium program conforms with the one (1) program with 1 chairperson, 1
training program head/director, 1 set of training staff with 1 designated assistant training
officer per institution, and 1 set of residents’ requirement (AT LEAST ONE FULL
RESIDENT COMPLEMENT and 3 residents per member hospital).

6.1.2 Before any consortium program can be ACCREDITED, it will have to pass through
the PROCESS OF APPLICATION.

6.1.3. There must be a Notarized Memorandum of Agreement signed by the Medical Directors
of the institutions forming the consortium and the Department Chairperson and Residency
Training Program Director of the Training Program. The MOA should contain the scope
of involvement, functions and responsibilities of the member hospitals. The coverage
period of such agreement should not be less than 5 years and should be entered into at
least two (2) years before the intended year of Application for accreditation as a
consortium (please refer to Procedure of Application).

6.1.4. There should only be one (1) Residency Training Program that will be implemented with
one (1) set of Residents rotating in all the member hospitals. The total number of residents
in training shall depend upon the capacity and capability of the consortium to satisfy all
the PSGS accreditation requirements.

6.1.5. The accreditation status of the consortium training program shall apply solely to the
consortium and not to any of the individual Departments of Surgery of the member
hospitals. Upon satisfying all the requirements for accreditation, the consortium will
initially be granted CONDITIONAL STATUS for a period of two (2) years but with
provisions for regular interim visits if deemed necessary by the accreditation committee.

6.1.7. Should the member hospitals in a consortium eventually decide to seek separate
accreditation after getting FULL ACCREDITATION STATUS, the program will have to
first officially inform the PSGS Board of Directors in writing (thru the Committee on
Accreditation) at least two (2) years prior to the projected date of dissolution of their
intention to dissolve the consortium.

6.1.7.1. Upon receipt of PSGS Board of Directors acknowledgment, the members of

the consortium should hold individual training program activities (parallel to
but separate from the consortium activities) and prepare individual Annual
Reports (separate from the Consortium Annual Report) for the 2 calendar
years immediately preceding the possible date of dissolution of the consortium.
The individual annual reports must include the designated Department
Officers, Consultant Staff and the roster of residents from the consortium that
will form the resident complement of the individual programs.
39
 6.1.7.2. The individual hospitals of the consortium program will be visited by the
Committee on Accreditation after submitting 2 years of Annual Report and a
formal application for accreditation as a new program. The consortium
program retains its original accreditation level until acted upon and decided by
the PSGS Board on the recommendation of the Committee on Accreditation.

6.1.7.3. Upon approval for dissolution of the consortium by the PSGS Board,
each individual program will be classified into conditional level of
accreditation.

Two (2) PSGS Accredited GS-Residency Training Programs may be allowed through a
Memorandum of Agreement (MOA) to support one (1) or both training programs thru
either one of these mutually agreed upon arrangements:

1. 'LINKAGE MOA' is a MOA supportive of both training programs thereby effecting a bilateral
exchange or outside rotation of residents between two (2) PSGS-accredited residency
training programs

2. 'AFFILIATION MOA' is a MOA supportive of only one (1) of the 2 accredited training
programs thereby effecting an 'affiliate outside rotation’ where the host hospital does not
send resident rotators in return. (exception is the high-volume center identified by the PSGS)

6.2. Guidelines for Linkage and Affiliation

6.2.1 The written approval of the PSGS Board of Directors must be obtained before any linkage
MOA or affiliation MOA may be implemented.

6.2.2 There must be a notarized Memorandum of Agreement signed by the responsible officers
of both institutions mutually agreeing to form and maintain a LINKAGE or an
AFFILIATION. The MOA must contain the scope of involvement, functions and
responsibilities of the hospital involved with a maximum effectivity period of five (5) years.

6.2.3 A photocopy of the latest updated MOA for a training program MUST be included in the
annual report. An annual review of the MOA as submitted in the annual report shall be
done to ensure that all required stipulations are effectively implemented.

6.2.4 An individual training program shall be limited to entering into a linkage or affiliation
MOA with a maximum of 2 different institutions especially if the MOA for outside
rotation is entered into with the intention of accumulating needed cases to fulfill the
accreditation requirements of the program. Moreover, a training program can only enter
into a MOA with other training programs for a maximum of two (2) case categories ONLY

40
 (e.g., Trauma and Hernia categories for both hospital linkages/affiliations) with the
purpose and specifics clearly stipulated in the MOA.

6.2.5 The rotating residents shall be governed by the rules and regulations of the host training
program/hospital. All cases accrued by the rotating resident in the host hospital shall
only be credited to the rotating resident’s base hospital and not to the host hospital for
accreditation purposes. All surgical procedures performed by the rotating resident in the
host hospital should however be duly noted in the annual report of the host institution as
cases given to the rotator but no longer credited to the host institution to fulfill their
accreditation case requirements.

6.2.6 A PSGS Accredited Training Program may enter into a MOA of Affiliation for outside
rotation with a PSGS-recognized and approved high-volume but non-accredited
institution for a specific category of operation only, i.e., Trauma. The non-accredited host
institution must have been previously identified by the PSGS as an institution with
Qualified Training Staff who are willing to and shall supervise the resident rotators.

6.3. Other MOA Limitations & Requirements

6.3.1. Any MOA that is referred to in the guidelines for GS Residency Training Program
Accreditation Guidelines must have official PSGS written approval before proper
implementation.

6.3.2. The maximum effectivity period of a MOA is five (5) years. Annual review of the MOA,
together with the annual report review, shall be done to ensure that all required stipulations
in the MOA are effectively implemented. A photocopy of any current MOA under
implementation involving a training program MUST be included in their submitted annual
report.

6.3.3. An individual training program shall be limited to entering into a MOA with a maximum
of two (2) different institutions especially if the MOA for outside rotation is entered into
with the intention of accumulating needed cases to fulfill the accreditation requirements
of the program. Moreover, a training program can only enter into a MOA with other
training programs for a maximum of two (2) case categories (e.g., Trauma and Hernia
categories; H&N and CTT categories) with the purpose and specifics clearly stipulated in
the MOA.

6.3.4. A training program may enter into one (1) additional MOA Subject to the
recommendation of the Committee on Accreditation and with the concurrence of the
Board of Directors only if the intention is NOT to fulfill accreditation case requirements
but rather for additional exposure of the resident rotator (i.e., SICU exposure, Thoracic &
Cardiovascular Surgery, Additional MIS exposure). It must be verifiable in the annual
41
report that none of the cases handled during such rotations are used to fulfill minimum
volume requirements for accreditation. However, the period of total outside rotation per
resident rotator must not exceed three (3) months for the entire duration of residency
training of that particular resident.

42
 Guidelines on infractions that may lead to one-level
downgrade of Current Accreditation Status:

7.1. All PSGS fellows in the consultant staff of an accredited training program are strongly encouraged
to maintain their good standing as part of the requirements for accreditation. Failure to comply
with the 5 PSGS Fellows in good standing for every 10 or fewer resident's ratio with 1 additional
PSGS Fellow for every 3 additional residents shall be a basis for the downgrading of the
institution's accreditation status by one level.

7.2. Submission of the annual report after February 28th but on or before March 31st of the calendar
year will be considered late submission and shall automatically result to a downgrading of the
current accreditation status by one level. For Interim Accredited Programs, submission of the
annual report after January 31st but on or before February 28th of the calendar year will merit a
downgrade of the current interim phase of the program.

7.3. Non-payment of the PSGS accreditation fee on or before March 31st of the calendar year will
result to a downgrading of the current program accreditation status by one level. For Interim
Accredited Programs, non-payment of the prescribed accreditation fee on or before February
28th will result to a downgrading of its current interim phase.

7.4. Since all graduates of PSGS-accredited Residency Training Programs must take the Philippine
Board of Surgery Diplomate Certifying Examinations, failure of at least fifty percent (50%) of
the training program's eligible graduates to pass both the written and oral examinations of the
Philippine Board of Surgery Diplomate Examination during the last 5 years MAY result to a
downgrading of the current accreditation status by one level.

7.5. Any significant change/s in the institution that may affect the General Surgery Residency
Training Program that was/were not formally communicated to the PSGS thru the Committee
on Accreditation via a ‘letter to inform’ will warrant a WARNING status immediately once
approved by the PSGS BOD, such as but not limited to the following:

7.5.1. Institution/Hospital DOH Level downgrading from (at least) Level 2 to Level 1.

43
7.5.2. A decrease in the number of residents that resulted to non-compliance of FULL
RESIDENT COMPLEMENT for the current year that was not communicated to the
PSGS thru the Committee on Accreditation.

44
 APPEAL on PSGS BOD DECISIONS regarding
Accreditation Status

8.1. The following DECISIONS ARE NOT SUBJECT TO APPEAL and the program must go
through the accreditation process to lift the corresponding penalty:

8.1.1. Suspension after determination of intellectual dishonesty

8.1.2. Downgrading of accreditation status that result from NON-PAYMENT of accreditation

Fee or LATE SUBMISSION of the annual report

8.1.3. DISAPPROVED Training Program Application for Accreditation

8.1.4. Failure to inform the Committee on Accreditation in a timely manner of significant

developments that may adversely affect the training program or its residents.

8.2. Appeals must be made in writing to the PSGS Board of Directors within thirty (30) days following
receipt of the Board's decision

8.2.1. Re-evaluation of a PROGRAM WITH APPEAL

8.2.1.1. The PSGS Board of Directors will decide if a re-visit is merited for a program that
has made an appeal. The accreditation team shall re-evaluate/ re-visit the
program and thereafter submit its recommendations to the PSGS Board of
Directors.

8.2.1.2. The PSGS Board of Directors shall decide whether to sustain, reverse, or modify
the recommendations of the Committee on Accreditation.

8.2.1.3. The PSGS Board of Directors shall notify the concerned institution of its final
decision within one (1) week after the last Board of Directors meeting held for
that purpose.

45
 Steps to Amend the Requirements and
Procedures of Accreditation

9.1 Suggested changes must be addressed to the PSGS Board of Directors thru the Committee on
Accreditation

9.2 The Committee on Accreditation shall make its recommendations to the PSGS Board of
Directors for approval

9.3 Any additional provisions approved by the PSGS Board of Directors thru a 2/3 vote of all its
members, shall be immediately executory and should be immediately disseminated to all concerned.

9.4 Additional requirements may be added for implementation upon the recommendation of the
Committee on Accreditation and upon the PSGS Board of Directors.

9.5 No change/s in this PSGS Accreditation Guidelines should be made earlier than 2028

9.6 All other issues, not covered in these Accreditation Guidelines and those arising from
differences in interpretation, shall be decided upon by the PSGS Board of Directors. All such
accreditation issues not covered by the manual and decided on by the PSGS Board of directors during
the period that these Accreditation Guidelines in General Surgery are in effect will be immediately
implemented and subsequently incorporated in the next revision of the guidelines.

46
Implementing Rules and Regulations for Interim Accreditation on General
Surgery Residency Training Program

10.1. General Principles

10.1.1. The new category of accreditation of training program in General Surgery shall be
known as “Interim Accreditation” of Residency Training Program in General
Surgery.

10.1.2. Application for “Interim Accreditation” shall be available to all qualified institutions
or health care facilities, be it government or private entity in accordance to section
3.1 of the 2023 PSGS Guidelines for Accreditation of Residency Training Programs
(GARTP).

10.1.3. The applicant institution shall commit to fully implement the 2023 PSGS
Standardized Curriculum in General Surgery (SCGS).

10.1.4. “Interim Accreditation” once granted to an institution by the Board of Directors of

the PSGS is considered an accredited training program in General Surgery, subject to
provisions provided for in this Implementing Rules and Regulations (IRR).

10.1.5. An interim accredited institution may use other provisions of the GARTP and this
IRR that may help them implement the process of training. This may include, among
others, entering into an affiliation with other Level I and II accredited training
programs, subject to phase-specific provisions in this IRR.

10.1.6. “Interim Accreditation” may be granted to institutions that can comply with the
basic requirements as provided for by the 2023 GARTP and provisions of this IRR
even before the program has a complement of residents.

10.1.7. “Interim Accreditation” may be granted to institutions that can comply with the
basic requirements as provided for by the Guidelines of Accredited Residency
Training Programs including submission of the 2-year annual report as required for
new applicants.

10.1.8. “Interim Accreditation” will be a progressive and graduated process that will
eventually lead up to a Level II Accreditation. It will be divided into four (4) phases
namely:

a. Interim Accreditation Phase I (1st year interim)

i. Phase I-0 – without resident at the time of application and/or
accreditation
ii. Phase I-R – with existing residents at the time of

47
 application and/or accreditation

b. Interim Accreditation Phase II (2nd year interim)

c. Interim Accreditation Phase III (3rd year interim)

d. Interim Accreditation Phase IV (4th year interim)

10.2. Basic Requirements

10.2.1. The applicant institution must satisfy the required hospital facilities and services as
provided for by section 3.1 of the GARTP.

10.2.2. The applicant institution must express in writing its hospital administrative support
and commitment to comply with the rules and regulations of accreditation as provided
by GARTP and this IRR.

10.2.3. The applicant institution must have an organized Department of Surgery and a
residency training committee, with a minimum of five PSGS Fellows/Diplomate,
Consultants, and all the necessary requirements to implement the process of training
and evaluation of resident trainees.

a. The applicant institution must have the required training facilities as provided by
section 3.2 of the GARTP.

b. The applicant institution must be able to progressively set-up a structured General

Surgery Residency Training Program as prescribed by the SCGS and as provided for
in Section 3.3 of the GARTP.

10.2.4. The applicant institution must have the necessary facility to accommodate service or
charity patients to ensure that 20 per cent of case materials are service cases (Note:
Application of section 3.3.4.1 shall be in accordance with the requirements set forth per phase of
Interim Accreditation)

10.2.5. The applicant institution must have the necessary mechanisms to recruit and employ
residents for training, including all the necessary guidelines for fair compensation and
working conditions.

a. The applicant institution or the interim accredited institution can accept a

maximum of two (2) first year residents effective 2023. This rule will apply while the
program is under interim accreditation.

48
 b. The institution given the Interim Accreditation Phase I-0 accreditation shall be
given ample time to recruit residents as prescribed in this IRR. It is expected that
programs given Phase I-0 accreditation shall be able to progress to Phase I-R before the
end of Phase I-0 accreditation. (Refer to No. 4 on procedures for Phase I Interim
Accreditation)

10.3. Procedures and Policies of Application and Accreditation

10.3.1. The process of application for “Interim Accreditation” shall follow the procedures as
prescribed in the GARTP, except for section 2.2.1.d (in as afar as having satisfactorily
complied the minimum annual PSGS case load requirement for accreditation) and
2.2.1e.

10.3.2. Payment of the following non-refundable fees:

a. Application and evaluation fee, upon submission of letter of application and pertinent
documents: PhP 30,00000

b. Accreditation visit fee, to be settled not later than 2 weeks prior to actual date of visit
as notified: PhP 70,000.00

10.3.3. Deadline of application on each year shall be on the last working day of June.

10.3.4. The Committee on Accreditation shall review the application of institutions and will
submit their recommendation to the PSGS Board of Directors (BOD). Once approved
by the PSGS BOD, the institution will be duly notified of the schedule of visit.

10.3.5. The Committee on Accreditation shall conduct a visit to applicant institution and will
submit a report and recommendation to the PSGS BOD, which in turn will give its
final action.

10.3.6. The applicant institution will be notified as to the visit outcome within one (1)
month from the time of visit.

10.3.7. The program starts immediately once approved by the PSGS Board of Directors, as
Phase I-0 or Phase I-R, until December 31st of the following year.

10.3.9. “Interim Accreditation” shall always start with Phase I Interim Accreditation.

10.4. Phase specific process, requirements and expected outcomes of “Interim Accreditation”

49
10.4.1. Phase I

10.4.1.1. Phase I Interim Accreditation shall be classified into two:

10.4.1.1.1. Phase I-0 – there is no resident at the time

of application and/or accreditation

10.4.1.1.2. Phase I-R - with existing resident at the time of

application and/or accreditation

10.4.1.2. Phase I interim accredited programs are only authorized to train 1st year
level or Junior Residents. Promotion into the next year level will depend on
the progression of interim accreditation to the next phase.

10.4.1.3. Phase I Interim accreditation starts at the time application is approved by

the PSGS BOD and will be in effect until December 31 of the following year.
Example: Interim accreditation granted on September 1, 2019. Phase I accreditation
will be in effect until December 31, 2020.

10.4.1.4. For Phase I-0 interim accreditation, the program must be able to recruit
residents within one year of being granted accreditation. Failure to do so will
result in automatic revocation of interim accreditation and the program may
only reapply after a period of 12 months from the time of revocation.

10.4.1.5. Reclassification from Phase I-0 to Phase I-R will happen only when the
program has already recruited and appointed residents. The program has to
notify the Committee on Accreditation with an appropriate report. The
possible reclassification can only take effect upon the recommendation of the
committee and approval of the PSGS BOD.

10.4.1.6. For Phase I-R interim accreditation, they may proceed with the program
with the existing residents that will be classified as 1st year level or Junior
Residents.

10.4.1.7. The program must submit an Annual Report on or before January 31st of
the succeeding calendar year.

10.4.1.8. The program shall pay an annual accreditation fee of PhP 25,000.00.

10.4.1.9. Progression into Phase II Interim Accreditation:

10.4.1.9.1. Recommendation on phase progression shall be based on the

review of the Annual Report and after satisfactorily complying with
ALL the minimum requirements as stated in the PSGS Accreditation

50
 Manual and a favorable endorsement submitted by the Committee
Accreditation to the PSGS Board of Directors for its approval.

10.4.1.9.2. Approval of a program’s progression from Phase I to Phase II

Interim Accreditation by the PSGS Board of Directors shall take effect
on January 1st.

Example:
Program A on Phase I-R accreditation (January-December 2019) has complied
with all the basic requirements and submitted an Annual Report that is phase
appropriate and was recommended and PSGS BOD approved for Phase II
accreditation on March 12, 2020. Phase II accreditation shall retroactively
take effect from January 1, 2020 and may promote 1st year residents to 2nd year.
The promotion of the residents from 1st to 2nd year level can then retroactively
take effect January 1, 2020, or based on the actual appointment date of the first
year resident.

10.4.1.9.3. Only Phase I-R programs can progress to Phase II Interim

Accreditation.

10.4.1.9.4. Unfavorable recommendation based on the Annual Report review

and/or failure to comply and maintain ALL the minimum
requirements for accreditation as stated in this manual applicable to
Phase I interim program shall result in retention to Phase I-R.

10.4.2. Phase II

10.4.2.1. Phase II Interim Accreditation is given to a program after a satisfactory

completion of Phase I-R Interim Accreditation and upon the recommendation
of the Committee on Accreditation and approval of the PSGS BOD.

10.4.2.2. Phase II Interim Accredited programs are authorized to train 1st year and
2nd year level residents. Promotion of the 2nd year level residents into the next
year level will depend on the progression of the program into the next level.

10.4.2.3. The program may be allowed to accept affiliate 3rd and 4th year level rotators
as host from a Level I or II accredited training program.

10.4.2.3.1. The cases done by the rotators will continue to be credited to the
census of cases of the host program.

10.4.2.3.2. The cases done by the rotator will be credited to his/her personal
case material for PBS board eligibility but not to the base
hospital accreditation purposes.

51
 10.4.2.4. The program must submit an Annual Report and pay an annual
accreditation fee of PhP 25,000.00 on or before January 31st of the
succeeding year in accordance to the specifications as prescribed in the
GARTP.

10.4.2.5. Progression into Phase III Interim Accreditation:

10.4.2.5.1. The Phase II interim accredited program will progress to the next
phase after satisfactorily complying with ALL the minimum
requirements as stated in the PSGS Accreditation Manual and a
favorable recommendation from the Committee on Accreditation
based on the review of the Phase I Annual Report, the Phase II Annual
Report year (Phase II) and the mandatory visit during the first quarter
of the succeeding year, then submitted to PSGS BOD for
approval.

10.4.2.5.2. The PSGS BOD approves the progression from Phase II to Phase
III Interim Accreditation and shall take effect on January 1st of the
same year of the progression. Promotion of the residents to the next
level may also be applied retroactively based on the tenure and actual
time of appointment of the residents concerned.

10.4.2.5.3. Unfavorable recommendation based on the accreditation visit,

Annual Report review and/or failure to comply and maintain ALL
the minimum requirements for accreditation as stated in this manual
applicable to Phase II interim program shall result in retention to
Phase II.

10.4.3. Phase III

10.4.3.1. Phase III Interim Accreditation is given to a program after a satisfactory

completion of Phase II Interim Accreditation and upon the recommendation
of the Committee on Accreditation and approval of the PSGS BOD.

10.4.3.2. Phase III Interim Accredited programs are authorized to train 1st year, 2nd
year and 3rd year level residents. Promotion of the 3rd year level residents into
the next year level will depend on the progression of the program into the next
level.

10.4.3.3. A mandatory accreditation visit will be conducted during the first quarter of
the Phase III year to assess promotion from Phase II to Phase III accreditation,
retroactive January of the current year.

52
 10.4.3.4. The program may be allowed to accept affiliate rotators from a Level I or II
accredited training programs.

10.4.3.4.1. The cases done by the rotators will continue to be credited in the
census of cases of the host program.

10.4.3.4.2. The cases done by the residents may be credited to the rotator to
his/her personal case material for PBS board eligibility but not to the
base hospital for accreditation purposes.

10.4.3.5. The program must submit an Annual Report and pay an annual
accreditation fee of PhP 25,000.00 on or before January 31st of the
succeeding year in accordance to the specifications as prescribed in the
GARTP.

10.4.3.6. Progression into Phase IV Interim Accreditation:

10.4.3.6.1. Recommendation on phase progression shall be based on the

review of the Annual Report and after satisfactorily complying with
ALL the minimum requirements as stated in the PSGS Accreditation
Manual and a favorable endorsement submitted to by the Committee
on Accreditation and approval by the PSGS Board of Directors.

10.4.3.6.2. The PSGS BOD approves the progression from Phase III to Phase
IV Interim Accreditation and shall take effect on January 1st of the
same year of the progression. Promotion of the residents to the next
year level may also be applied retroactively based on the tenure and
actual time of appointment of the residents concerned.

10.4.3.6.3. Unfavorable recommendation based on the Annual Report review

and/or failure to comply and maintain ALL the minimum
requirements for accreditation as stated in this manual applicable to
Phase III interim program shall result in retention to Phase III.

10.4.4. Phase IV

10.4.4.1. Phase IV Interim Accreditation is given to a program after a satisfactory

completion of Phase III Interim Accreditation and upon the recommendation
of the Committee on Accreditation and approval of the PSGS BOD.

10.4.4.2. Phase IV Interim Accredited programs are authorized to train 1st year, 2nd
year, 3rd year and 4th year level residents. Promotion of the 4th year level

53
 residents into the next year level will depend on the progression of the program
into the next level.

10.4.4.3. A mandatory accreditation visit after the end of Phase IV accreditation

(during the first quarter of the following year) to assess promotion to
Conditional Accreditation (Level 1).

10.4.4.4. The program may be allowed to accept affiliate rotators from a Level
I or II accredited training programs.

10.4.4.4.1. The cases done by the rotators will continue to be credited in the
census of cases of the host program.

10.4.4.4.2. The cases done by the residents may be credited to the rotator as
his/her personal case material for eligibility purposes.

10.4.4.5. An interim program can accept lateral entry residents up to 3rd year level in
accordance with the provisions on lateral entry residents in the GARTP.

10.4.4.6. The program must submit an Annual Report and pay an annual
accreditation fee of PhP 25,000.00 on or before January 31st of the succeeding
year in accordance to the specification as prescribed in the GARTP.

10.4.4.7. The PSGS Board of Directors shall give an Annual Report review to the
program on or before January 31st of the following year.

10.4.4.8. The program in Phase IV Interim Accreditation is expected to be able to

comply on the provisions on program factors for case materials as provided
for by Section 3.3.4 of the GARTP (program factor of minimum of 1). The
senior level resident/4th year resident may go into an outside rotation for
TRAUMA CASES subject to a formal MOA with other institutions with
PSGS accredited GS training program and approval of the PSGS BOD.

10.4.4.9. Progression into Level I Accreditation (Conditional Accreditation):

10.4.4.9.1. Recommendation on progression shall be based on the review of

the Phase IV Annual Report submitted to the Committee on
Accreditation and the mandatory visit prior to granting Level I
accreditation (first quarter of the following year).

10.4.4.9.2. The Phase IV Interim Accredited program will progress to Level

I Accreditation after a favorable recommendation from the Committee
on Accreditation and approval of the PSGS BOD, retroactive on
January 1st of the current visiting year.

54
 10.4.4.9.3. Unfavorable recommendation based on the accreditation visit,
annual report review and failure to comply and maintain ALL the
minimum requirements for accreditation as stated in this manual
applicable to Phase IV interim program shall result in retention to
Phase IV.

10.4.4.9.4. Progression into Level I Accreditation shall have the following

process:

10.4.4.9.4.1. There will be a mandatory visit of the Committee on

Accreditation to programs on Phase IV before they can be
recommended to progress to Level I Accreditation.

10.4.4.9.4.2. Payment of an accreditation visit fee of PhP

70,000.00.

10.4.4.9.4.3. The Committee on Accreditation shall notify the

program on the date of visit.

10.4.4.9.4.4. The Committee on Accreditation shall now apply the

accreditation rules and regulations for Level I accreditation
based on the GARTP.

10.4.4.9.4.5. This process will allow the Interim Accredited

programs to be incorporated in the regular level of
accreditation once they have satisfactorily complied with ALL
the stipulated requirements.

10.4.4.9.5. Based on the result of the visit, the Committee on Accreditation

shall make a recommendation to the PSGS BOD. The
recommendations may be one of the following:

10.4.4.10.5.1 Promotion of the program into Level I Accreditation

10.4.4.10.5.2. Retention in Phase IV Interim Accreditation

10.5. Provisions for retention and re-visit

10.5.1. The Committee on Accreditation shall review the annual report and will submit their
recommendation to the PSGS Board of Directors. If there are deficiencies
noted in the Annual Report review, the program will be notified and are
expected to make the necessary corrections.

55
 10.5.2. If in the review of the succeeding Annual Report the deficiencies noted previously are
still present or there are new deficiencies seen, then a mandatory visit by the
Committee on Accreditation will be made.

10.5.3. Unfavorable recommendation based on the visit may result to a phase retention, a
warning status or suspension, depending on the severity of the program deficiencies
and assessment of the Committee on Accreditation and subsequent recommendation
to the Board of Directors. The program will be visited again after one year.

10.5.4. If a third unfavorable evaluation and recommendation is given by the visiting team,
upheld by the Committee on Accreditation and approved by the Board of Directors,
the program’s interim accreditation will be terminated. The program may re-apply
after 12 months from the time of termination.

10.5.5. An accreditation visit fee of PhP 60,000 will have to be settled on all visits brought
about by a second unfavorable Annual Report review and after a warning status is
given.

All other issues not covered in this IRR with respect to above mentioned “Interim Accreditation”
and those arising from differences of interpretation, should be decided upon by the PSGS BOD. All
such issues on “Interim Accreditation” not covered by this IRR and decided upon by the Board of
Directors during the time that this IRR is in effect will immediately be effective and implemented

56
 Appendices

11.1. Appendix 1 – Forms

11.1.1. PSGS Form 2023-1: Application Letter for Accreditation in General Surgery
11.1.2. PSGS Form 2023-2: General Surgery Accreditation Information Sheet

11.2. Appendix 2 - Annual Report Table of Contents

11.3. Appendix 3 – 2023 Content and Format: PSGS Annual Report

11.3.1. PSGS Table 2023-I: Signature Page
11.3.2. PSGS Table 2023-II: Breakdown of Operations
11.3.3. PSGS Table 2023-III: Tabulation of Operations (14 Main Categories and Specific
Operations)
11.3.4. PSGS Table 2023-IVa: Tabulated Summary of Program’s Census
11.3.5. PSGS Table 2023-IVb: Tabulated Listings of Operations done by residents during
Outside Rotation or as a Straight rotator
11.3.7. PSGS Table 2023-Va: Program Structure
11.3.8. PSGS Table 2023-Vb: Tabulated Name of Residents, Respective Year Level,
Appointment to Current Year Level/Annual Report Year,
And Resident’s Schedule of Rotations for the Year
11.3.9. PSGS Table 2023-Vc: Tabulation of Residents – New Appointments, Resigned,
New Lateral Entry Residents, Terminated and Rotators from
Another Institution
11.3.10. PSGS Table 2023-Vd1: Tabulation of Residents’ PSGS CERES and PBS RITE
Results
11.3.11. PSGS Table 2023-Vd2: Tabulation of Evaluation and Assessment Tools and
Schedule
11.3.12. PSGS Table 2023-Ve: List of Graduates of the Program and their Status
11.3.13. PSGS Table 2023-VIa: List of Year’s Conferences and Activities
11.3.14. PSGS Table 2023-VIb: Roster of Consultants for the Annual Report Year
11.3.15. PSGS Table 2023-VIc: Training Committee Members for the Annual Report Year
11.3.16. PSGS Table 2023-VII: 3-Year Tabulated Cumulative Operation Summary (Main
Category Operation and Index Cases Only)
11.3.17: List of Hospital’s Existing and New Facilities, Equipments, Clinical Departments
and Committees for the Annual Report Year

11.4. Appendix 4 - PSGS Rubrics for Evaluation of Residency Training Programs

11.5 Appendix 5 - Guidelines and Criteria for Eligibility to take the Certifying Examinations in
General Surgery

11.6 Glossary

57
Appendix 1- Forms: PSGS Form 2023-1: Application Letter for Accreditation in General Surgery

APPLICATION FOR ACCREDITATION

IN GENERAL SURGERY

I, ________________________________________, by the authority vested in me by the Governing

Body or Director or Chief of Hospital of ____________________________________________
(Name of HOSPITAL), hereby voluntarily apply for accreditation of our Residency Training Program
in GENERAL
SURGERY.

We are fully aware that this application is on a voluntary basis and the hospital authorities submit
unconditionally to the inspection, review and survey of all items pertinent to accreditation including
the physical plant, facilities, hospital records, working staff of the hospital, and processes particularly
of the Department of Surgery.

We, the hospital authorities, express our commitment to comply with ALL the rules and
regulations on accreditation set forth by the Society, to implement the Standardized Surgical
Curriculum for General Surgery, to actively participate and support all Society and Chapter activities
and projects, and to abide by the decision of the PSGS Board of Directors.

Signature and Printed Name of CHAIR

DEPARTMENT of SURGERY

Noted:

Signature and Printed Name of CHAIRMAN of

BOARD or MEDICAL DIRECTOR or
CHIEF of HOSPITAL

58
 Appendix 1- Forms: PSGS Form 2023-2: General Surgery Accreditation Information Sheet

GENERAL SURGERY ACCREDIATION

INFORMATION SHEET
(To be accomplished in Triplicate by the Department applying for Accreditation)

HOSPITAL : _____________________________________
DATE : _____________________________________
MEDICAL DIRECTOR : _____________________________________
SIGNATURE : _____________________________________
DEPARTMENT CHAIRPERSON : _____________________________________
SIGNATURE : _____________________________________
*for consortium:
Department Chairperson for Hospital A : _____________________________________
Signature : _____________________________________
Department Chairperson for Hospital B : _____________________________________
Signature : _____________________________________
PROGRAM DIRECTOR/TRAINING OFFICER : _____________________________________
SIGNATURE : _____________________________________
*for consortium:
Training Officer of Hospital A : _____________________________________
Signature : _____________________________________
Training Officer of Hospital B : _____________________________________
Signature : _____________________________________

I. HOSPITAL

1. Total number of beds (excluding bassinets): __________________________

2. Existing Departments:
*Indicate if program is accredited by respective Specialty Society
*Indicate if there is a separate department for:
DEPARTMENT ACCREDITED
Internal Medicine ( ) YES ( ) NO ( ) YES ( ) NO
OB-Gyne ( ) YES ( ) NO ( ) YES ( ) NO
Pediatrics ( ) YES ( ) NO ( ) YES ( ) NO
Anesthesiology ( ) YES ( ) NO ( ) YES ( ) NO
Others:
Specify ________________________

3. Out-Patient Department: ( ) YES ( ) NO

59
 Number of surgical consultations per year: ___________________

4. Laboratory:
a) Name of Head: _________________________________________
b) Examinations done:
( ) CBC, urinalysis, fecalysis, blood typing
( ) Blood Chemistry
( ) Serum Enzymes
( ) Microbiology (culture and sensitivity test)
( ) Tumor markers
( ) Breast Panel (ER/PR and Her-2-neu assays)
( ) Others (please indicate): _________________________

5. Radiology:
a) Name of Head: __________________________________________
Name of other staff members: ____________________________________________
____________________________________________
____________________________________________
____________________________________________
b) Diagnostic Services:
( ) Chest x-ray
( ) Abdominal x-ray
( ) Skull and skeletal survey
( ) KUB x-ray
( ) Upper G.I. Series and Barium Enema
( ) Intravenous Pyelography (IVP)
( ) Portable x-ray
( ) Operative Cholangiography
( ) C-arm
( ) Angiography
( ) Ultrasonography
( ) CT scan
( ) MRI
( ) Nuclear Medicine
( ) Mammography
( ) FNAB
( ) Core needle biopsy
Others, please indicate: _____________________

6. Pathology:
a) Name of hospital Pathologist: __________________________________

60
 b) Frozen Section Biopsy: ( ) YES ( ) NO
c) Number of autopsies done last year: _________________

7. Facilities for blood processing/storage (blood bank): ( ) YES ( ) NO

8. Ancillary Facilities:
a) Electrocardiogram ( ) YES ( ) NO
b) Heart Station ( ) YES ( ) NO
c) Surgical Care Facilities ( ) YES ( ) NO
d) Recovery Room ( ) YES ( ) NO
e) Rehabilitation Facilities ( ) YES ( ) NO
f) Chemotherapy Facilities ( ) YES ( ) NO
g) Radiation Therapy Facilities ( ) YES ( ) NO
h) Dialysis Center ( ) YES ( ) NO
i) Skills Lab/Animal Laboratory ( ) YES ( ) NO
j) Others, please indicate: _________________________________

9. Endoscopic Facility
Upper GI Endoscopy: ( ) YES ( ) NO
Lower GI Endoscopy
Proctosigmoidoscopy: ( ) YES ( ) NO
Flexible sigmoidoscopy: ( ) YES ( ) NO
Colonoscopy: ( ) YES ( ) NO
ERCP: ( ) YES ( ) NO
Choledochoscopy: ( ) YES ( ) NO
Others, please indicate: ____________________________

10. Facilities for Minimally Invasive Surgery: ( ) YES ( ) NO

* Trainer Box for residents: ( ) YES ( ) NO

11. Medical Library

a) Textbooks Name of Author Edition
( ) Principles of Surgery
( ) Atlas of Operative Techniques
( ) Anatomy
( ) Surgical Anatomy
( ) Physiology
( ) Surgical Oncology
( ) Trauma and Critical Care
( ) Minimally Invasive Surgery
b) Surgical Journals

61
 Peer-reviewed journals like:
( ) Philippine Journal of Surgical Specialties
( ) Foreign Surgical Journals:
- Journal of the American College of Surgeons
- Surgical Clinics of North America
- Annals of Surgery
- American Journal of Surgery
- British Journal of Surgery
- Others: ___________________________
c) Information Technology:
- Internet Access ( ) YES ( ) NO
- E-books for Surgery ( ) YES ( ) NO
- Digital Library ( ) YES ( ) NO
- Access to E-Journals ( ) YES ( ) NO

12. Records Section: ( ) YES ( ) NO

Number of Years charts are preserved: _________________

13. Hospital/Department of Surgery Tumor Board ( ) YES ( ) NO

14. Quality Assurance Board or Committee ( ) YES ( ) NO

15. Ethics Review Board ( ) YES ( ) NO

II. DEPARTMENT OF SURGERY

1. Total number of surgical beds:

a) Private beds - ____________________
b) Service beds - ____________________

*Major operations per year (for the past 2 years) – please attach as separate sheet
*Medium operations per year (for the past 2 years) - please attach as separate sheet

2. Name of the Head of the Department and qualifications

(Please attach curriculum vitae)

3. Members of the Surgical Staff

(Names, qualifications, please attach curriculum vitae)

4. Name of Program Director/Training Officer and members of the Residency Training Committee

62
 and their qualifications

5. Conferences:
Frequency
( ) Mortality and Morbidity ________________________
( ) Audit and Census ________________________
( ) Pre-Op & Post-Op/Case Conferences/Grand Rounds ________________________
( ) Journal Club ________________________
( ) Tumor Conference ________________________
( ) Quality Assurance & Patient Safety Conference ________________________
( ) Others like: (please state)
( ) Lectures on Surgical topics ________________________
( ) Clinico-Pathologic Conference ________________________

6. Do your residents keep a record of operated and assisted operations: ( ) YES ( ) NO

* Please submit a copy of the Annual Report for the last 2 years

III. THE RESIDENCY TRAINING PROGRAM

1. Number of surgical residents: ___________

2. Names of Residents:

1st year: _________________________________________________________________

_________________________________________________________________

2nd year: _________________________________________________________________

_________________________________________________________________

3rd year: _________________________________________________________________

_________________________________________________________________

4th year: _________________________________________________________________

_________________________________________________________________

5th year: _________________________________________________________________

_________________________________________________________________

* NSAT RESULTS (if any):

Names of Residents/Month or Year taken/Percentile Ranking

63
 1st year: _________________________________________________________________
_________________________________________________________________

2nd year: _________________________________________________________________

_________________________________________________________________

3rd year: _________________________________________________________________

_________________________________________________________________
4th year: _________________________________________________________________
_________________________________________________________________

5th year: _________________________________________________________________

_________________________________________________________________

3. Description of Residency Training

*For those submitting for the first time, take into consideration:

a) Rotation / Clinical Exposure (what departments or sections, and for how long)

b) Duties and responsibilities

c) Supervision

d) Operative opportunities

e) Others

64
 Appendix 2: Annual Report Table of Contents

ANNUAL REPORT - GENERAL SURGERY TRAINING PROGRAM

I. Signature Page / Hospital and Department authorities attesting the report is true and correct

II. Breakdown of Operations

III. Tabulation of Operations (based on the 14 main case categories of operations)

IV. Program and Residents Census

a. Tabulated summary of program’s census (based on the 14 main case categories of
operations
b. IF APPLICABLE: (These LISTINGS are included in the annual reports of both the Host
and Affiliated/Linked institutions and institutions with “Straight Rotators”
i. TABULATED LISTING OF CENSUS OF OPERATIONS DONE BY
INDIVIDUAL RESIDENTS DURING OUTSIDE ROTATION certified by
Host Authorities (Chair, Training Officer, Chief Resident/Fellow) together with a
PHOTOCOPY of the CURRENT MOA and PSGS APPROVAL Letter OR
TABULATED LISTING OF CENSUS OF OPERATIONS given to
INDIVIDUAL RESIDENTS on ROTATION from another institution.
Certified as Authorities of Host Hospital (Chair, Training Officer, Chief Resident/
Fellow) together with a PHOTOCOPY of the current MOA and PSGS
APPROVAL letter.
ii. TABULATED LISTING OF CENSUS OF OPERATIONS DONE BY
INDIVIDUAL “Straight Rotator Residents”

V. RESIDENTS AND PRODUCT STATUS / TABULATED ROTATIONS AND

PROGRAM STRUCTURE
a. Program Structure
b. Name of residents with respective year level, appointment dates to current year level/
Annual Report Year, divided according to year level and schedule of rotation for the year
c. Tabulated Names of all residents divided according to year level, original date of
appointment in the program, and designation of residency item (GS, “straight
rotator” of other subspecialty surgery)
d. New residents appointed (for Annual Report Year), date of appointment, NSAT result
(if any)
e. Names of residents who resigned (date and reason for resignation)
f. If any, Name of the LATERAL ENTRY RESIDENT and copy of notarized certification
of last completed residency level from Hospital of origin and required letters of
recommendations/certification

65
 g. Name of residents terminated (date and reason for termination)
h. Names of residents from another institution/s rotation in your program including
duration of rotation (specific date/period), parent institution
i. Names of resident/s who took the CERES and PBS RITE with corresponding grades
including each tests MPL per year level
j. Tabulated list of internal evaluation and assessment tools with corresponding grades and
schedule, feedback to residents and its frequency
j. List of graduates of the program and their status (i.e., Diplomate, Fellows, other specialty
training)

VI. LISTING OF YEAR’S CONFERENCES AND ACTIVITIES: Type of conferences (specific

topics/cases, if any), dates, speakers (state whether resident, consultant or invited guests), number
or percentage of active consultant attendees
a. Pre-Op / Post-Op / Grand Rounds / Case Presentations
b. Census Conference (weekly or monthly)
c. Mortality / Morbidity Conference
d. Department/Hospital Tumor Conference
e. Journal Clubs
f. Other Department Activities and Institutional Activities / Attendance to PSGS activities
and other Post Graduate Conventions
g. Scientific Research and Paper Outputs

VII. List of Department Staff (ROSTER OF CONSULTANTS) for the Annual Report Year
a. Designation on whether General Surgery or Other Specialty Surgery Consultant
b. Active of Visiting Status (based on the program’s or hospital’s designation)
c. A tabulated list of the members of the Residency Training Committee to include position
(Training Officer/Program Director, Asst. Training Officer, Year Level Coordinators) if
Applicable, whether Fellows of PCS and/or PSGS or their respective specialty society (for
Non-GS member of the committee), and whether a PATOS member

VIII. 3-Year (past 2 years prior to the current Annual Report Year) TABULATED CUMULATIVE
OPERATIONS SUMMARY (including Index cases), i.e. 2023 Annual Report will have 2021,
2022 and 2023 tabulated cumulative summary of cases

IX. List of current and new hospital departments/committees/programs and equipment/facilities

For the Annual Report Year that is/are pertinent and relevant to the General Surgery Training
Program
a. Existing and New Clinical Department/s, indicate whether it has an accredited training
program
b. Existing and New Hospital equipment and facilities (laboratory, radiology, pathology,
endoscopy, MIS, other ancillary facilities)

66
 Appendix 3 - 2023 Content and Format: PSGS ANNUAL REPORT

PSGS TABLE 2023-I: SIGNATURE PAGE

ANNUAL REPORT 20XX

GENERAL SURGERY RESIDENCY TRAINING PROGRAM

HOSPITAL: ________________________________________________________________________

Certified True and Correct by:

TRAINING OFFICER/PROGRAM DIRECTOR: _______________________________________

Signature: ________________________________ Date: _________________________________

*for consortium:

ASSISTANT TRAINING OFFICER FOR HOSPITAL A: _________________________________

Signature: ________________________________ Date: _________________________________

ASSISTANT TRAINING OFFICER FOR HOSPITAL B: _________________________________

Signature: ________________________________ Date: _________________________________

DEPARTMENT CHAIR: _____________________________________________________________

Signature: ________________________________ Date: _________________________________

*for consortium:

DEPARTMENT CHAIR OF HOSPITAL A: ____________________________________________

Signature: ________________________________ Date: ________________________________

DEPARTMENT CHAIR OF HOSPITAL B: ____________________________________________

Signature: ________________________________ Date: ________________________________

HOSPITAL DIRECTOR: ______________________________________________________________

Signature: ________________________________ Date: _________________________________

67
 PSGS TABLE 2023-II: BREAKDOWN OF OPERATIONS

BREAKDOWN OF OPERATIONS

TOTAL OPERATIONS (excluding minor procedures):

1. ELECTIVE
2. EMERGENCY
a. Trauma
b. Non-Trauma

Operations done by Consultants:

a. Private Cases
b. Service Cases

Operations done by regular GS residents:

a. Private Cases
b. Service Cases

Operations done by straight rotators in the institution:

Operations done by residents in outside rotation / or residents rotating from another institution:

Operations done in outreach surgical missions:

Mortality rate:

Morbidity rate:

Mortality rate based on the following formula:

Total # of deaths from Categories I-XIII

X 100
Total # of cases from Categories I-XIII

Morbidity rate based on the following formula:

Total # of morbidities from Categories I-XIII

X 100
Total # of cases from Categories I-XIII

68
 PSGS TABLE 2023-III: TABULATION OF OPERATIONS
(14 Main Categories and Specific Operations)

TABLE OF OPERATIONS HANDLED IN 20XX

Number of Residents: _____
Program Factor (PF): _____

Main category operations (170)

Number of Operations
(Case load requirement for Program Factor (PF))
Require
Total
d
Total progra
progra
(Do not proced m
m case
Specific fill this ures credit
load
operations as column handle proced
Clustered sub-category Service (S) Pay/Private (P) require
encountered by : for d per ures per
ment
program PSG main main
per
S categor categor
main
use) y y
categor
y
Resid Cons Reside Consult PF x
ent ultant nt (Rp) ant require
(Rs) (Cs) (Cp) d
I. HEAD AND NECK (20) (S+P) (S+0.35 PF X 20
x P)
A. Thyroidectomy / Excision A. Thyroid
of Thyroglossal Duct Cyst lobectomy, right
B. Thyroid
lobectomy, left
C. Subtotal
thyroidectomy
D. Near total
thyroidectomy
E. Excision of
Thyroglossal duct
cyst
F. Total
Thyroidectomy
G. Completion
Thyroidectomy
H. Transoral
endoscopic total
thyroidectomy
B. Major Salivary Gland
Surgery/Neck Dissection

Excision of
Branchial Cleft
Cyst
C. Surgical airway
Cricothyroidotom
y
Tracheostomy
II. BREAST (10) (S+P) (S+0.35 PF X 10
x P)
A. Mastectomy with or Specific
without SLNB/ALND; BCS/ operations as
partial mastectomy with encountered
SLNB/ALND (5 - not factor
dependent) Cyst

69
B. Specific
Segmentectomy/quadrantect operation as
omy/partial mastectomy/Wide encountered
excision
III. Esophageal, Gastric, (S+P) (S+0.35 PF X 5
Duodenal Surgery x P)
(excision/resection/repair) (5)

A. Gastric/GastroDuodenal Specific
Surgery operations as
encountered
B. Gastrointestinal Bypass Specific
operation as
encountered
C. Esophageal Surgery Specific
operation as
encountered
D.
Gastrostomy/Esophagostomy
/Duodenostomy

IV. SMALL and LARGE BOWEL

SURGERY (25) (S+P) {S+(0.35xP)} PFx25

A. Adhesiolysis/ Specific
Enterolysis (2) operation as
(for endometriosis, encountered
bowel obstruction
and malignancy)

B. Specific
Bowel resection and operation as
anastomosis, bowel resection encountered
and ostomy (10), and bypass

C. Specific
Intestinal OSTOMY operation as
/Closure of ostomy/Tube encountered
Jejunostomy

70
V. RECTAL SURGERY (2)
(S+P) {S+(0.35xP)} 2 or
more
cases

Specific operation
Low Anterior Resection/ as encountered
APR
(2- fixed requirement and not
Program/factor dependent)

TransAnal Rectal Mass Exc./

Total Proctectomy-
anal mucosectomy (sphincter-
saving)

VI. ANAL SURGERY (10) (S+P) (S+0.35 PF X 10

x P)
Hemorrhoidectomy/fistul Specific
otomy/fistulectomy/fissu operations as
rectomy/sphincterotomy encountered

VII. APPENDECTOMY (S+P) (S+0.35 PF X 20

(ADULT AND x P)
PEDIATRIC) (20)
A. Open Appendectomy Specific
operations as
encountered
B. Laparoscopic
Appendectomy

VIII. HEPATOBILIARY, (S+P) (S+0.35 PF X 30

GALLBLADDER, x P)
PANCREAS, LIVER,
SPLEEN (30)
A. Open Cholecystectomy Specific
operations as
encountered
B. Laparoscopic
Cholecystectomy
C. Lap or Open CBD
Exploration/T-tube
choledochosotmy/ Biliary
Enteric
Anastomosis/Biliary
Drainage/Sphincterotomy
/Sphincteroplasty
D. Pancreatic Surgery
E. Hepatic resection

IX. THORACOSOTMY (S+P) (S+0.35 PF X 5

(trauma and non- trauma) x P)
(5)
THORACOSTOM
Y

X. TRAUMA (8) (S+P) (S+P) PF X 8

71
A. Exploratory laparotomy
for intra- abdominal injuries

B. Conservative/Non-
operative Management for
intra-operative Solid
Organ Injury
C. Thoracotomy

D. Neck exploration

E. Major Vascular Repair

F. Limb amputation

XI. VASCULAR ACCESS (S+P) (S+0.35 PF X 5

(IJ, x P)
cutdown, subclavian,
portacath) (5)

XII. OPEN/LAP ADULT (S+P) (S+0.35 PF X 15

AND PEDIATRIC x P)
ABDOMINAL WALL
HERNIA (incisional,
ventral, inguinal,
umbilical) (15)
Specific
operation as
encountered
Open hernia repair,
Inguinal

XIII. SKIN AND SOFT (S+P) (S+0.35 PF X 5

TISSUE TUMOR x P)
SURGERY (5)
Specific
operation as
encountered

XIV. OTHER (S+P) (S+0.35 PF X 10

SUBSPECIALTY x P)
SURGERY (10)

72
 PSGS TABLE 2023-IVa: TABULATED SUMMARY OF PROGRAM’S CENSUS

I. HEAD AND NECK

a. Thyroidectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Major salivary gland surgery

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

c. Neck dissection
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

d. Surgical Airway
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

II. BREAST
a. Mastectomy with or without SLNB/ALND
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

73
 b. Partial Mastectomy/Segmentectomy/Quadrantectomy/Wide
Excision/Lumpectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

III. ESOPHAGEAL, GASTRIC AND DUODENAL SURGERY

a. Esophageal Surgery
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Gastric/Gastroduodenal Surgery
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

c. Gastrointestinal Bypass Surgery

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

IV. SMALL AND LARGE BOWEL SURGERY

a. Adhesiolysis / Enterolysis
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

74
 b. Bowel Resection with or without anastomosis / ostomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

c. Intestinal Ostomies (creation / closure of ostomies, tube jejunostomy)

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

V. RECTAL SURGERY

a. Low Anterior Resection / Abdominoperineal Resection

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Trans-anal Rectal Mass Excision / Total Proctectomy – anal

mucosectomy (sphincter saving)
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

VI. ANAL SURGERY

a. Hemorrhoids / Anal Fistula / Anal Fissures

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

75
 VII. APPENDIX

a. Open Appendectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Laparoscopic Appendectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

VIII. HEPATOBILIARY SURGERY

a. Open Cholecystectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Laparoscopic Cholecystectomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

c. Open or Laparoscopic CBDE/ T-tube choledochostomy/ Biliary-

enteric Anastomosis/ Biliary drainage/
Sphincterotomy/ Sphincteroplasty
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

76
 IX. THORACOSTOMY

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd

Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

X. TRAUMA

a. Exploratory laparotomy for intra-abdominal injuries

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

b. Non-operative Management for intra-operative solid organ injury

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

c. Thoracotomy
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

d. Neck exploration
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

77
 e. Major vascular repair
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

f. Limb surgery / amputation

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

XI. VASCULAR ACCESS SURGERY (IJ, subclavian, femoral,

cutdown, IVAD)

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd

Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

XII. ABDOMINAL WALL HERNIA SURGERY (open or

laparoscopic, pediatric or adult)

a. Inguinal, incisional, ventral, femoral, umbilical hernia surgery

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

XIII. SKIN AND SOFT TISSUE TUMOR SURGERY

a. Skin / Soft tissue tumors

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

78
 b. Debridement (burns, diabetic foot, non-healing wounds)
Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd
Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

XIV. SUBSPECIALTY SURGERY (categorize please)

Initials/Age/Sex/ Preop Procedure Postop HISTOPATH Service/ Surgeon/ First 2nd

Hospital Number/ Diagnosis Diagnosis If applicable Pay Year Level Assist/ Assist/
Date of Operation (Final (write Year Year
Diagnosis) ‘consultant’ if Level Level
applicable

79
 PSGS TABLE 2023-IVb: TABULATED LISTINGS OF OPERATIONS DONE BY
INDIVIDUAL RESIDENTS DURING OUTSIDE ROTATION, certified by host authorities
(Chair, Training Officer, Chief Resident/Fellow) together with PHOTOCOPY of the
CURRENT MOA and PSGS BOD APPROVAL LETTER (included in both the Host’s and
Affiliate/Linked Hospital’s Annual Reports)

OPERATIONS DONE BY INDIVIDUAL RESIDENTS on Outside Rotation or as a Straight

Rotator:

Name of Resident: _______________________

Year Level: ____________
Institution: _____________________________
Date of Rotation: _______________

Initials/Age/Sex/ Preop Diagnosis Procedure Postop HISTOPATH S or A1

Hospital Number/ Diagnosis If applicable
Date of Operation

Certified True and Correct by: ________________________________

Signature/s of designated Host Hospital/Department authorities:

_____________________________

Copy of the PSGS BOD Letter of Approval of Current Notarized MOA supporting the rotation

Copy of the PSGS Approved Current Notarized MOA of the rotation

NOTE: Operations listed above and given to a ‘rotator’ from another institution:

 Are included in the TOTAL operations handled in the BREAKDOWN OF OPERATION

page of the Annual Report and declared in the Operations given to rotators
 Included in the Case Material Tabulation BUT is EXLUDED in the computation of Total
Program Credited Procedures (per main category)
 S – as surgeon or A1 – as First Assists to a QUALIFIED Trainer
 FOR STRAIGHT ROTATORS: NO NEED TO ENTER THE Copy of the MOA or
PSGS Approval of MOA; operations given to straight rotators are still credited case
materials of the training program

80
 PSGS TABLE 2023-Va: PROGRAM STRUCTURE

*sample tabulation
PROGRAM STRUCTURE 5-YR GS
RESIDENCY
October-
January-March April-June July-September
December
1ST YEAR General Surgery (GS) OPD / Ward
2ND YEAR Pedia
Surg/Plastic/Neuro/TCVS/GS/ER/OPD/Ward
3RD YEAR Pedia Surg/Plastic/Neuro/TCVS/GS/OPD/Ward
4TH YEAR GS/Trauma/ER/OPD
5TH YEAR GS/Trauma/ER/OPD

1st Year – NO ER Rotation

1st Year and 5th Year – GS Rotation
1st and 5th Year – NO Outside Rotation

GS Rotation 48 Months
1st year 12 months
2nd year 6 months
3rd year 6 months
4th year 12 months
5th year 12 months

Subspecialty 12 Months
1st Year 0 month
2nd Year 6 months
3rd Year 6 month
4th Year 0 month
5th Year 0 month
a. General Surgery Rotation:
48 months of GS
12 months of subspecialty surgery

b. Rotation in other surgical specialties

Urology
Thoracic and Cardio-Vascular Surgery
Plastic and Reconstructive Surgery
Pediatric Surgery
Neurosurgery
Orthopedics

81
 PSGS TABLE 2023-Vb: TABULATED NAMES OF RESIDENTS

* sample only
RESIDENT
and Jan Feb Mar Apr May June Jul Aug Sept Oct Nov Dec
APPOINTME
NT
date to current
year level
5th
year
4th
year

PSGS TABLE 2023-Vc: TABULATION OF RESIDENTS / NEW APPOINTMENTS

/ RESIGNED/ NEW LATERAL ENTRY RESIDENTS/ TERMINATED /
ROTATORS FROM ANOTHER INSTITUTION

Resident for the Annual Date of Appointment Note if regular GS resident or

Report Year and Year ‘straight rotator’ of other
Level subspecialty surgery

New residents for the annual Date of Appointment NSAT result and date taken if
report year any

Name of residents who Date of Appointment Date of resignation

resigned

Name of the LATERAL Year level and Date Note: attach photocopy of
ENTRY RESIDENT of appointment notarized certification of last
completed residency level
from hospital of origin and
required letters of
recommendation/certification

82
 Name of terminated residents Date of Termination Reason for termination
(Annual Report Year)

Name of rotators from other Inclusive date of rotations Mother institution and reason
institutions and year level for rotation (as stated in the
PSGS approved MOA)

PSGS TABLE 2023-Vd1: TABULATION OF RESIDENTS’ PSGS CERES AND PBS RITE
RESULTS

PBS PSGS -
RITE CERES
Residents Yr Raw Yr Level Overall Residents Yr Raw Yr Level Overall
Level Score percentile percentile Level Score percentile percentile
ranking ranking ranking ranking

* Please indicate MPL per year level

PSGS TABLE 2023-Vd2: TABULATION OF EVALUATION AND ASSESSMENT TOOLS

AND SCHEDULE

DEPARTMENT INTERNAL WRITTEN

EXAMS
Date of Internal Examination Number of residents who took the exam Percent passing based on 50% MPL
Total number of residents

ORAL
EXAMS
Date of Oral Examination Participants Type of Oral Examination Feedback Percent
Given from faculty passing
(E.g. standardized module, well- based on
case conference, others) documented 50% MPL
(Y/N)

83
 TECHNICAL SKILLS
(MAY INCLUDE BOTH ACTUAL SURGICAL EVALUATION OR LAPAROSCOPIC TRAINER BOX
EXERCISES)
Used rubrics from curriculum as evaluation tool for all residents % passing rate

Answerable by (Y/N)

ATTITUDINAL COMPETENCE
Used rubrics from curriculum as evaluation tool for all residents % passing rate

Answerable by (Y/N)

CLINICAL COMPETENCE
Used rubrics from curriculum as evaluation tool for all residents % passing rate

Answerable by (Y/N)

SCHEDULE OF RESIDENT FEEDBACK FROM TRAINING COMMITTEE

Resident’s Evaluation Feedback done Frequency
(Y/N)

PSGS TABLE 2023-Ve: LIST OF GRADUATES OF THE PROGRAM AND THEIR STATUS

Roster of Graduates:

Name of Graduate Year Graduated STATUS re: Certification Area of Practice or Additional
& Membership in Specialty Post-Graduate Studies
Society (PSGS, PCS, etc)

84
 PSGS TABLE 2023-VIa: LIST OF YEAR’S CONFERENCES AND ACTIVITIES

Pre-operative/Post-operative/Grand Rounds/Case Presentation

Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

Audit and Census Conference

Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

Mortality and Morbidity Conference

Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

Journal Club
Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

Tumor Conference
Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

Quality Assurance and Patient Safety Conference

Conference Type and Specific Date and Venue Presenter and Year Level Number of consultant
Topic attendees/ Number of
active consultants X 100

*Average attendance in %

85
 Other Department Activities/ Attendance to PSGS activities and other Post
Graduate Conventions
Activity Date and Venue Attendees Indicate if speaker, poster
presentor, reactor,
moderator etc.

Scientific Research Papers/Output

TITLE AUTHOR PUBLICATION: Journal
S Date/Volume/Number/Page (state if
unpublished)

PSGS TABLE 2023-VIb: Roster of Consultants for the Annual Report Year

General Surgery 1.
2.
3.
4
Other Specialty Surgery 1.
2.
3.

PSGS TABLE 2023-Vic: TRAINING COMMITTEE MEMBERS FOR THE

ANNUAL REPORT YEAR

Chairman for the Training Committee: ____________________________

Committee Member Name PCS PSGS PATOS Other society memberships

(indicate position if available,
e.g. Asst TO, year
level coordinator, etc):
General Surgery:

Subspecialty:

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 PSGS TABLE 2023-VII: 3-YEAR (PAST 2 YEARS PRIOR TO AND THE ANNUAL
REPORT) TABULATED CUMULATIVE OPERATION SUMMERY (MAIN CATEGORY
OPERATION AND INDEX CASES ONLY

3-year tabulated cumulative operation summary:

Main Category Operations 2 years immediately 1 year immediately Annual report for FOR PSGS use
Index Cases preceding current preceding current the current year please do not fill
annual year report annual report this column

I. Head and Neck

Thyroidectomy
Parotidectomy
Neck Dissection
II. Breast
MRM
III. Esophagus, Stomach and
Duodenum
Gastric resection of
any variety
IV. Small and large bowel
surgery
Adhesiolysis
Bowel resection with
or without
anastomosis
V. Rectal Surgery
APR
Low anterior
resection
VI. Anal Surgery
VII. Appendectomy (Adult and
Pediatric)
VIII. Hepatobiliary,
Gallbladder, Pancreas,
Liver
Open
cholecystectomy
Laparoscopic
cholecystectomy
CBD Exploration
Biliary enteric
anastomosis
IX. Thoracostomy
X. Trauma
XI. Vascular Access
XII. Hernia Repair
XIII. Soft tissue tumor
resection
XIV. Other subspecialty
surgery

87
 LIST OF HOSPITAL’S EXISTING AND NEW FACILITIES, EQUIPMENTS, CLINICAL
DEPARTMENTS AND COMMITTEES FOR THE ANNUAL REPORT YEAR

I. Clinical Departments:
*Indicate if program is accredited by respective Specialty Society
*Indicate if there is a separate department for:
DEPARTMENT ACCREDITED
Internal Medicine ( ) YES ( ) NO ( ) YES ( ) NO
OB-Gyne ( ) YES ( ) NO ( ) YES ( ) NO
Pediatrics ( ) YES ( ) NO ( ) YES ( ) NO
Anesthesiology ( ) YES ( ) NO ( ) YES ( ) NO
Others:
Specify ________________________

II. Hospital/Department of Surgery Committees:

Hospital/Department of Surgery Tumor Board ( ) YES ( ) NO
Quality Assurance Board or Committee ( ) YES ( ) NO
Ethics Review Board ( ) YES ( ) NO
Others: (*please specify): __________________

III. Hospital Facilities and Equipments

A. Laboratory
( ) CBC, urinalysis, fecalysis, blood typing
( ) Blood Chemistry
( ) Serum Enzymes
( ) Microbiology (culture and sensitivity test)
( ) Tumor markers
( ) Breast Panel (ER/PR and Her-2-neu assays)
( ) Others (please indicate)

B. Radiology:
( ) Chest x-ray
( ) Abdominal x-ray
( ) Skull and skeletal survey
( ) KUB x-ray
( ) Upper G.I. Series and Barium Enema
( ) Intravenous Pyelography (IVP)
( ) Portable x-ray
( ) Operative Cholangiography
( ) C-arm
( ) Angiography
( ) Ultrasonography
( ) CT scan
( ) MRI
( ) Nuclear Medicine

88
 ( ) Mammography
( ) FNAB
( ) Core needle biopsy
( ) Others (please indicate): __________________

C. Pathology
Frozen Section Biopsy: ( ) YES ( ) NO
Blood Bank:
Processing ( ) YES ( ) NO
Storage ( ) YES ( ) NO
Other, please specify: _________________

D. Endoscopic Facility
Upper GI Endoscopy: ( ) YES ( ) NO
Lower GI Endoscopy
Proctosigmoidoscopy: ( ) YES ( ) NO
Flexible sigmoidoscopy: ( ) YES ( ) NO
Colonoscopy: ( ) YES ( ) NO
ERCP: ( ) YES ( ) NO
Choledochoscopy: ( ) YES ( ) NO
( ) Others (please indicate): __________________

E. Ancillary Facilities
Electrocardiogram ( ) YES ( ) NO
Heart Station ( ) YES ( ) NO
Surgical Care Facilities ( ) YES ( ) NO
Recovery Room ( ) YES ( ) NO
Rehabilitation Facilities ( ) YES ( ) NO
Chemotherapy Facilities ( ) YES ( ) NO
Radiation Therapy Facilities ( ) YES ( ) NO
Dialysis Center ( ) YES ( ) NO
Skills Lab/Animal Laboratory ( ) YES ( ) NO
Minimally Invasive Surgery ( ) YES ( ) NO
Internet Access ( ) YES ( ) NO
E-Books and E-Journals ( ) YES ( ) NO
( ) Others (please indicate): __________________

89
Appendix 4: PSGS COMMITTEE ON ACCREDITATION RUBRICS SYSTEM OF
EVALUATION OF THE PROGRAMS

90
91
92
93
94
95
96
97
98
99
100
101
102
103
Total Rubrics Score: (example)
I. Administrative Support = 8%
II. Training Facilities = 8%
III. Structured GS Residency Training
Program = 8%
IV. Clinical Material = 32 %
V. Learning Activities = 8%
VI. Output = 11.25 %
SCORE TOTAL = 75.25%
*passing score of 60%

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 Appendix 5 - GUIDELINES AND CRITERIA FOR ELIGIBILITY TO TAKE THE
CERTIFYING EXAMINATIONS IN GENERAL SURGERY

1. The following guidelines and criteria shall be used for the evaluation of Graduate Residents
(candidate) from the different PSGS Accredited Training Programs in General Surgery to
determine their eligibility to take the Certifying Examination in General Surgery given by
the PBS.

2. Requirements for tenure of residency:

A candidate must have satisfactorily completed a cumulative period of 5 years of
residency training in a PSGS Accredited Training Program in General surgery.

3. Requirements on the qualifying examinations – The PSGS CERES (Comprehensive External

Residents Evaluation System) Written Examination and the PBS RITE (Residency-in-
Training Examination):
a. A candidate must have taken at least 4 PBS RITE during his/her tenure as resident in
General Surgery.
b. A candidate to be eligible to take the PBS Certifying Examination must have passed
based on the minimum passing level (MPL) set for the particular CERES written
examination at least one (1) out of three (3) examinations taken during the first
three (3) years of residency (Junior and Intermediate Levels) and at least one (1)
out of two (2) examinations taken during the last two (2) years of residency (Senior
Level).
c. In the even a candidate fails to comply the above requirements and had already finished
his tenure of residency, he/she is required and shall be allowed to retake the
CERES written examinations for the Senior Level until he/she is able to comply
and pass two (2) CERES written examinations.

4. Requirements for operative experience:

a. Requirements for operative experience by the candidate shall be based on the cases
submitted for evaluation.
b. Cases submitted shall be reported and tabulated as (1) Independently performed, (2)
Performed under direct supervision, and (3) Cases assisted. For the cases assisted,
it should be further reported if the candidate assisted as first or second assist and
the year level when the operation was performed.
c. Operative experience and categories:
i. Head and Neck Surgery (15)
1. Thyroidectomy – must have performed at least 5 operations
independently and 5 operations under direct supervision.
2. Parotid Surgery - must have at least 1 independently performed or
under direct supervision.
3. Neck Dissection – must have at least 1 independently performed or
under direct supervision.
4. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.

105
ii. Breast Surgery (10)
1. Includes major cases such as Modified Radical Mastectomy (MRM)
and variations of Breast Conserving Surgery (BCS). A candidate
must have performed at least 5 operations independently and 5
operations under direct supervision of the preceding operations.
2. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
iii. Esophagus, stomach and small intestines (10)
1. Includes Adhesiolysis, small bowel resection and gastric surgery. A
candidate must have performed at least 5 operations
independently and 5 under direct supervision of the preceding
operations.
2. Gastrectomy shall include either total, partial or wedge resection.
3. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
iv. Colorectal (10)
1. Includes colectomy and either Low Anterior Resection (LAR) or
Abdominoperineal Resection (APR). A candidate must have
performed at least 5 operations independently and 5 under direct
supervision of the preceding operations.
2. LAR or APR shall remain as index operation/s and a candidate MUST
have performed at least 1 independently or under direct
supervision.
3. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
v. Appendectomy (10)
1. A candidate must have a minimum of 10 independently performed
surgeries either for simple or complicated appendicitis.
2. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
vi. Hepatobiliary (25)
1. Includes Cholecystectomy (open and/or laparoscopic) with and
without common bile duct exploration shall remain as index cases
with a minimum of 10 independently performed surgeries and at
least 15 surgeries performed with supervision.
2. It is also required that a candidate must have performed at least five (5)
Laparoscopic Cholecystectomies independently or under direct
supervision and have assisted in at least ten (10) of the same
procedure.

106
 3. A candidate is also required to have performed one (1) CBDE
independently or under direct supervision.
4. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
vii. Trauma (10)
1. Exploratory laparotomy for intra-abdominal injuries / neck
exploration / thoracotomy / major vessel repair with a minimum
of 5 independently performed surgeries and at least 5 surgeries
performed with supervision.
2. Non-operative management for abdominal trauma may be considered
as long as the case reported is well documented to include the case
abstract and the necessary imaging modalities utilized available
for verification.
3. If a candidate cannot comply with the requirements above, assisting in
3 similar operations as First Assist during his/her senior years of
residency, will be considered as 1 operation performed under
direct supervision.
viii. Major sub-specialty surgery (10)
1. Includes either performing independently or under direct supervision
and assisting in a minimum of 10 major sub-specialty surgeries.

5. This guideline shall take effect upon joint approval of both the PSGS and PBS except for
certain provisions that are to be implemented after a specified transition period. This includes
the provision on the requirements on qualifying examinations, that is the PSGS CERES and the
PBS RITE.

107
 GLOSSARY

1. (NEW) Applicant GS-Residency Training Program: Any currently

NONACCREDITED General Surgery Residency Program, single institution or a
consortium of institutions, that applies to the PSGS for Accreditation of the Training
Program
2. ANNUAL REPORT of the Accredited GS-Residency Training Program or the
ANNUAL REPORT: a collated documentation of the year's Hospital (in relation to the
GS -Residency program) and the Department of Surgery activities and programs
implementing the structured GS-Residency Training Program using the Standardized
Surgical Curriculum for General Surgery
3. 'NON-Qualified' Applicant Training Program or 'DISAPPROVED' Applicant Training
Program: An Applicant Training Program that after preliminary evaluation, has NOT
MET the minimum PSGS requirements for an actual accreditation 'VISIT'; the applicant
training program is thus, denied a 'VISIT'
Outside Rotation for ADDITIONAL EXPOSURE': A rotation of a resident, from one
accredited training program to another accredited training program for the purpose of
supplemental experience on specified specialized areas of surgery (i.e. SICU exposure,
Thoracic & Cardiovascular Surgery. Additional MIS exposure) and NEVER the purpose
of accumulating volume of case materials to fulfill Minimum requirements of accreditation
5. 'QUALIFIED' Applicant Training Program of 'APPROVED' Applicant Training
Program: An Applicant Training Program that, after preliminary evaluation, has met the
PSGS requirements for actual 'VISIT' for the purpose of accreditation. A high volume (eg.
TRAUMA / MIS etc.) institution identified and allowed by the PSGS BOD to accept
resident rotators for specified purpose.
6. ACCREDITATION VISIT FEE: The FEE set by the PSGS for the actual 'VISIT' and
evaluation of a 'QUALIFIED' applicant training program for the purpose of accreditation
7. Adequate Exposure in the Subspecialties: programmed rotation of GS - residents to the
other surgery specialties for them to be able to achieve listed competencies in the Surgical
Curriculum for General Surgery
8. AFFILIATION: Rotation on the strength of a PSGS approved MOA of residents from an
accredited affiliate training program to another accredited host surgical residency program.
The host hospital will not send a resident in return.
9. ANNUAL ACCREDITATION FEE: a schedule of annual fee required of ALL PSGS
Accredited GS Residency Training Programs
10. Annual Report of an Applicant Training Program: The same as the ANNUAL REPORT
BUT it should be identified in the signature page as Annual Report of an Applicant
Training Program
11. CASE LOAD REQUIREMENT: Program Case Load Requirement: the volume, variety
and service cases required to be handled by an accredited residency training program in a
given year to maintain PSGS accreditation.
12. CERES: Comprehensive External Residents' Evaluation System; written a skills
examination given by the Committee of the PSGS that serves as a multifaceted external
evaluation tools for GS-residents

108
13. CONFERENCES: as listed in the guidelines, these activities must be conducted regularly
as prescribed.
14. CONSORTIUM: at least 2 (maximum of 3) hospitals whose individual capabilities cannot
meet the minimum requirements for accreditation of a general surgery residency training
program that group together to form one (1) program - with one (1) chairman, one (1) set
of qualified training staff and one (1) set of residents' staff - as a consortium
15. FULL RESIDENT COMPLEMENT: a complement of at least five residents at a given
time AND distributed with at least 1 Junior level resident, 1 intermediate level resident
and 1 senior level resident. A JUNIOR LEVEL resident is a 1st year resident. An
INTERMEDIATE LEVEL resident is a 2nd and/or a 3rd year resident. A SENIOR
LEVEL resident is a 4th year and/or a 5th year resident.
16. GRAND ROUNDS: a case-presentation teaching- learning activity or conference
prescribed over by a Moderator with Specialist Reactors from the different medical
disciplines in attendance
17. GS (General-Surgery) Rotations: rotations in Trauma. ICU/CCU/SICU, MIS, ER and
OPD are to be considered as GS rotations in the structure and design of the program
18. GS-Residency Training Program Committee: a Training Program Department of
Surgery 'working group'. Headed by the Residency Training Officer, this group implements
the structured GS-residency training program and is composed of Qualified Training Staff.
As head of the committee, the Residency Training Officer may designate members to assist
in the implementation of some of his/her specific tasks.
19. INDEX CASE: listed in bold, italicized, underscored specific procedures, under a Main
Category Operation, that is training program requirement. These identified operations are
specific minimum case requirements that a training program must handle annually to
ensure residents' exposure to these specific cases. Index case requirement of a program is
fixed and independent of the program factor.
20. JOURNAL CLUB: a teaching-learning activity specifically set for discussion and critical
appraisal of scientific journal articles
21. LINKAGE: The bilateral exchange of residents coming from accredited residency training
programs
22. MEDICAL LIBRARY: an organized, systemized collection of medical and medically
oriented books, films, records, slides: their electronic analog or digital equivalents used for
storage and retrieval of knowledge.
23. MEMORANDUM OF AGREEMENT (MOA): a legally -binding, notarized agreement
entered into by two or more consenting parties to implement what is contained therein (i.e.
Affiliation, Linkage, Consortium, etc.) For the purpose of PSGS Accreditation. NO such
agreement may be implemented WITHOUT a written APPROVAL from the PSGS BOD.
24. PROCESSING FEE: The FEE set by the PSGS for the preliminary evaluation and
processing of the submitted required documents in the Application of Accreditation
25. PROGRAM FACTOR: the factor used to compute the CASE LOAD requirements of an
accredited GS Training program at a given year: and is based on the resident complement
of the program during that particular year. If a stand-alone program has 5 residents (for 12
months) in a certain year, the PROGRAM FACTOR for that year is 1. The minimum

109
 Program Factor for any accredited program is 1; any program with less than 5 residents in
a given year will still have a program factor of 1.
26. QUALIFIED TRAINING STAFF: the set of surgical consultant staff of an institution that
is recognized by PSGS as qualified to be involved in the implementation of a GS Residency
Training Program. The minimum requirement is that the must be PSGS FELLOWS IN
GOOD STANDING, and PCS Fellows or Fellows of other specialty societies IN GOOD
STANDING for the other specialty staff.
27. RESIDENTS' CASE: CASE HANDLED whereby the Resident is THE SURGEON of
the procedure
28. RESIDENT-CANDIDATE FOR GRADUATION CASE LOAD REQUIREMENT
29. (for 'ELIGIBILITY): the volume, variety, and index cases required to have been handled
by a resident (performed or 1st assisted) during his/her intermediate and senior years of
residency for eligibility to take the Diplomate Certifying Examinations.
30. RESIDENT EXPOSURE to a case: resident's handling of a case material either as a
'surgeon' or as an assistant to a qualified training staff
31. RESIDENT-SUPERVISION: a committed, appropriate and responsible, followed
through, oversight or guidance of a Resident-in-training specifically in the aspect of patient
evaluation/care, management decisions, and performance of surgical procedures-
preoperative, intra-operative, and post-operative care of the surgical patients.
32. SURGICAL OUTREACH PROGRAM or SURGICAL MISSION: Surgical
program/operations done by the Team (including training staff and resident staff) from the
Accredited Institution, OUTSIDE OF THE ACCREDITED TRAINING HOSPITAL
(as opposed to the In-House or In-Hospital Missions which are performed within the
accredited institution). In order to avoid itinerant surgery, the program must participate in
the preoperative, intra-operative and postoperative management of the patients. There
must be evidence of a teaching-learning process.
33. THE CASE MATERIALS OR CASE HANDLED: comprise all cases managed by the
program's qualified training staff and the resident staff, either operatively (as surgeon or
assistant) or non-operatively. This is a training program Resource of clinical teaching-
learning materials. In reference to Accreditation, there is a minimum yearly case load
requirement specific per training program/institution.
34. THE VISITING TEAM: A Team of at least 3 members of the PSGS Committee on
Accreditation that physically calls-on an institution to do a 'VISIT'.
35. TRAINING MATERIALS: consists of Histopathology reports, patients handled or
managed by residents in training under the supervision of a qualified training staff and any
other resources utilized for training purposes.
36. TUMOR BOARD: A Hospital Board that supervises activities and programs related to
tumors
37. TUMOR CONFERENCE: a specific time set aside by the Department for an activity
where a variety of malignancies, their diagnoses and management are discussed.
38. VISIT: a process wherein a Team, of at least 3 members of the PSGS Committee on
Accreditation, physically call-on a scheduled institution to evaluate if the Structured GS-

110
 Residency Training Program fulfills ALL the requirements for accreditation and properly
implements the current Standardized Surgical Curriculum for General Surgery.

DEFINITION OF GENERAL SURGERY

The Philippine Society of General Surgeons, Inc. defines General Surgery as requiring:

A basic knowledge of surgical anatomy, physiology, pathology, oncology, metabolism, wound

healing, surgical bacteriology and sepsis, shock and resuscitation, immunology and organ
transplantation, fluid and electrolytes, nutrition, burns, critical care and Minimally Invasive
Surgery.

A sound understanding of the principles of radiology, ultrasonography, CT scan, MRI, and

other diagnostic aids including the use of radioactive isotopes and mammography.

An adequate practical experience in proctosigmoidoscopy and indirect laryngoscopy. The

general surgeon must have participated in a variety of endoscopic examinations such as direct
laryngoscopy, bronchoscopy, esophagoscopy, gastroscopy, choledochoscopy, colonoscopy
and laparoscopy.

A comprehensive skill in diagnosis, preoperative, operative and postoperative care of patients

with diseases of the a) alimentary tract, b) abdomen and its contents, c) the head and neck, d)
breast, e) the vascular system, f) the endocrine system and g) skin and soft tissues.

Adequate knowledge and skill in all phases of care of the injured patient, including care
provided in the Emergency Room and Intensive Care Unit. The general surgeon must show
competence in the emergency management of trauma, including trauma to the head and neck,
chest, abdomen and the extremities.

An appropriate clinical experience to include operative and nonoperative care of common

problems in the special disciplines of thoracic and cardiovascular, gynecologic, neurologic,
orthopedic, plastic, pediatric and urologic surgery and anesthesiology, acquired by exposure in
these disciplines.

111
2022-2023 PSGS BOARD OF DIRECTORS

Jaime B. Lagunilla, MD

President

Leonardo O. Ona III, MD

Vice-President

Alfred Q. Lasala II, MD

Treasurer

Jose Macario V. Faylona, MD

Treasurer

Directors:

Robert B. Bandolon, MD

Roberto A. Chacon Jr., MD

Axel L. Elises, MD

Venerio G. Gasataya Jr., MD

Christian Raymond S. Magbojos, MD

Miguel C. Mendoza, MD

Raymund Andrew G. Ong, MD

Andrew Jay G. Pusung, MD

Michelle C. Payagen, MD

Arthur C. Sebastian, MD

Jose U. Tan Jr., MD

112
2023 PSGS COMMITTEE ON ACCREDITATION

Jose A. Solomon, MD
Chairman

Leonardo O. Ona III, MD

Director-In-Charge

Members:
Andrei Cesar S. Abella, MD
Aaron Q. Agdamag, MD
Sir Emannuel S. Astudillo, MD
Dale C. Avellanosa, MD
Allan Troy D. Baquir, MD
Jose Ravelo T. Bartolome, MD
Domingo S. Bongala Jr., MD
Luisito R. Co, MD
Shalimar C. Cortez, MD
Sherry O. Cunanan, MD
Alfred Philip O. De Dios, MD
Dakila P. De los Angeles, MD
Surlito B. Encarnacion, MD
Eduardo S. Eseque, MD
Dennis H. Littaua, MD
Elvis C. Llarena, MD
Sheila Macalindong, MD
Karl T. Morales, MD
Neil C. Mendoza, MD
Alejandro M. Palines Jr., MD
Anthony R. Perez, MD
McArthur Conrado A. Salonga, MD
Andrea Joanne A. Torre, MD
Christopher Q. Victorio, MD

113