Hospital Medical Directorate

The Hospital Medical Directorate plays a central role within the hospital organization. The Medical Director manages the assigned facility with a focus on hygiene, public health, and medico-legal aspects, actively contributing to the achievement of institutional goals as defined by the Strategic Directorate. The scope of responsibility includes key areas of clinical and operational governance. 

Primary responsibilities include ensuring the quality and safety of healthcare services, both inpatient and outpatient. The Directorate coordinates and promotes multidisciplinary diagnostic-therapeutic pathways, aligning care delivery with patients’ clinical and healthcare needs. It chairs critical committees such as the Transfusion Committee and the Therapeutic Commission, and manages clinical space allocation within the facility. 

The Directorate is also instrumental in preventive medicine, health education, and workplace health protection. It oversees environmental hygiene, hospital waste management, and the effectiveness of cleaning, disinfection, pest control, and sterilization services. It also supervises catering and hotel services, ensuring compliance with hygiene and nutritional standards. It handles mortuary police procedures and the prompt reporting of notifiable infectious diseases and other mandatory events. 

The Hospital Hygiene Service, comprising specially trained nursing staff, reports to the Medical Directorate. This service is responsible for infection prevention and control, hand hygiene surveillance, outbreak contact tracing, Legionella control, and site hygiene suitability. It also contributes to protocol and technical specification drafting and staff training in hygiene best practices, in line with regional and national regulations. 

The Employee Health Protection Office, operating under the General Director, coordinates the Occupational Health Physician. It ensures workers’ health surveillance, radiation protection, accident monitoring, and proper archiving of employees’ health records. It also supports the technical offices in environmental upgrades and technical document drafting. 

The organizational and management area includes waiting time governance, oversight of patient admission and discharge procedures, and clinical documentation review. It supports decisions on procurement of medical equipment and furniture, and staffing, maintaining close collaboration with the hospital’s Social Services and Religious Services. 

Regarding performance and resource management, the Directorate monitors healthcare service delivery, assesses appropriateness, and ensures clinical documentation completeness according to regional standards. It organizes continuity of care during emergencies, oversees medical shift coverage, and contributes to budget planning and monitoring. It also collaborates with marketing on evaluating agreements with other healthcare facilities and oversees epidemiological data collection and reporting to regional and national health authorities. 

From a medico-legal standpoint, it ensures proper execution of mortuary procedures and the issuance of medical certifications. In collaboration with the Risk Manager, it develops and implements clinical risk management tools and policies, working closely with the Legal Office on complaints and litigation. 

Strategically, the Directorate manages the verification processes for institutional accreditation and contributes to drafting implementation documents based on regional directives. The Medical Director is part of the negotiation team in discussions with trade unions, influencing future organizational structures.