Practice Tips

The Importance of Having a Policy and Procedure Manual

A well-developed policy and procedure manual is essential for any physician practice. It serves as a comprehensive guide for staff, ensuring consistency, compliance, and efficiency in daily operations. Here are some key reasons why having a policy and procedure manual is important:

1. Consistency: A manual ensures that all staff members follow the same procedures, leading to consistent patient care and office operations.
2. Compliance: It helps the practice stay compliant with legal and regulatory requirements, reducing the risk of violations and penalties.
3. Training: New staff members can quickly get up to speed by referring to the manual, making the onboarding process smoother and more efficient.
4. Risk Management: Clear policies and procedures help mitigate risks by providing guidelines on how to handle various situations, from medical emergencies to patient complaints.
5. Quality Improvement: Regularly updating the manual allows the practice to continuously improve its processes and adapt to changes in the healthcare environment.

For practices that are either hospital-owned or hospital-based, policies and procedures within the practice may need to be revised to reflect an integrated health system. Hospital risk managers, practice managers, and administrators must work together to identify areas where policy revision or implementation and subsequent education and training must occur.

Creating an Office Policy and Procedure Manual:

• Begin with an introduction that describes the purpose of the manual.
• State the office philosophy and the expectation that employees will adhere to the policies set forth.
• Include an organizational chart with lines of authority by position.
• Ensure policies and procedures are realistic and do not detail matters related to the standard of care. Do not be restrictive by being too specific yet avoid ambiguity and vagueness. A policy should be practical in carrying out the practice's day-to-day operations.
• Use straightforward language and avoid terms such as “shall,” “will,” or “must” in the policy or procedure, and do not use superlative words such as "highest quality" or "perfect."
• Use a bullet point or numbered step format for ease in reading. A staff member should be able to navigate the policy quickly.
• State the procedure step-by-step, following a logical sequence. Briefly outline who, what, when, where, and how of procedures.
• Address patient/staff safety and health needs as priorities.
• Ensure that the policy/procedure applies to all locations of a practice when appropriate.

Maintenance of the Office Policy and Procedure Manual:

• Record the date when each policy or procedure is adopted.
• Keep an up-to-date index or table of contents.
• Perform reviews every three years for relevancy and compliance with current state and federal laws, or more frequently as new rules or laws become known or changed. If revisions are necessary, place revision dates on the new policy.
• Retain a copy of each revised policy for the time period that is commensurate with your state's statute of limitations for filing a medical malpractice claim. See our practice tip The Life of a Malpractice Claim.
• Practices with electronic policy platforms should discourage staff from printing and saving policies. If printing is allowed, add to the policy header a statement, “This policy is only current on the day it was printed. Current policies are located at ___________.”
• Obtain signatures for policy approval from responsible parties.
• Obtain input from an attorney or general counsel of the organization if there is a concern around a policy to make sure they are reasonable and achievable.

Staff Education Regarding Office Policies and Procedures:

• Provide training to explain pertinent policies. Utilize policies and procedures as part of competency for staff as applicable. Consider an ongoing review of practice policies at staff meetings.
• Obtain employees' signatures on a form indicating their review of the manual.
• Enforce established policies. Monitor compliance with policies as part of quality improvement efforts.
• Remind employees of their obligation to know practice policies and procedures and to follow them.

Policy Format

It is important to use consistent formatting. Keep in mind that if you are part of a health system or are hospital-owned, you may have a set format that should be used.

• Standard sections (as they apply)
• Policy title
• Policy purpose
• Policy statement
• Additional authority/reference
• Scope
• Definitions
• Procedure
• Equipment
• References
• Forms and attachments
• Dates of origination of policy, the reviews, and revisions
• Designated policy experts/contacts

References:

American Medical Association. (2014, August 26). Improved policies and procedures help your practice thrive. The article discusses the benefits of having a well-developed policy and procedure manual, including improved workflow, compliance with privacy measures, and consistency in operating procedures.

Zanda Health. (n.d.). Why you need a practice operations manual in healthcare. This article outlines the necessity of having a practice operations manual, highlighting the benefits of standardized policies and procedures for practitioners and staff.

UNF Pressbooks. (n.d.). Policies and procedures – practice management in healthcare. This resource provides an overview of the importance of policies and procedures in healthcare practice management, including expected work habits, demeanor, and productivity of physicians.

American Society for Health Care Risk Management. (2016). Physician Office Risk Management Playbook. American Hospital Association.