Often referred to as the ‘practice bible’, the Policies & Procedures Manual should be readily accessible and not a reference document that accumulates dust on a backroom shelf, writes Karen Crouch.
In a three-part series earlier this year (see ‘More Reading’ below), I described the phased approach to starting a practice. With this in mind, it’s an appropriate time to review one of the essential foundation documents that practices depend on for reference, training and more.
A Policy and Procedures (P&P) Manual should ideally be completed as part of the start-up process, preferably prior to opening the practice to the public. A thoroughly documented manual, detailing various policies of the practice and the manner in which they are to be executed procedurally, is not only a vital reference guide but is often viewed as the “practice bible”.
This important manual should also provide protection against litigation claims and complaints from patients, staff or external parties as they are a reflection of the practice’s normal operating processes and procedures which should be favourably viewed by a court, insurer, or workers’ compensation authority.
It is also important to ensure operating success by regulating personnel performance so that procedures are carried out accurately, consistently and efficiently, in accordance with the P&P Manual.
Apart from its usefulness as a training tool for new staff, it also serves as an authoritative point of arbitration in situations where staff have differing opinions on operational matters. Such situations should also highlight any unclear directions which deserve attention to ensure clarity.
In summary, a comprehensively documented and regularly updated P&P Manual will serve the following purposes:
• Reference point: new or existing staff may verify or clarify correct procedures from time to time;
• Risk management: provides evidence of documented instructions and training that staff are given, a defence against claims that the employer may be liable for acts and/or omissions by administrative and/or clinical employees;
• Induction: a training tool for new staff to absorb the policies and procedures of the practice and also understand the owner’s principles and preferred culture;
• Practice performance: to determine whether the most efficient systems are employed and whether periodical amendments – such as alignment with recent regulations – are deserving;
• Staff appraisals: provides benchmarks and service standards by which staff performance may be measured when conducting appraisals and/or salary reviews;
• Professional standards: regular reviews and updates will ensure the highest standards within the practice and compliance with any recent regulatory requirements.
In compiling a P&P Manual, it is comprised of two parts:
• Policies which dictate the manner in which practice operations and business administration should be framed to meet the owner’s aspirations to develop a particular culture and reputation; and
• Procedures by which various policies and healthcare practices will be executed.
While the procedural aspects are adequately covered above, it is appropriate to focus on the base aspect of how and who should develop policies – a sort of “policy on policies”. In this standalone section of the P&P Manual, the following matters deserve inclusion:
• Employees, administrative or clinical, who are authorised to dictate ‘policy’ as distinct from administrative procedures. This section will logically include a Delegation Schedule listing relevant staff by name or title (including ‘standby’ delegations to cover possible staff absences or vacancies);
• The nature and extent of areas in which a delegated employee may frame a particular policy and whether it requires confirmation by a senior employee. Suggested actions to execute the newly dictated policy, including carefully project managed implementation, may be entrusted to a different individual/team for actual execution and ultimate confirmation that the overall process represents a practical action.
Responsibility for compiling the P&P Manual and regularly updating it usually rests with the practice manager (and a clinician for clinical matters) who should be familiar with the overall process and capable of documenting one as a critical ‘practice start up’ action. Additionally, other clinical staff will need to be involved in preparation of policies and procedures such as ophthalmologists, orthoptists and nurses laying the ground for development of a meaningful clinical governance structure.
Finally, the P&P Manual should be readily accessible to all staff and not one of those reference folders that accumulate dust on a backroom shelf. Periodical reviews, typically organised by a practice manager, will ensure the contents are current and in accordance with latest regulations and best practice management and healthcare aspirations of the owner.
About the author
Karen Crouch is the Managing Director of Health Practice Creations Group, a company that assists with practice set ups and the administrative, legal and financial management of a practice. Email email@example.com or visit www.hpcgroup.com.au.