Set and Review Policies and Procedures


A policy and procedure manual is an important tool for defining practice operations. In well-run practices, there is one set of rules every staff member understands and follows. The alternative is risky—procedures that vary from physician to physician or between staff members make it easy for errors or omissions to occur.

Develop a comprehensive manual of specific policies and procedures that explains how tasks are performed in your office, and make it readily available to all staff. It’s important for staff to review and initial that they have read and are aware of these policies and procedures.

The following is a list of suggested topics to address in your policies and procedures manual:

1.     Clinical Protocols/Patient Care

2.     Patient Relations and Confidentiality

3.     Health Information Management (Medical Records)

4.     Laboratory (Test Tracking and Follow-up)

5.     Radiology

6.     Appointment Scheduling

7.     Patient Tracking and Follow-up

8.     Infection Control

9.     Human Resources

10.     Practice Operations

11.     Special Procedures

12.     Safety

You may need to add or subtract certain topics to best address the specific areas of your practice. It also is prudent for the physician (or a committee of physicians and staff members) to annually review policies and procedures—and perform an audit to ensure staff is performing the procedures as outlined in the manual. Periodic adjustments to your policy and procedure manual may be necessary as your practice and the healthcare industry grow and change.

-Jeremy Wale is a licensed attorney in Michigan where he works as a Risk Resource Advisor for ProAssurance.