Policies and Procedures (P & P) are practices that are set up to instruct personnel on how to perform operational tasks. P & Ps should answer why a task is being performed and how the task is expected to be completed. They are generally written for the purposes of operational management, regulatory compliance, accreditation standards and legal mandates.
Writing a Policy & Procedure
For diagnostic and treatment centers, a P & P should be written for every procedure including patient testing, medication dispensing, admission/discharge, emergency management, billing, equipment cleaning/storage, pain management, chain of command, patient and employee grievance/incident reporting process, scheduling and quality assurance. It is usually a work-in-progress that should be updated whenever new issues arise or old practices become outdated. The Policy & Procedure manual should be a living guidebook that employees reference often. Therefore, the manual should be located in a central location that can be reviewed at any time by any employee to answer any questions at hand.
Keep the format simple and direct, yet include all the steps required in order to be concise and comprehensive. Remember that anytime an incident arises which leads to legal action, your company’s Policy & Procedure will likely be called into court to determine if the employee followed the P & P guidelines.
Each P & P should include the following: subject (i.e. the title of the P&P such as “Patient Scheduling”), department (if more than one department works under a single entity), an approved-by line (the name of the contact person), reference No. (a numerical number assigned to that P&P), pagination (to ensure that all pages are accounted for in each P&P), effective date (the date that the policy goes into effect. Usually this is the date that it’s written), revised date (the date at which the policy is altered or changed in any way), policy (a simple and direct statement as to the purpose of each P&P, such as “To ensure that every patient is scheduled for testing within 4 days”), and procedure (the details as to how the policy is to be carried out, which can be quite lengthy or very short depending on how complicated the process or how many steps are involved for completion).
This list is considered the minimal amount of data that you should include in each policy and procedure. You can include more information if needed.
Align with National Guidelines
When writing P & Ps, it is important to align your practices with national guidelines. Refer to your national organization to ensure that your practices meet the benchmarks set forth by industry leaders. In addition, your national organization may also be responsible for accreditation standards that you may need. Some national organizations may include JCAHO, AAAHC and AAAASF. There is a national organization for nearly every scope of practice.
Finalizing the Manual
Once all of the Policies & Procedures have been written, include a Table of Contents and organize them into an easy to access manual (a binder or an electronic copy will do fine). Administrative personnel and the Medical Director will need to approve the manual by signing off. This document needs to be placed as page 1 of the manual and will need to be signed initially and every year thereafter.
The signature page should include one line for each person responsible for authorizing the manual. The following information should be included on each line.
Printed Name, Signature, Title and Date