Put Policies in Writing

July 1, 2003

How to create and use a complete and well-thumbed policies and procedures manual

These days, practices have to focus on physician productivity, not managing staff crises or worrying about violating some regulation. Having a complete, written, and well-thumbed policies and procedures manual can help. Word-of-mouth policymaking or holding onto an outdated manual that no one reads only hampers smooth operations. The new trend is to use written protocols as a tool for efficient practice management.

"When policies and procedures are 'living and breathing' documents for employees, there is a reduction in variation in work processes, which leads to increased efficiency and a way to measure and monitor performance," explains Deborah Walker, a principal with Boehm/Walker Associates, a medical group management consulting firm in Surfside, Calif. 

"Many practices lack an infrastructure for achieving efficiency," says Bette Warn, practice administrator for Woodridge Orthopaedic and Spine Center, a nine-physician practice based in Denver. "But by putting policies and procedures in writing, you avoid saying things in multiple ways."

Warn ought to know. She is co-author, with Elizabeth Woodcock, of Operating Policies and Procedures Manual for Medical Practices, a 443-page "bible" on developing and updating operating procedures, complete with a CD containing content boilerplate practices can customize (visit www.mgma.com, the Web site for the Medical Group Management Association, to buy a copy).

Decide what to include

Warn and Woodcock's book has 17 sections encompassing everything from sexual harassment to storing and retrieving medical records, greeting patients on the telephone, authorizing referrals, and coding. Such a broad reach may be too burdensome for some practices, but others flourish by having everything covered.

Jo Anne Kroener, office manager for Dallas Asthma and Allergy Center, a three-physician practice, doesn't waste time reinventing the wheel. She relies on the book to provide basic policies and procedures and then adds others that reflect the practice's operations and philosophy. The practice's manual received an overhaul last September, when a new computer system was introduced. Many tasks once accomplished manually are now handled electronically, such as scanning insurance cards into the computer instead of using a copy machine.

Kroener warns against getting too detailed, though. Some older policies and procedures in her office had gotten so outdated or exhaustive that "if we had to tell you that, you shouldn't be working here," she says. One even told employees to keep pencils in pencil holders.

What could develop into a monster -- hundreds of pages of detailed policies and procedures dictating every process in a medical practice -- can be designed to be much more user-friendly. "You have to look at what's significant or employees will get bogged down and not read any of the policies and procedures," Warn says.

Kroener's manual gives standardized directions for making patient appointments so any staff person can handle the task. The manual also provides a quick ruling on whether an employee on unpaid sick leave can receive her salary for the holidays that coincided with her absence. (She cannot.)

Use common sense when deciding what to include in a manual, warns Alex Fernandez, executive administrator for Gastroenterology Care Center, an 11-physician practice in Miami. His practice uses a series of manuals addressing corporate compliance, employee issues, medical records, and HIPAA. He likes how the manuals train employees to do things "our way" and add a touch of professionalism to the group.

Jayne Oliva with Croes/Oliva Group, a medical group management consulting firm in Burlington, Mass., further suggests separating administrative and clinical protocols when deciding what to include in a manual. That makes for easier reading and helps physicians stay clinically focused instead of worrying about answering phones. But when it comes to issues that directly affect them -- such as triage, traffic flow, and patient preparation -- physicians should jump right in.

Pinehurst Surgical Center in Pinehurst, N.C., maintains a separate Physician Owners' Manual which fleshes out 140 different clinic policies and procedures, including income distribution, physician recruitment, use of physician assistants, expenses, contributions to charitable organizations, malpractice insurance coverage, and dispensing controlled substances. When a physician comes on board, he or she receives a copy so there are no gray areas, says William M. Edsel, CEO.

Right process helps

It's one thing to decide you need a manual, another thing to actually get it written.


For best results, Oliva suggests that an office administrator take the first crack at drafting administrative policies and procedures, supported by input from employees, while a medical director tackles the clinical side. Ultimately, though, the two sides need to work cooperatively. It does no good, for example, for physicians to create such complex scheduling protocols that schedulers can't possibly follow them.

No matter who crafts the rules, it's important that physician leaders approve them. That boosts physician and employee compliance and eliminates bickering later on about a policy's validity.

Pinehurst Surgical Center has more than 100 policies and procedures affecting employees, issues that have bubbled up from the organization. The rules face a rigorous review process by a committee of physician owners and the human resources manager, who make recommendations to an executive committee comprised of clinic officers and committee chairs. If the vote is unanimous, the motion passes; however, even one dissenting vote kicks the idea up to the board of directors for final approval.

Keep it up to date

Once approved, no policy should stagnate. Industry regulations and even physician preferences change over time and so should the manual. Pinehurst Surgical Center reviews its manual every two years.

New policies, such as HIPAA, may make faster review necessary. Although Operating Policies and Procedures Manual for Medical Practices does not contain much information on HIPAA, Warn says it is necessary to cross-reference patient information protection rules with personnel and medical records policies to ensure privacy and confidentiality.

Pinehurst has been readying itself for HIPAA over the last year and a half. Confidentiality and security policies are incorporated into the employee handbook and intranet and describe how to appropriately safeguard patient  information.

Similarly, the manual for Medical Consultants in Muncie, Ind., is a work in progress, especially those aspects related to security and privacy, says Wayne Winney, CEO of the 40-physician multispecialty practice. The practice includes HIPAA requirements in its policies and procedures manual, but Winney's primary objective is to find efficient ways to comply. For example, HIPAA requires patients to sign a variety of different forms. Medical Consultants developed a policy to consolidate the forms so patients could deal with them all at one time.

Taking it off the shelf

Developing a policies and procedures manual is only half the battle; getting staff and physicians to use it is like winning the war. Joseph Zumpano, managing partner of Ferrell, Schultz, Carter, Zumpano and Fertel, a law firm in Miami, has a few ideas for ensuring compliance:

  • acknowledgement by staff and physicians that they have read and understand policies and procedures;
  • appointment of a compliance officer to monitor and audit compliance;
  • objective and specific methodology for enforcing penalties for non-compliance; and
  • educating staff and physicians to avoid potential violations.

"Senior physicians must set the tone by establishing a code of conduct which everyone is expected to follow," says William Spratt, Jr., a partner with Kirkpatrick & Lockhart, a law firm based in Miami. "There must be orientation for new employees and training at all levels as to those expectations. And the practice must commit to addressing each issue in a fair and objective way consistent with its code of conduct."

It can also help to make sure the manual is very clear and well-suited to the real world. Arcane, misunderstood rules are the most likely to be broken. Here are some ways to stay relevant:

  • Make sure the policy or procedure can be supported by the facility, reflects what the practice is doing, and how that relates to what is expected of employees. Back up each policy with a rationale.
  • Use a team approach so no one person is responsible for developing policies and procedures; checks and balances are key.
  • Ensure everyone is interpreting a policy in the same way to avoid potential business risk.
  • Incorporate policies and procedures into everyday activities.
  • Keep the format easy-to-read and brief; no one will use the manual if they can't locate what they need. If the information is in a binder, use tabs with section names, or icons for online versions.
  • Include flowcharts in policies and procedures manuals outlining steps for a particular work process, Walker recommends.
  • Review one policy at each staff meeting to ensure its currency, relevance, and understanding. 
  • Get physician and employee buy-in. Most people are reasonable and will accept policies if they understand them; if policies are imposed by edict, buy-in is unlikely, Edsel says.

A policy that gets off the shelf and into the heads of staff and physicians can help eliminate redundancies and distracting bickering.

Mari Edlin can be reached via editor@physicianspractice.com.

This article originally appeared in the July 2003 issue of Physicians Practice.