MSP Advisor: Creating a process and procedure manual
Dear Colleague,
Last month, I discussed how the right medical staff software program is essential for the daily management of the medical staff office. This month, I’d like to address another medical staff office essential: a policy and procedure (P&P) manual. Too frequently, when I conduct medical staff office (MSO) and credentialing verification office assessments, I find that this best practice tool is no where in sight or so outdated that I have to clear off the cobwebs before I can take a peek inside.
Whether you are the sole person in the MSO or a leader for one or more medical staff services professionals (MSPs), having a P&P manual will give your team a clear description of office protocol and performance expectations. This is particularly useful when team members must cover for one another during periods of illness or absence. It can be used as a handbook to help employees understand the guiding principals that affect their employment and responsibilities, as well as to promote a broad and uniform approach for individual members of the department to operate as a team.
You have the great benefit of designing a P&P manual that best meets the needs and culture of your organization. Keep the contents of your manual simple. Follow a template borrowed from another department within your organization, check with your local and state organization for samples, or ask a fellow MSP to share a copy of his or her manual or table of contents. When building your P&P manual, it should include at least 10 elements:
- Organization and department name
- Table of contents
- Department mission, objectives, and goals
- Policy name
- Policy number
- Date of origin, review, and revision
- Purpose
- Procedure
- Definitions (as needed)
- Approval body
Some examples of the most popular P&Ps that I see during my consulting visits include the following information:
- Personnel (job titles, contact info)
- Job descriptions
- Hours of operation
- Keys, ID badge, access to secure areas
- Orientation (includes facility map, tour)
- Recruitment, hiring, recognition, retention
- Performance review, salary merit increases
- Data base entry and maintenance
- Committee appointment process
- ER call schedules
- Meeting management
- Peer review
- Performance improvement initiatives
- Budget (monthly financials)
- Social events
- Annual report
- Conversion to paperless
- Medical staff leadership support
- Roster distribution
- Bylaws distribution
- Credentialing and privileging (see associated medical staff manual)
- Archives (record retention)
- Overtime
- Coverage (vacation, illness)
- Mail processing
- Phone and communication protocol and etiquette (i.e. office, cell phone, e-mail, instant messaging)
- Cyber security
- Continuing education
- Memberships
- Appearance and courtesy
Identify your core systems, then record the process to get the job done, including a time line when appropriate. Require new employees to review and sign a form to acknowledge that they have received the manual.
This tool can become a performance improvement project for your department, and each member can be assigned various chapters. You will be amazed at how empowering this exercise will be for those involved!
If you don’t have a department P&P manual yet, consider the guide above to get you started. If it’s a matter of updating what you currently have, follow the suggestions and you will see that you are well on your way to ensuring a strong foundation to support your department’s varied activities.
Until next we speak…SMILE!
Donna K. Goestenkors, CPMSM
Consultant—Credentialing & privileging practice
The Greeley Company