During the initial orientation session after joining a multiple-physician group, a new associate will likely receive a policies and procedures manual. This document reflects the group’s views on the expected work habits, demeanor, and productivity of its physicians. These are the policies or “rules” the group has agreed upon. The procedures or “operational guidelines” for completing tasks may include standardized forms or templates for dictation. Together, the policies and procedures should make it easier to navigate the early adjustment period to a new practice environment. Physicians may assume that all new office staff are being trained appropriately. However, as more staff are added and trained by different people, a definite lack of standardization of routine tasks is bound to occur. This is when the implementation of written policies and procedures is critical. It would be wise to obtain and review the current policy and procedure manual for the office staff as well. This is the best way to become familiar with what is expected of the staff and which staff member is the appropriate contact person for specific tasks.

If the policy manual is due for an update, volunteer to assist in that process. If no written policies or procedures exist, the managing physicians may have been too busy to take the time to complete the job. Often the group may have started with one or two physicians in a small office with minimal staff. More often than not, expansion to a multiple-physician or multiple-location practice occurs without prior thought to design the infrastructure to support this change in staffing needs.

Take an interest in the operations of your new practice. If you see an opportunity to improve a process or standardize procedures to improve efficiency, present the idea to the senior partners. Participating in the development of new policies and procedures is the perfect chance to start developing valuable management skills early in your career.

What Is the Purpose of a Policies and Procedures Manual?

The purpose of a written organizational policies and procedures manual is multifaceted. First, the standardization of typical daily tasks promotes increased efficiency. Second, a well-written and concise volume will serve as both a training tool for new employees and an ongoing reference tool. Finally, by defining expectations and duties clearly, the policies and procedures provide guidelines to measure and monitor employee performance.

Standardization of Procedures

The policies are the rules and expectations of the company or organization, and procedures are the step-by-step guidelines used to complete required tasks and expected duties. Procedural guidelines should include definitions, sample forms, and process examples. They should be written with whatever level of detail is necessary for the users to complete the defined tasks properly.

For example, the billing policy and procedure should clearly walk an employee through the standard billing process with examples of completed billing slips, claim forms, and links to appropriate billing guides or coding manuals. Contact information for a billing specialist or additional resources for available assistance should also be listed.

Training Tool and Reference Guide

Well-written policy and procedure manuals should provide all the necessary information for an employee to complete routine tasks and understand how his or her workflow relates to that of other staff members. All new employees should receive a copy of the organization’s policy and procedure manual during training or orientation. A useful manual will serve as the “required text” for any formal training program. After orientation or training is completed and the new employee has been made aware of the contents of the policy and procedure manual, he or she should sign a form acknowledging receipt and understanding, and this form should be filed in the employee’s personnel folder.

Beyond initial training, the manual should be useful as a reference guide. For example, the scheduling policy and procedure should be kept in a folder or ring binder in the reception area. This way, any employee helping to cover the telephones or reception desk could correctly schedule a patient appointment if necessary.

Employee Performance Evaluations

The policy and procedure manual should clearly define duties and expectations for each described position. Once an employee receives their initial training and signs the acknowledgment form contained in the manual, it immediately becomes a valuable employee evaluation tool—and yes, you will in all likelihood be asked to be an evaluator as your role in the practice grows. The procedural guidelines are the benchmarks for performance or productivity. Consistent and efficient completion of assigned tasks should be rewarded on periodic evaluations. Likewise, poor performance and disciplinary employee counseling can be adequately documented by referring to specific duties listed in the policy and procedure manual. Specific examples of failure to perform should be cited, and the section or page number of the listed duty in the manual should be quoted on any written documentation.

In addition to performing outlined tasks and duties, each employee should fully understand how his or her position is related to and dependent upon others. This will promote teamwork and open communication among the staff.

How to Develop Written Policies and Procedures

The first and most critical step in creating or updating any policies or procedures is to analyze the current organizational structure and workflow. You must know what tasks need to be completed and who is responsible for ensuring the work is done properly. The simplest way to do this is to ask employees to write a one-page summary of their typical daily tasks. This also enlists the input of all members of the organization. Policies and procedures are much more likely to be accepted and followed if the employees feel that they have been involved in the process.

Next, construct an organizational chart reflecting all of the current job titles and indicate who functions as a supervisor. Then match the tasks with the appropriate job title. Look for duplication of work or other inefficiencies in the flow of work. Now is the time to seek input from the supervisors. The administrative supervisor, most often the office manager, will know which employee is best suited to which task. Sometimes, the office manager also has nursing experience and will oversee the clinical employees as well.

It is critical to have supervisors not only ensure that tasks are divided appropriately among the staff members but also to act as the physician manager’s spokesperson. A good supervisor, whether clinical or administrative, will allow the physician to focus both on the practice of medicine and the art of management without becoming overwhelmed by either. However, it is also important to establish boundaries for supervisors.

Ultimately, the physician must ensure that all members of his or her office staff project a pleasant and professional demeanor. The patient and referring physician will have to deal with many individuals in your office, so think about how your staff reflects on you. They are often the first impression a new patient or referring physician receives. Whether or not you like it, the first experience with your staff will trigger either positive or negative judgment of you. Make sure the personnel assigned to patient and telephone interactions understand their duties and customer service responsibilities thoroughly.

What Topics Should Be Covered?

A complete policies and procedures manual will cover all possible topics related to company policy and the performance of duties. It will likely be a lengthy document and may be broken down into several different sections. The broadest topic is typically organizational policies. This includes general expectations, such as regular work hours and overtime policies. There is usually an explanation of company benefits, including vacation, sick leave, group insurance plans, and retirement plans. Beyond these topics, the manual should be subdivided into specific areas of importance.

At an organizational level, the manual should detail what is required of all employees. If a group has multiple practice locations, there may be different procedural requirements at each individual clinic. The following summary describes important topics to include.

Organization-Specific Policies and Procedures

These are the general policies governing the entire organization. If you join a group with policies already in place, these topics are most likely included. They typically will not change dramatically over time but should be updated to reflect compliance requirements when any new laws or regulations are passed. If the group is due for a review and update, involvement in the process will be quite a learning experience. Organizational policies are usually only changed after a group consensus.

• HIPPA Compliance. The Health Information Portability and Protection Act requires that all medical office personnel are trained initially and complete annual updated training sessions. The manual should describe what training the organization requires and how the employee is expected to maintain updated certification of training. It should also detail the organization’s procedure for the release of medical records and include a sample of the appropriate forms. Expectations regarding patient privacy should be emphasized.

• Code of Ethics and Business Standards. The organization should state specific principles of practice that all employees are expected to understand and follow. Specifically, issues such as quality of care, compliance with applicable laws, rules and regulations, human resources, and conflicts of interest should be addressed. The policy and procedure should clearly explain expectations for maintaining timely and accurate patient records and ensuring that coding and billing accurately reflect only those services provided and documented.

• Code of Conduct. A code of conduct puts forth the expected level of professionalism required when dealing with coworkers, subordinates, or clients/patients. A harassment policy should also be included. This policy should cover both sexual and nonsexual harassment and include an appropriate procedure for filing and investigating complaints.

• Health and Safety. All employers must provide a safe work environment. The organization’s policy must also describe compliance with the Occupational Safety and Health Act (OSHA). Typically, an annual in-service training program will be provided by the organization, and employees are required to attend and maintain proof of completion.

• Grievance Policy. There should be a clearly defined method for filing and investigating complaints associated with any of the above-listed policies.

Clinic Specific Policies and Procedures

These are the working guidelines for daily tasks performed by personnel in the medical office. They are often specific to one location or to a group of clinics under the same management. If no written policies exist in the practice you have joined, helping to create policies and procedures specific to the office location where you primarily work is an excellent opportunity to become involved in the management process.

• Reception and Telephone Triage. Many physicians have incorrectly assumed that no special training is needed for a receptionist. The all-important initial impression your office makes on a new patient is usually through that patient’s interaction with your receptionist. Whether this occurs in person or over the telephone, it is extremely important that the receptionist speaks and acts in a pleasant and professional manner. Extensive texts and training courses have been created to address this problem. The simplest test of performance is to call your office and pretend to be a patient trying to schedule an appointment. More often than not, you will be surprised at the lack of courtesy and unprofessional behavior displayed by a poorly trained receptionist. If no other policy exists in your office, this is the MOST IMPORTANT one to start with. A well-written script with standard responses to the most common calls is the best initial tool. Beyond that, the receptionist should be trained to appropriately triage calls to the right person and minimize time on hold.

• Scheduling. A clearly defined scheduling procedure should be instituted and maintained near the computer or book used to schedule patients. The goal of this procedure is to keep patients flowing efficiently throughout the day and minimize waiting time both in the waiting room and in the exam room. An extremely long wait for a new patient appointment is often enough to prompt the patient to seek care elsewhere. The physician should define what number of patients can reasonably be seen in one day and when he or she would like to be notified of a potential backlog. For example, if the wait for a new patient appointment is more than one week, but there are multiple follow-up visit appointment openings later this week, the physician should allow the scheduler the flexibility to convert a block of follow-up appointments into a new patient slot. The parameters must be clearly defined to prevent inappropriate scheduling of complex patients in too short a time slot as well. Only by working with the scheduler and clinical staff will the workflow become optimal for physician productivity.

• Medical Records. The patient chart, whether paper or electronic, is the record of all medical decision-making and contains all documentation for appropriate billing. The personnel responsible for constructing and maintaining the medical record should have a clearly defined set of procedures to ensure standardization in the organization of information.

• Test Results. In a busy medical office, there must be a clearly defined procedure for obtaining, triaging, and acting on laboratory, radiology, or other test results. There are both patient care and legal ramifications for failure to follow through with the results of ordered tests. For example, the nurse or medical assistant who receives an abnormal test result on a patient should clearly flag, and the procedure for presenting this test result for action by the physician should be clearly defined. This will prevent unnecessary delays in triaging a patient with an urgent issue. It will also minimize the frustration of frequent interruptions of the physician to review normal test results.

• Charge and Billing Procedure. Although the organizational policies should include an overview of the ethics and integrity expected in the billing process, the clinical policy and procedure manual should contain detailed information on the nuts and bolts of the billing process. This should include references to coding manuals and copies of sample billing and claim form specific to the practice. Whether computerized or manual systems are used, the most important administrative task in a medical office is the submission of the accurate and complete billing information for payment. This is the basis for all income to a medical practice. If poorly managed, even the busiest medical practice can consistently lose money due to denied claims or an unacceptably high level of uncollectible accounts.

• Collections Protocol. Simply completing the billing procedure is not enough to ensure actual inflow of payments. Often, denied claims may only need to be re-submitted with corrected information. Other times, a formal appeal must be filed with an insurance company, which may take three to six months. When dealing with patients who have been directly billed but refuse to pay, a collections procedure should be in place to standardize the approach. For example, a letter is often sent when a bill is more than thirty days overdue, and a second letter may be sent after an appropriate interval if no payment has been received. The second letter should be more forceful and offer either a good faith payment plan or the account will be turned over to a collections agency. Most busy practices will not pursue collections themselves, as this is very time-consuming.

• Purchasing Protocol. Office supplies will need to be replenished regularly. Larger purchases of equipment or office fixtures will occur less frequently. There should be a procedure in place for both types of purchases. Typically, a standing account with an office supplies vendor should be established for routine supplies, and the office manager should have oversight on all requests and maintain an office budget for supplies. Larger purchases may require the approval of the physician managers.

Conclusion

Although it may not be the most glamorous aspect of managing a medical office, the creation of a written document to define policies and procedures is certainly one of the most important. Positions of importance, such as receptionist and billing clerk, are unfortunately also positions with low long-term retention, which means that new employees will frequently be hired to work in these positions. Written policies and procedures are excellent training guides and reference tools when they contain the appropriate level of detail. Also, clearly defined expectations make a valuable measuring tool for performance evaluations.

Whether reviewing and updating existing policies or creating an entirely new written manual, it is vital to follow the steps described. It is important to enlist employee and supervisor input when updating policies. This validates the process and increases compliance with the final product.

Finally, it is imperative to review and update policies and procedures regularly. Technology and personnel requirements change over time, and many manual tasks have become automated. Procedural guidelines need to be updated to reflect changes in workflow when new technology is implemented. The completion of a written policies and procedures manual is not the end product of the process. It is the beginning of an ongoing quality improvement process that can and should change as both the clinical and administrative needs of the medical office evolve.