Policies and
Procedures
The Joint Commission on Accreditation of Healthcare Organizations defines Policies and Procedures as the "formal, approved description of how a governance, management, or clinical care process is defined, organized, and carried out."
A Policies and Procedures (P&P) manual is, therefore, a series of documents that describe how the dental clinic functions. The manual provides instructions for all of the program's functions, including procurement, health records, recruitment and retention of staff, position descriptions, hours of operation, scope of services, evaluation, etc.
Staff members of any healthcare organization come from diverse educational backgrounds and points of view. Without guidance from an established set of P&Ps, each person would develop individual strategies to accomplish job responsibilities, which may be disjointed and lead to inefficient and possibly ineffective clinic operations. The P&P manual ties all functions together; it is the instruction manual that helps to ensure smooth and efficient operations. It should be used to help orient new staff to their jobs and to update current staff whenever policies or procedures are changed. Summaries of various P&Ps can be made available to the clinic's user population to explain why the clinic provides services the way it does.
Establish a uniform or standard format for all Policies and
Procedures (P&Ps) used throughout the facility. A common format includes:
·
purpose of the policy
·
policy statement
· a step-by-step description of the procedures required to implement the policy.
Most IHS facilities will already have an approved format for
P&Ps that the dental program should follow in developing its manual.
All P&Ps should be marked as either "new" or "revised", and should be signed and dated by the person having authority to approve and implement them. Policies should be reviewed at least annually and revised as necessary.
Sample Table of Contents
The following section provides a sample table of contents for a dental program P&P manual. The topics are only suggestions, as local service unit policies may stipulate other topics that should or should not be included in the manual. Many of the policies suggested in the Table of Contents can be service unit policies and may not need to be developed specifically for the dental program
SAMPLE POLICY AND PROCEDURE MANUAL
TABLE OF CONTENTS
Introduction
Facility
or Service Unit Goals and Objectives
Facility
or Service Unit Organizational Chart and Lines of Authority
Dental Program
Goals and Objectives
I.
Facility Dental
Program
·
Facility Dental
Program Description
o
Policy
o
Purpose
o
Dental Scope of
Services/Functional Statement
o
Description of
Dental Facility
·
Organization
o
Organization
Chart
o
Qualifications of
Staff
·
Daily Program
Operations and Priorities of Care
o
Clinic Hours
o
After Hours
Procedures
II. Patients'
Rights and Responsibilities
·
Bill of Rights
and Responsibilities
·
Confidentiality/HIPAA
·
Grievance
Procedures
·
Release of
Information
·
Informed Consent
·
Patient Education
·
Language
Interpretation
·
Handling of
alleged or suspected child abuse cases
III. Referrals
·
Emergency Patient
(DDS unavailable)
·
Medical
Consultation and Follow-up
·
Dental Specialist
Consultation
IV. Emergency
procedures
·
Medical Emergency
(Code Blue)
·
Fire Evacuation
Plan
·
Disaster Plan
V. Dental Program
·
Continuous
Quality Improvement/Performance Improvement Plan
·
Technical Quality
of Care Evaluations
·
Program Reviews
·
Prevention
Programs
·
Levels of Care
·
Patient
Management
o
Eligibility
o
Fee
Schedule/Sliding Fee Schedule (if appropriate)
o
Outpatients
§
Emergency Patient
§
New Patient
§
Recall Patient
§
Checking Blood
Pressures, Blood sugars, etc.
§
After-hours
Emergency Coverage
§
Prescriptions
§
Narcotic
Prescriptions
o
Inpatients
§
Admissions
(Hospital and Emergency Room)
§
Consults
§
Inpatient seen in
dental clinic
§
Inpatient seen in
a hospital room
§
Inpatient
prescriptions
§
Property of
patient
o
Clinical Charts
§
Charting Symbols
and Procedures
§
Approved
Abbreviations
§
Retention of
medical records
§
Retirement of
inactive records
o
Appointments /
How to access the appointment system
o
Broken and
Cancelled Appointment Policy
o
Recall Policy
o
Deferred Services
o
Referral Policy
o
Use of Standing
Orders
o
Policy for
Utilization of Dental Laboratories
o
Adverse Drug
Reaction Policy
o
Drug Sample
Policy
o
Storage of Medications
in the Dental Clinic
o
Antibiotic
Prophylaxis Policies
·
Operational
Procedures
o
Environmental
Concerns
o
Safety Policies
o
Security Plan
o
Equipment
Maintenance Schedules and Repair Policies
o
Inventory/Procurement
Procedures
o
Infection Control
Protocols
§
Needle Recapping
§
Autoclave use and
Monitoring
§
Handwashing
§
Surface
Disinfection
§
Exposure Control
Plan and Bloodborne Pathogens
o
Mercury Safety
o
Biopsy Monitoring
o
Response to
medical device recalls and hazard notices
o
Hazard
Communications
VI. Human Resources
·
Billets/Job
Descriptions
·
Standards of
Performance
·
Career Plans with
Educational Requirements
·
Knowledge,
Skills, and Abilities per Position
·
Staff Training
·
Volunteer Process
·
Student
Requirements
·
Volunteer Process
·
Temporary/Intermittent
Employees
·
Credentialing Process
·
Privileging
·
Orientation
·
Provision for
Employee Health Services and Screening
·
Continuing
Education Policy
·
Staff Grievance
Procedures
·
Peer Review
VII. Short
and Long-Term Plans
VIII. Listing of Standard Forms
IX. Dental
Reference Documents
Additional Resources
Appendix I of this chapter contains samples of Policies and Procedures that have been used in IHS dental programs in the past. These samples do not represent IHS policies or guidelines. Rather, they are examples that should be used as templates to help dental clinics develop policies and procedures for local circumstances.
The following links provide examples of Policies and
Procedures manuals and other clinic protocols currently in use by community
dental clinics around the country:
Tennessee Department of Health
Plan de Salud del Valle (Salud Family Health Centers, Fort
Lupton, CO