Modules
Module 1: Policies and Procedures
1.1 Policies and Procedures Manual

Overview

The foundation of clinic P&Ps is the P&Ps manual—a series of documents that describes the clinic’s day-to-day functioning and outlines its P&Ps. The manual serves as a framework for organizing clinic operations such as staffing, risk management, health records and information management, purchasing and inventory management, patient scheduling and consent, billing and collections, infection control, staff recruitment, hours of operation, scope of services, and evaluation.

The P&Ps manual helps ensure that the clinic operates smoothly and efficiently. The manual is used to help orient new staff and to update current staff whenever policies or procedures are changed. Clinic staff can use various P&Ps to explain why the clinic operates as it does.

Definition

The Joint Commission defines P&Ps as the “formal, approved description of how a governance, management, or clinical care process is defined, organized, and carried out.”

Topics

A sample table of contents for a P&Ps manual and a list of other topics that could be considered for P&Ps development appear below. These examples can serve as a guide for developing a manual or revising an existing manual. Click on the contents and topics links to see more detail or download the sample P&P.

Sample P&Ps Manual Table of Contents

Introduction
Goals and Objectives
1. Facility Dental Program
  • Facility Dental Program Description
    • Dental Scope of Work/Functional Statement
    • Dental Facility Description
  • Organization
    • Organizational Chart
    • Staff Qualifications
  • Daily Program Operations and Priorities of Care
2. Patients’ Rights
  • Bill of Rights
  • Confidentiality
  • Grievance Procedures
  • Release of Information
  • Informed Consent
3. Referrals
  • Emergency Patient (when a dentist is unavailable)
  • Medical Consultation and Follow-Up
  • Dental Specialist Consultation
4. Emergency Procedures
  • Medical Emergency (code blue)
  • Fire-Evacuation Plan
  • Disaster Plan
5. Dental Program
  • Continuous-Quality-Improvement Plan
  • Technical Quality-of-Care Evaluations
  • Program Reviews
  • Safety Policies
  • Prevention Programs
  • Level of Care
  • Patient Management
    • Eligibility
    • Outpatients
      • Emergency Patient
      • New Patient
      • Recall Patient
      • After-Hours Emergency Coverage
      • Prescriptions
      • Narcotic Prescriptions
    • Inpatients (applies to hospitals)
      • Admissions (Hospital and Emergency Room)
      • Consults
      • Inpatient Seen in Clinic
      • Inpatient Seen in a Hospital Room
      • Inpatient Prescriptions
      • Patient Property
    • Clinical Charts
      • Retention of Medical Records
      • Retirement of Inactive Records
    • Appointments
    • Broken and Cancelled Appointment Policy
    • Recall Policy
    • Deferred Services
    • Referral Policy
    • Use of Standing Orders
    • Adverse-Drug-Reaction Policy
    • Drug-Sample Policy
    • Handling of Alleged or Suspected Child Abuse Cases
    • Operational Procedures
      • Environmental Concerns
      • Equipment Maintenance Schedules
      • Inventory/Procurement Procedures
      • Infection Control
      • Biopsy Monitoring
      • Response to Medical Device Recalls and Hazard Notices
6. Personnel Matters
  • Job Descriptions
  • Standards of Performance
  • Career Plans with Educational Requirements
  • Knowledge, Skills, and Abilities per Position
  • Staff Training
  • Volunteer Process
  • Student Requirements
  • Temporary and Intermittent Employees
  • Credentialing Process
  • Staff Privileges
  • Orientation
  • Provision for Employee Health Services and Screening
  • Continuing-Education Policy
7. Standard Forms
8. Dental Reference Documents

Other Topics to Be Considered for P&Ps Development

Clinical P&Ps
  • Prescription policy
  • Storing of medications
  • Security Maintenance and repair
  • Prophylaxis against infective endocarditis
  • Checking blood pressure and blood sugar
General Program P&Ps
  • Organizational chart and lines of authority
  • Scope of services available
  • Eligibility Fee schedule and sliding scale
  • Clinic hours After-hours procedures
  • Charting symbols and procedures
  • Approved abbreviations
  • Policy for use of dental laboratories
  • Quality-improvement plan Prevention program
Appointment System
  • How patients access the appointment system
  • Required procedures during first appointment
  • Recall visits
  • Referrals for specialty care
Infection Control
  • Plan for control of blood borne-pathogens exposure
  • Infection-control protocols
    • Needle recapping
    • Autoclave monitoring
    • Handwashing
    • Surface Disinfection
Patient Rights and Responsibilities
  • Patient education
  • Language interpretation
  • Confidentiality
  • Patient grievances
  • Release of information
Management
  • Procurement of supplies
  • Inventory system
Safety
  • Mercury safety
  • Emergency preparedness
  • Fires and fire drills
Human Resources
  • Position descriptions
  • Credentialing and privileging
  • Staff grievance procedures
  • Peer-review procedures
  • Competency evaluation and standards of performance
  • Training
  • Volunteer processes
  • Student processes
  • Orientation

The following links provide examples of P&Ps manuals and other clinic protocols currently in use by clinics around the country:

•      Plan de Salud del Valle
•      Dental Program Procedures