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5 Critical Things to Keep in Mind When Putting Together an ASC Policy & Procedure Manual

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Sarah GammermanPolicy and procedure manuals serve multiple purposes in an ASC, from dictating the rules and guidelines staff will follow when performing and completing tasks to meeting regulatory and accreditation requirements.

The importance of an up-to-date policy and procedure manuals should never be overlooked. They are critical to the success of an ASC, and help ensure the facility delivers consistent, high-quality care that supports efforts to achieve short- and long-term goals.

Here are five critical things to keep in mind when putting together an ASC policy and procedure manual or revising an existing manual.

1. Reflect changes in regulations and accreditation standards. Regulations and accreditation standards undergo revisions and additions regularly. The reasons for such changes vary, and can include adverse events, increased knowledge, outcomes studies, outdated information, regional differences and emerging consumerism.

As information becomes available and rules change, ASCs need to keep up-to-date with these developments and adjust their policies accordingly for legal, ethical and moral reasons. The policies and procedures you follow as the basis for providing care to patients needs to be current, not behind the times, and staff need to know to follow the most current edition of your manual.

Your manual and the manner in which you accomplish tasks need to be in sync; what you say you do you have to do. In the event of a lawsuit, if the policy says you do something and it was not done, you can be found liable.

2. Maintain consistency with board-approved governance documents. Maintaining consistency between your manual and board-approved governance documents is important for a few reasons. ASCs should always strive to "do right" by their patients and deliver the best outcomes possible. If something in the governance changes, then the staff in the ASC needs to be aware of those changes so they can adjust processes within the center.

3. Receive input from clinicians. Clinicians actually provide the care to patients; they know what works and does not work within their scope of practice. Staff needs to be encouraged to read and stay current on issues related to the ASC and be encouraged discuss those issues with other staff.

Regularly scheduled meetings with different practitioners, including physicians, RNs, techs, the medical director and CRNAs, will facilitate and encourage dialogue to help refine and/or redefine processes.

4. Develop processes to help staff understand the policies and procedures. As policies change throughout the year, the staff should be made aware immediately through communication logs, email, in-services, bulletin boards and any other means that helps accomplish this objective. All staff should be required to review the policy and procedure manual at least annually, including your physicians.

5. Keep manual from collecting dust. Even a thin layer of dust on a policy and procedure manual is a problem. When staff is busy doing their jobs, policy and procedure reviews can get pushed to the back burner. But for the sake of patient safety and compliance, ASCs must make sure this does not happen.

Consider putting items for review on a calendar throughout the year, and make sure you stick to this calendar. By spacing out your review, it will make completing the review less daunting than if you tried to review everything at the end of the year or right before a pending survey. The administrator and/or clinical manager can be tasked with divvying the policies and procedures up between staff members (in areas of their expertise) and sharing the responsibility for providing education on the various issues.

When an ASC makes developing a robust policy and procedure manual and keeping it current a priority, the facility will be in a better position to run itself at maximum efficiency and safety. There must always be oversight of the policies and procedures, and administration and staff need to be held accountable and responsible for keeping up with industry standards and changes in those standards. Initially this can feel like a tedious process, but when ongoing review and updates are continuous, you will establish a routine that makes the task less daunting and is ultimately in the best interest of your patients and staff.

Sarah Gamerman (This email address is being protected from spambots. You need JavaScript enabled to view it. ) is a senior consultant for Avanza Healthcare Strategies (formerly ASC Strategies), which provides healthcare organizations with strategic guidance, with a focus on outpatient services and community collaborations. Sarah has worked closely with ASCs and hospitals, taking them from ground breaking through licensing, Medicare certification and accreditation. Learn more about Avanza Healthcare Strategies at www.avanzastrategies.com.

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