Keeping Your Policies and Procedures Up to Date

Ted Markgren, CO, Senior Surveyor


One of the many opportunities ABC’s facility accreditation affords your practice is the annual review of your policy and procedure manual. At its inception in 1996, the ABC Facility Accreditation program required the documentation of many ‘new’ elements that at the time seemed burdensome to many small O&P businesses. As a result, policy manuals were created and sold by various consultants and companies to assist in the development of organizational policies and procedures.

While such an approach is not inappropriate, many organizations simply purchased policy manuals and placed them on the shelf to gather dust. Even today, twenty years after the standards were rolled out, many practices continue to rely on policy manuals that are woefully out of date and not specific to the current practice or the current standards.

It takes time and effort to review the policies and re-write or delete those that do not apply or have changed. But keep in mind that the policy manual is not for the benefit of the surveyor; the policy manual is the operations guide for your practice. Your policy manual informs and guides all your employees as to company rules, policies and expectations.

If your policy manual was purchased from a consultant, at a minimum it should be customized to reflect the activities of your practice. You don’t need endless pages of policies and procedures for rental equipment or delivery vehicle maintenance if you do not offer these services. All extraneous material needs to be removed from your policy manual. Your ABC surveyor evaluates your business practices based on what your policy manual says that you provide as well as what is observed while on site. Policies that cover actions and services that you don’t provide are more harmful than helpful.

Take some time to thoroughly read and update your policy manual. Assure yourself that all policies are applicable to your practice and services provided. Seek input from your employees and let them participate in policy development, your employees are the ones most often affected by the business’ policies.

Make sure you have an electronic copy of your manual to edit and keep updated; having this will also be beneficial in the event of an emergency that results in the loss or damage to any hard copies. An electronic copy will also help if any third parties, like ABC or a payer, request this information.

This simple, though somewhat time-consuming, activity can yield worthwhile improvements to your practice and improve staff productivity.

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