When to Review and Change Your Office’s Policies and Procedures

When setting up their practice or soon thereafter, most healthcare professionals took the time to develop employee manuals, policies and procedures, websites, and other documentation to be used in the practice.  It is important to remember that these documents and websites must grow and adapt with your medical practice and with the evolving environment in which the physician practices.  Regular review and revision of documents used in the practice along with policies and procedures can help to minimize risks to your practice and assist in the practice running more efficiently.

It is best practice to proactively review documentation, policies, and procedures annually.  Don’t wait for a problem, violation or claim to trigger a review.  The healthcare industry is constantly changing and evolving, as are advances in medicine.  Therefore, a thorough review of documentation and information provided to patients should be reviewed.  This includes a review of informed consents, and any literature or websites that the physician recommends a patient review.

Changes to laws or regulations also dictate review of policies, procedures, employee manuals, and other documentation.  As the Covid-19 pandemic struck, many office procedures had to be changed, including telehealth, work from home practices, collaboration with nurse practitioners, sanitization of the office, and many other changes.  With the end of the pandemic, some regulations have expired, and enforcement provisions for HIPAA are once again in effect.  It is the best practice to ensure that your policies and procedures comply with the current regulations.  Also, work from home policies in the employee manual may need to be updated and revised to reflect your practice’s current needs and provide the rules that employees are to follow.

Recent changes to Missouri laws regarding marijuana should also trigger a review of the employee manual and office policies.  Language may need to be revised regarding working under the influence and the proper handling of any potential violation of office policy regarding drug or alcohol use or abuse.  With the legalization of marijuana, medical practices may need to consult with an attorney to revise policies to avoid legal disputes.

Physicians should also be reviewing collaborative practice agreements and confirm or revise those agreements to accurately reflect the medical acts, methods of treatment, drug prescription practices, jointly agreed protocols, process of review and other conditions of the collaboration.  If the practices, treatments, or any other matter contained in the collaboration agreement has changed, then the agreement should be revised. Missouri regulation requires the collaborative arrangement be reviewed at least annually and revised as needed.

Another reason for regular review of your policies and procedures is ever-changing technology.  More and more practices have a patient portal.  Those practices need to have policies and procedures that directly relate to the patient portal.  An example is whether test results should be made available on the portal before the physician has had time to review and sign off on the results.  Another example is the ability to communicate within the patient portal, and the policies and procedures that need to be followed regarding this.  The patient portal is likely to evolve over time, and therefore any policies and procedures associated with the portal will need to be reviewed and if necessary revised.

A review of the employee manual, policies and procedures should also regularly be done to address the practice’s online presence and cyber security.  Documentation may need to be revised to provide added protection from ransomware, malware, or other hacks and computer viruses.  In addition to adding protections pertaining to cyber security, a physician should also review their own website as well as other websites addressing both positive and negative aspects of the practice provided by patients.  After learning about patient reviews, policies and procedures can be reviewed and revised to enhance the patient experience.

Keystone Mutual regularly provides guidance to its policyholders on these matters.

Please contact us with any questions or for assistance.