Unit 4: Administrative Operations
Administrative Operations

Section 1. Policies and Procedures

Policies and Procedures Manual

A policies and procedures manual, sometimes called a clinic manual, is a roadmap. It is one document, or a series of documents, that describe how a safety net dental clinic is managed and how it functions on a daily basis. The manual provides instructions for all the clinic’s functions, including procurement, health records, recruitment and retention of staff, position descriptions, hours of operation, scope of services, evaluation, and more.

Staff members of any health care organization come from diverse educational backgrounds and perspectives. Without guidance from an established set of policies and procedures, each person would develop individual strategies to accomplish job responsibilities, which may be disjointed and might lead to inefficient and possibly ineffective clinic operations. A policies and procedures 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 policies and procedures can be made available to patients to help them understand why the clinic provides services in the manner that it does.

Patient Safety and Quality Healthcare shows how formalized, written policies and procedures fulfill a number of important purposes:

  • Facilitate adherence with recognized professional practices.
  • Promote compliance with regulations, statutes, and accreditation requirements
  • Reduce practice variation.
  • Standardize practices across multiple entities within a single a health system.
  • Serve as a resource for staff, particularly new personnel.
  • Reduce reliance on memory, which, when overtaxed, has been shown to be a major source of human errors or oversights.
It is not necessary to have all policies and procedures in place when the clinic opens; some can be developed as the clinic operates. There are, however, essential policies and procedures that should be in place when operations begin.

  • Organizational structure
  • Mission, vision, and values
  • Scope of services
  • Position descriptions
  • Hiring procedures, including credentialing and privileging of professional staff
  • Employee handbook
  • Financial-management procedures
  • Clinic insurance
  • Appointment and walk-in procedures
  • Informed consent procedures
  • Infection control procedures, including exposure-control plan (required by federal regulation)
  • Hazard-communications program (required by federal regulation)
  • Clinic safety protocols
  • Health Insurance Portability and Accountability Act (HIPAA)
  • Patient records and privacy (may be a component of HIPAA)
  • Nondiscrimination policies (to comport with requirements of state and federal law, including Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act of 1990, and Section 1557 of the Patient Protection and Affordable Care Act of 2009).
  • Radiation control
  • Quality assurance (QA) plan
  • Evaluation plan