Chapter 4. Clinical Operations

Policies and Procedures Manual

What is a policies and procedures manual?

The Joint Commission defines policies and procedures as the "formal, approved description of how a governance, management, or clinical care process is defined, organized, and carried out."

A policies and procedures (P&P) manual, sometimes called a clinic manual, is a roadmap or a series of documents that describe how the dental clinic functions on a daily basis. The manual provides instructions for all the organization's functions, including procurement, health records, recruitment and retention of staff, position descriptions, hours of operation, scope of services, evaluation, etc.

Handbook with roadmapStaff members of any health care organization come from diverse educational backgrounds and points of view. Without guidance from an established set of P&Ps, each person would develop individual strategies to accomplish job responsibilities, which may be disjointed and lead to inefficient and possibly ineffective clinic operations. The P&P 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 P&Ps can be made available to the clinic's user population to explain why the clinic provides services the way it does.


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