Since more and more surgeries and procedures are being performed in outpatient settings, the policies, plans, and procedures for these services are of increasing importance. 50 Policies and Plans for Outpatient Services details commonly used policies and plans in free-standing ambulatory care centers. Included are plans and policies concentrating on emergency management, medication safety, informed consent, and medical staff credentialing to name a few.
As an introduction to the model documents presented, the book begins with a how-to chapter to guide readers through the process of formatting the documents and making them their own. The policies and plans discussed serve as templates and can apply to licensing and regulatory agencies such as Medicare, the Joint Commission, and AAAHC. The documents included in this book are excellent templates to use as a starting point for producing policies and plans that help create the flow and process in an organization.
Knowing their specific local, state, and other governing agency requirements, readers can customize the documents to reflect the unique structure and qualities of their organization through the use of the enclosed CD. The resulting policies, procedures, and plans are the back-up documents that provide rationale, vision, and theory, and can be valuable tools for making effective clinical and administrative decisions. In addition to the documents provided on the CD-ROM, the book also includes a list of helpful resources.
Table of Contents
How to use this book
Instructions on the policies and CD
50 Policies and Plans
Abuse, domestic violence, and reporting cases to public authorities
Disposition of specimens
Distribution and control of controlled substances
Distribution and control of stock medications
Documentation of controlled substances
Exposure control plan for bloodborne pathogens
Exposure to blood or other potentially infectious materials(OPIM)
Exposure to human immunodeficiency virus (HIV)
Fall prevention program
Fire safety management plan
Hazardous materials and waste management plan
History and physical examination
Impaired physicians and practitioners
Infection control program
Initial competency evaluation policy
Laboratory specimen labeling requirements
Licensure, registration, and certification requirements
Life safety management plan
Management of disruptive individuals
Medical equipment management
Medical plans of care
Medical staff code of conduct
Medical staff credentialing process
Medical staff peer review
Medical staff proctoring
Medication management labeling requirements
Nursing competency plan
Proficiency survey program for point-of-care testing
Quality control protocol for point-of-care testing
Radiation safety operation and procedures
Reporting panic and urgent laboratory results
Safe management plan
Safe medical device act reporting
Safe patient handling and movement
Safety consideration for infants and pediatric patients
Scope of services
Secure environment management plan
Sentinel event, adverse events – serious and never events – near misses, reportable events
Single and multi-dose medication containers
Surgical site identification
Utilities management plan
Carole Guinane RN, MBA
Carole’s quality and leadership journey began in 1989 as a senior leader/Vice President at Parkview Episcopal Medical Center in Pueblo, Colorado. Parkview’s success story was published in 1992 by The Joint Commission, with the forward of the book written by Donald M. Berwick, MD. The book, Striving for Improvement: Six Hospitals in Search of Quality shared the process, methods, and rewards that our leadership team, employees, and physicians experienced. It was magical. Applying quality principles to clinical processes was new to healthcare at the time, but groundbreaking results occurred. Carole took the lessons learned from those early days and continues to grow her knowledge base for operational and clinical improvement application.
Carole has worked as Chief Clinical and Compliance Officer for an Ambulatory Surgery Center company, Vice President of Medical Staff Services and Quality for a healthcare system, Vice President for Applied Business Science and Education for a specialty hospital and healthcare system, Consultant/Clinical Improvement Director for a Center for Continuous Improvement and Innovation, and Vice President for Ambulatory Clinical Improvement/ASC Clinical Operations for an integrated healthcare system. She has had the pleasure of building and growing quality and clinical operations programs for large healthcare systems, small and rural hospitals, ambulatory surgery centers, insurance companies, and ambulatory entities. Carole is a trained Six Sigma Black Belt. She has published books and journal articles on clinical pathways, quality tools, Six Sigma, clinical operations, and consumer driven healthcare.
Joseph earned his degree in design from the School of Visual Arts in New York City. His debut into healthcare came as a system administrator, concentrating on the technical oversight of information systems at Presbyterian Hospital in Charlotte, North Carolina in 1990. Early on Joseph trained and became certified as a system engineer and certified trainer. He has been responsible for leading teams of technologists, including infrastructure, web services, data center operations, call centers, disaster recovery planning and help desk services, and has managed scores of system implementations over the past two decades.
Joseph co-led the creation and implementation of an electronic medical record system, which included full financial, transcription and scheduling integration. Physicians were given office access to the scheduling and clinical documentation platforms. This integration strategy created immediate medical record completion, eliminating the need for backend inspection and rework resources. Joseph has consistently delivered efficiencies through standardization, recruiting and retaining key talent and launching enthusiastic customer service programs for a variety of professionals, patients and vendors. Joseph has been published in numerous technical journals and industry magazines and has authored several books, including one on patient advocacy. A seasoned executive, Joseph has worked as Chief Executive Officer for a Southeast Consulting firm, Chief Information Officer for an Ambulatory Surgery Center company, and Chief Information Officer for a Midwest county hospital system.