Doctors looking at documents

Are You Prepared?

Standard operating procedures, office policy manuals and emergency preparedness plans are all different (but similar) ways of preparing for unexpected events. What's the difference and which one(s) are best for your practice? Read on.

Very few of us were prepared for the events the pandemic sent (and continues to send) our way. While we cannot possibly plan for every situation, one thing we know for sure: We need to be better prepared in the future. These tools can help.

Standard Operating Procedures

Standard operating procedures (SOPs) are operational policies and procedures required to be set in motion when specific circumstances arise. They are focused on achieving quality, safe operations and security.

Some SOP considerations:

  • Consider moving patient care topics from your SOP to your office policy manual (see below).
  • Be sure they are consistent with professional regulations from credible sources, like OSHA or the CDC.
  • Maintain quality control when they are being drafted and as you are following them.
  • Give them a more specialized name, such as “facility operations plan,” to differentiate them from other policies and plans.

Office Policy Manual

Don’t confuse SOPs with your office policy manual. While both contain policies and procedures, your office policy manual should be focused on patient care scenarios as opposed to operations. We encourage our insureds to have an office policy manual to deal with situations such as how to properly dismiss a patient, handling prescription refills and/or handling a patient-related office emergency. Both the SOP and the office policy manual are meant to encourage consistency and compliance throughout your practice.

Emergency Preparedness Plan

A third choice is to have an emergency or disaster preparedness/recovery plan, which you will hope to never use. You can individualize or broaden this type of plan to encompass various types of emergencies and your proposed actions should such emergencies arise.

What’s the Difference?

Office policy and procedures manuals, an SOP and an emergency preparedness plan are all written processes to achieve a desired outcome from slightly different perspectives. Here’s how they would differ in a pandemic recovery cycle scenario:

  • SOP: One example of a standard operating procedure should be to screen each patient prior to them entering your practice.
  • Office policy/procedures manual: Focus on activities with high-risk consequences, such as record-keeping standards, human resources processes, tracking and informed consent. 
  • Emergency preparedness plan: Identify specific actions to take if another pandemic happens, such as changing office hours, adjusting the number of daily appointments, having PPE on hand, etc.    

During a claim, it is not uncommon for your defense counsel to inquire whether you have a policy and followed “standard operating procedure” regarding the issue at hand. Be aware that ignoring your own guidelines can also cause problems. Your counsel wants to focus your defense on the standard of care, so while having written SOPs and office policies with procedures can be a good practice, they can also create another way for plaintiff’s counsel to attack you if you are not adhering to them. The lesson: If you set guidelines, make sure you follow through.

When creating your policies/procedures manual be sure to consider the following:

  • Who will be doing this activity (their role/responsibility)
  • What that individual will be doing (how, including frequency, criteria, etc.)
    • Engage those staff members for their input
  • What is the desired outcome
  • When the activity will take place
    • Evaluate the proposed policy/procedures
  • Why the activity is being done
  • How the activity will be done
    • Consider the impact this policy/procedure will have on staff/patients
  • Is this procedure consistent with the regulations being recommended by credible sources
    • Confirm the policy/procedure is aligned with the standard of care


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