Medical Staff

Q&A: What should the hospitalist program policy and procedure manual include?

Hospitalist Leadership Connection, March 9, 2010

A: The hospitalist program policy and procedure manual should include the following operational issues:

  • The program’s mission, vision, and objectives: These tenets reflect the basis for the program’s creation. All key stakeholders should be informed of these principles.
  • The program’s hours of service
  • Hospitalist provider responsibilities:
    • Start and end time of the workday or shift
    • Time of morning and evening rounds
    • Patient rounding protocol
    • Communication protocol with patients, referring and primary care providers, specialists, and hospital staff
    • Admission and discharge protocol
    • Use of off-service notes and evidence-based clinical guidelines/protocols
    • Chart documentation and completion
    • Practice responsibilities
    • Medical staff responsibilities and meeting attendance expectations
    • Provider evaluations
    • Coding and billing responsibilities
    • Nighttime, weekend, and holiday coverage
  • Front-office responsibilities for clinical and nonclinical staff:
    • Employee schedules
    • Meeting attendance
    • Annual evaluations

 The above excerpt is adapted from The Hospitalist Program Management Guide, 2nd edition, published by HCPro, Inc.

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