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Constructing a new policy and procedure manual

Patient Access Weekly Advisor, April 30, 2008

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Although it took two years to finish, for Cathy Pallozzi, CHAM, CCS, director of patient access at Albany (NY) Medical Center and her team of access managers, constructing a new, comprehensive policy and procedure manual was worth the wait.

The process involved all access managers, a quality and development manager, and an administrative coordinator. And, of course, it included the access staff members.

Setting deadlines is key, Pallozzi says, adding that, “at first, deadlines for each aspect of development was a soft deadline.”

Albany Medical needed to organize the information collected to identify its pain points. The process involved the following steps:

1. List all tasks. Ask staff members to write down everything they do, from answering phones to sending a fax to encountering a patient, Pallozzi says. “No task was too small or too big.”
2. Collect and review e-mails and existing policy and procedures and training documents. This can happen concurrently to task listing, Pallozzi says, adding that she is fortunate to have a quality and development person who is the coordinating facilitator in the mission to create a policy and procedure manual. Albany Medical had access managers collect e-mails they sent to staff members. “The staff is an incredible resource,” Pallozzi says. “We had some staff who never had thrown away one bit of information.”
3. Separate training documents from policy and procedure documents. Review any existing training documents to ascertain what might be a policy and procedure vs. a training resource.

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