Standard operating procedures, or SOPs, are a key ingredient in any successful business. SOPs create a master plan everyone in a medical practice can follow, from how to onboard a new insurer to how to take a tissue sample to how to sanitize an exam room.
What Are Medical SOPs?
SOPs are detailed, written instructions that outline business functions. By removing variability in how processes are carried out, they increase productivity and reduce the risk of errors. SOPs are especially crucial in a healthcare practice. Medical SOPs ensure patients receive a high level of care, even in a stressful emergency situation.
When every member of the medical staff knows what to do in specific scenarios, it reduces the risk of a negative patient outcome. This promotes patient safety and reduces clinic liability.
Medical safety and liability are not a practice’s only concerns. Healthcare practices routinely work with sensitive personal information, including health records and financial data. Administrative SOPs ensure this sensitive data is kept secure.
SOPs also help medical clinics operate more efficiently. When everyone in the practice follows the same processes, you can reduce waste, improve patient flow, and stabilize revenue.
Small practices benefit from SOPs just as much as large clinics. Even if there is just one person on your team responsible for a specific function, their process can be documented. When that person takes time off or when your team expands, business carries on without a hitch.
An important characteristic of good SOPs is that they are tailored to your practice. It’s fine to start from a template to ensure all the important information is included, but be sure the processes you document accurately reflect what you’ve found to work best for your unique business.
What to Include in Healthcare SOPs
Your practice is likely to have two kinds of SOPs. Medical SOPs are guidelines for performing medical procedures, such as how to perform an exam or how to handle samples for testing. Administrative SOPs apply to business operations, such as billing or facility maintenance.
Some SOPs can be applied throughout the clinic, while others will be specific to individual roles. For example:
- Front desk personnel have SOPs for greeting patients as they arrive
- OR nurses have SOPs for handing devices to the surgeon
- Billing staff have SOPs for pursuing unpaid claims
- Ophthalmology techs have SOPs for tonometry screening
- The entire clinic has SOPs on hand washing and sanitation
Parts of an SOP at a Small Practice
Standard operating procedures have two parts. The first is document control. This is like an executive summary. It describes what the SOP is and who it is for. This helps you organize your SOPs so they are easy to find and reference.
The second part of an SOP is its content. This includes the actual step-by-step process to be followed.
What to Include in Document Control
Document control should make it clear at a glance how the SOP is to be used and whether it is up to date.
- Clinic name and business information
- SOP title and number
- SOP author – the management-level staffer responsible for ensuring the content is accurate
- Effective date
- Date for next review
What to Include in SOP Content
The most basic SOP is simply step-by-step instructions. Effective SOPs go further, making it clear who they are for, why they exist, and how their contents should be interpreted.
- Purpose (why this SOP exists)
- Scope (what area of the practice it pertains to)
- Roles and responsibilities (who follows this SOP)
- Definitions of terms
- Step-by-step procedure
- Criteria used to evaluate this SOP
- References (where the guidance used to create this SOP came from)
- Appendices (such as glossaries, regulatory language, or charts)
- Name of the author
- Names of the people on the review panel that approved the SOP
Medical SOPs Your Practice Needs
Each practice is unique, and each will have its own unique SOPs. Here are some standard SOPs many small practices find useful to start.
1. Scheduling and Onboarding
Scheduling and onboarding processes are an important factor in an efficient patient flow. They create a positive start to the patient experience and ensure you have all the information you will later need to serve and bill the patient.
Consider creating SOPs for:
- Scheduling appointments, including processes for online, phone, and in-person scheduling
- Collecting patient information — if your practice management software includes a patient portal, you need a process for directing patients to it. You will also need processes for collecting information from patients who prefer not to use a portal.
- Creating and maintaining an electronic health record
- Collecting co-pays and entering billing information
- Setting up ongoing patient communication — establish triggers and processes for sending emails, text messages, or automated phone calls
2. Maintaining Supply Levels
Processes for monitoring inventory can keep your clinic from running short on needed supplies and from overspending on your supply budget.
Consider creating SOPs for:
- Choosing suppliers
- Negotiating and renegotiating contracts
- Organizing and managing inventory
- Ordering replenishments
- Managing a transparent procurement system
Inventory is a tedious manual process, which often leads to it being neglected in a busy practice.
You can lighten the load with technology like the inventory management tools in Nextech’s specialty-specific practice management software.
Besides showing real-time, at-a-glance inventory, Nextech enables product tracking to reduce loss and price tracking to reduce costs.
3. Consultations
While each patient will have a unique experience with your practice, SOPs ensure they receive a uniform level of care.
Consultation processes aim to give prospective patients all the information they need about a procedure.
These processes also help clinicians evaluate prospective patients to ensure the practice only takes on good candidates — for example, making sure a plastic surgery candidate has realistic expectations for the outcome of their procedure.
Consider creating SOPs for:
- Information exchange — what information is collected from the patient and what information is shared with them. This process can be documented within the EHR where the patient’s information is stored, so nothing falls through the cracks.
- Scope of consultation — whether it includes a physical exam, and if so, what the exam includes
- Describing the next steps for good-fit candidates
- Describing the next steps for candidates who are not a good fit
4. Procedures
Each procedure your practice performs will need its own SOPs. For example, a med spa will have a different SOP for delivering dermal fillers than it has for laser hair removal.
Nonetheless, each SOP will cover some of the same topics. Ensuring every clinician and surgeon at your practice approaches procedures in a uniform way reduces the level of risk inherent in any medical procedure.
Be sure each procedure’s SOP includes:
- Qualifying patients
- Presurgical testing
- Physically and mentally prepping patients for treatment
- Safe handling of equipment
- Monitoring the patient before, during, and after the procedure
- Responding to a negative reaction to treatment
- Documenting treatment and follow-up in the patient’s EHR
- Delivering post-op instructions and educational materials to the patient
The patient portal in your practice management software is an excellent hub to allow communication between the patient and the surgical team.
When post-op instructions are placed in the portal, the patient has easy access to them at any time, without the risk of losing or misplacing paper instructions.
5. Hygiene Protocols
Documented hygiene protocols are critical for maintaining a safe medical environment and for complying with healthcare regulations.
Consider creating SOPs for:
- Staff hygiene, including routine handwashing and surgical scrubbing
- Cleaning and sanitizing of common areas like waiting rooms
- Cleaning and sanitizing of patient areas like exam rooms
- Disposing of PPE and single-use products like table covers
How to Create Medical SOPs
By definition, SOPs are written instructions. Whether you are creating processes from scratch or documenting processes your staff already follows, write the procedures down and store them in a central location, such as your practice management system.
Identify Processes to Document
You might find it easiest to start with processes with wide application. For example, hygiene protocols apply to everyone on staff, and appointment scheduling applies to every patient.
Walk through the patient journey of each service you offer to identify the processes involved. Consider each responsibility in the job descriptions of your staff to find additional processes.
Once you have a list of processes that require SOPs, prioritize them. Address those that could potentially impact patient safety, data security, or regulatory compliance first.
Involve Staff in Developing SOPs
If an SOP is impractical, it won’t be followed. Involve the people who do the work in creating the step-by-step process.
While it’s important to give staff a voice in developing the SOPs, remember only one, management-level person will be named as the author. That person is responsible for the content of the SOP, and has the final say as to what the process will include.
Keep It Simple
SOPs are meant to be clear and easy to understand. Use simple language and include visual aids like graphics and flow charts.
Err on the side of being overly specific. Leave no question as to how an action should be performed.
For example, “Separate used linens for laundering” is not as specific as, “Place used linens in the bin labeled ‘Linens’ in the southwest corner of the room and close the lid.”
A good test of specificity is to ask if a new hire could read this SOP and carry out the process without additional instruction.
Include Practice Technology
Look for ways to streamline your SOPs using technology.
Nextech’s comprehensive EHR and practice management software solution can be integrated into SOPs throughout your organization, from scheduling to billing.
It automates manual work, creates a single source of truth, and enables staff across the organization to communicate.
Review Drafts
Assemble a panel to review and revise SOPs. After passing review, SOPs typically receive final approval from the medical director (for medical SOPs) or practice manager (for administrative SOPs).
Plan to review and update processes every two to three years. Update them earlier if there are changes in the practice, such as the introduction of a new tool.
Train Staff and Monitor Compliance
Even if staff had input into the SOPs, once they are finalized, walk everyone through them.
Employees may object to SOPs that change the processes they’re used to. Explain why the new process was created and why following it is important.
Monitor compliance and hold regular refresher trainings to keep people from sliding into complacency.
Streamline Your SOPs for a More Efficient Practice
Nearly every SOP in your practice can be streamlined with a fully integrated EHR and practice management solution.
Nextech’s specialty-specific software enables practices in dermatology, ophthalmology, med spa, plastic surgery, and orthopedics to operate more efficiently.
Keep records in stunning detail, and find the specific information you need fast. Automate routine tasks so your staff can spend more time on patient care. Reduce waste, grow revenue, and encourage patient engagement with easy-to-use tools.
See the impact Nextech could make for your practice. Schedule a demo today.
FAQ
What are medical SOPs?
Medical SOPs are documented standard operating procedures a healthcare practice uses to deliver consistent care.
Why should a small medical practice have SOPs?
SOPs reduce risks to patient safety, patient data, and clinic liability. They also provide stability and predictability to a small practice.
SOPs:
- Improve patient safety by removing variability in the delivery of care
- Improve efficiency by streamlining workflows and putting guidelines around the use of resources
- Improve collaboration and communication among staff by removing ambiguity and reducing misunderstandings
- Help new employees get up to speed quickly so they can begin contributing positively to the team
- Provide a reference point for auditors and inspectors to ensure compliance and quality assurance
- Enable quick, decisive action in the event of an emergency
What are the most important things to remember when creating medical SOPs?
When writing medical SOPs:
- Approach each procedure from the viewpoint of creating an excellent patient outcome
- Use clear, easy-to-understand language, formatting, and visual aids
- Be specific about the scope of the SOP, so there is no confusion about when or to whom it applies
- Before implementing SOPs, have them approved by the staff roles affected and signed off by upper management