Why does my practice need an Employee Policy and Procedure Manual?

As an employer there are a range of processes your employees and contractors will need to follow to ensure high quality patient care and maintain the professional reputation of your practice.

While it may seem sensible to address this in an employment contract, we recommend you instead maintain a separate policy and procedure manual.

But why do I need a separate manual?

The purpose of policies and procedures is to set the consistent standard of behaviour you expect of all staff and to provide information staff will require to work safely in your practice. Therefore, you may need to rely on your policies and procedures to manage poor performance, terminate employment, defend a staff claim for workplace injury or defend a negligence claim from a patient.

As a contract is agreed at a single point in time it doesn’t allow you to update policies and procedures and add new ones over time.  And if you don’t want the contract to be too long, you may be tempted to leave out some detail.

Therefore, if you just include this information in a contract, you can only rely on a version of information provided at a particular date. You will also end up with your employees being bound by various versions of policies depending on when they were employed.

This could lead to a case of unfair dismissal or employer negligence by trying to rely on policies which don’t actually apply to the relevant employee.  Unfair dismissal and employer negligence claims can carry significant penalties and financial and reputational consequences, which you will obviously want to avoid.

So how do I ensure my staff comply with the policies and procedures of the practice?

Step 1: The employment contract

All staff contracts should state that the employee/contractor must review, acknowledge and comply with all policies contained in the policy and procedure manual and that lack of compliance may result in disciplinary action.  The contract should also state that the manual will be updated from time to time and that, while staff will be given reasonable notice of the changes, they are required to review, acknowledge and comply with all lawful updates and additions to the manual.

A current copy of the manual will need to be provided at the time any new employee/contractor receives their contract.

Step 2: The Policy and Procedure Manual

The manual itself should be centrally coordinated, so there is only one version available to staff at any time and should preferably be electronic (on a practice intranet or shared drive) to support version control. Each policy and procedure should include its version number, the date on which the current version takes effect and should discourage staff from keeping their own printed copy as this risks them using an out of date version.

To ensure all staff have the chance to become familiar with updates, staff should be notified before the new version becomes binding and required to review and acknowledge updates before they take effect.  For complex topics you should consider providing staff education on the updates.

What should I include in my Policy and procedure manual?

The range of topics may depend on the nature of your health care practice. Some suggestions for you to consider include:

  • Clinical:
    • Patient assessment and treatment protocols
    • Diagnostic and treatment equipment instructions
    • Body fluid exposure
    • Disposal of clinical waste
    • Disposal of soiled linen
  • Administrative practices:
    • Staff orientation
    • Hours of work
    • Leave procedures
    • Use of practice vehicles
    • Quality management
    • Continuous improvement
  • Safety:
    • Emergency and evacuation procedures
    • Health & Safety Policies
  • Professional standards:
    • Uniform and dress standards
    • Performance appraisal and development
    • Continuing professional development
    • Outside employment
    • Code of conduct
    • Use of Social Media
    • Representing the practice to the public
    • Dealing with confidential and personal information
    • Dealing with complaints and incidents

Disclaimer: The information provided in this article is general only and is not legal advice.

If you would like advice on your staff contracts, policies or procedures from a specialist health business lawyer, don’t hesitate to contact us here or our Director, Chris Setter on 0477 211 732 or chris@healthlawsolutions.com.au.

Acknowledgement: We acknowledge the earlier article on this topic published by Albert Gigl of MW Partners, Specialist Dental Accountants, which is available on the MW Partners website.