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Policies, Protocols and Procedures

by in Employment Law, GP Practice Management, Health & Safety, HR - Human Resources

Policies, Protocols and ProcedureThe idea of old-fashioned common sense and getting on with the job has gone and in place of this we have robotic, over-legalised pen-pushery! The role of a doctor’s surgery practice manager seems to have become over complicated and subject to random testing – just like being back at school! My sympathy lies entirely with anyone new to the role, quivering under the threat of a CQC inspection.  I’ve been there!

Hazard Data Sheets – or Time Consumables?

1997 my first dealings with Health and Safety legislation loomed with the COSHH manual. A little light reading it is not so I asked the cleaning contractor to take this on and she very kindly did. There are hazard sheets and safety alerts for everything you can think of – I even discovered that typing corrector fluid is considered hazardous! Each person within the practice, doctors, nurses, cleaning staff et al must enslave themselves to the enormous folders which must be kept up to date with various drug and patient alerts and directives but the problem which then arises is that staff adopt too many different methods of circulating them. Who knows if the people who need to see them actually do?  A breach of confidentiality is, of course, the worst sin within a practice, but then that is a great excuse for a new protocol!

Quality Protocols

It became clear that, in order to gain points under the Quality Outcomes Framework, all practices needed to acquire and display a degree of professionalism in the maintenance of their protocol paperwork in order to impress the Primary Care Trust.  At that time – 2004 – I agreed with this and set about preparing reams of paperwork with which to impress the local PCT inspection team. Unfortunately I began to wonder about the quality of said paperwork.  Like were they up to date and fully compliant with all the relevant legislation?  Did I have enough copies, on paper and on disk? And would the PCT people know what should be in each document?

Models are Guides Only – Don’t PLAGIARISE!

When the Care Quality Commission inspects surgeries nowadays they expect ever higher legislation-backed standards. The price for failing to impress them can be punitively high, even the closure of the service. The CQC inspectors are looking for the correct policies, protocols and procedures but their ideas of what should be there are probably different from yours.

You must be careful when preparing your documents that they relate to your practice and are not just copied ‘off the internet’. They should not be POACHED, PLAGIARISED or PURCHASED. Documents written by a third party will, in a saved file, record the author’s name, company and copyright. By all means take advice and do your research but make sure your document is an accurate reflection of your practice. And be wary of using a pre-prepared document. These are often 20 pages or more long and, best will in the world, no-one reads through every word before adopting them as their ‘own work’.  I know of one manager who was pestered daily to write a Disaster Plan but this, for reasons known only to her, she failed to do and instead delegated the task. The Plan was prepared at the last minute pending the imminent arrival of the inspection team – never a good idea!

Model documents are just meant to guide you. Different web sites have varying numbers of model documents too, so how do you know how many is right?  The thing to remember is – make your documents relevant to YOUR practice, date them and show a lead name.

To conclude – don’t wait for the inspector to call. Prepare your documents in advance.  Take advice but make it original.  And then give yourself a pat on the back!


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Robert Campbell

Robert Campbell

Former GP Practice Manager with over 25 years experience working in Upton, near Pontefract, Seacroft in Leeds, Tingley in Wakefield, Heckmondwike and more recently Cleckheaton, West Yorkshire. www.gpsurgerymanager.co.uk

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One Response to “Policies, Protocols and Procedures”
  1. Avatar
    Terry Hooke Says:

    I am familiar with the Summary Care Record system but I have recently heard about a document called The Summary Page.

    I can find no information on this document and the Department of Health has no information.

    Can you help with any information. Thank you.


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