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" The Voice Of Interventional Pain Management "

celebrating our 10th anniversary
 

Pain Management Center
Policy and Procedure Manual
Table of Contents

VOLUME I
 
EXECUTIVE SUMMARY
  SECTION I. ORGANIZATIONAL FUNCTIONS
  1. Purposes

A. Mission
B. Vision
C. Values
D. Goals
E. Objectives
F. Code of Ethics
G. Services 2. Governing Body
A. Responsibilities
B. Organization
C. Organizational Structure
D. Chief Executive Officer
E. Conflict of Interest
 

 3. Administration

A. Principles
B. Administrator
C. Director of Insurance
D. Staff Recruitment and Retention
E. Licensure and Certification
F. Job Performance Review
G. Information Management
 

  4. Fiscal Management

A. Principles
B. Financial Records
C. Business Procedures
D. Collections
E. Financial Expenditures


  5. Administrative Policies

A. Smoking Policy
B. Non-Discrimination
C. Use of Outside Resources
D. Review of Contract Services
E. Loss or Theft of Property or Money
F. Solicitation and Distribution of Literature
G. Visitor Injury/Mishap
H. Incident Reports


  6. Medical Staff

A. Goals
B. Objectives
C. Organization of Medical Staff
D. Medical Staff Membership
E. Medical Staff Credentialing
F. Medical Staff Executive Committee
G. Medical Staff Management
H. Impaired Physician
I. Independent Clinical Staff
J. Patient Management 

SECTION II. PATIENT FOCUSED FUNCTIONS


  1. Purposes
A. Principles
B. Patient's Bill of Rights
C. Patient Responsibilities


  2. Patient Rights

A. Patient Complaints
B. Informed Decision Making
C. Access to Medical Records
D. Informed Consent
E. Patient Confidentiality
F. Confidential Messages
G. Patient Valuables
H. Discrimination Policy
I. Patient Directives
J. Care of Terminally ill Patient
K. Research and Experimentation
L. Speech or Hearing Impaired Patients


  3. Patient Consent
A. Consent Policy
B. Consent for Evaluation
C. Consent for Invasive Procedures
D. Consent - HIV Testing
E. Consent to Photograph 

  4. Patient Abuse


  5. Patient Management

A. Patient Assessment – Pain Management
B. Patient Assessment – Physical Therapy/Psychology
C. Patient Assessment – Medical Group
D. Storage of Medications
E. Emergency Carts
F. Patient Transport
G. Patient/Family Education
H. Continuum of Care
I. Discharge Against Medical Advice
J. Protection of Patients From Hazardous Materials
K. Restraints and Seclusion
L. Death at the Center 

SECTION III HUMAN RESOURCES


  1. General Principles

A. General Policies
B. Employment
C. Personnel Records
D. Classification of Employees
E. Performance Assessment
F. Verification and Control Systems
G. Confidentiality
H. Dress Regulations
I. Attendance
J. Employee Communication
K. Work/Salary
L. New Employee Orientation
M. Employee Requests for Time Off
N. In-Service Education Program
O. Sexual Harassment
P. Personal Telephone Calls
Q. Disciplinary Procedure
R. Termination of Employment


  2. Employee Health

A. Objectives
B. Employee Health Program
C. Exposure Control Plan
D. Tuberculosis Screening Program
E. Immunizations
F. Post Exposure Prophylaxis of Hepatitis
G. Exposure to HIV
H. Exposure to Meningococcal Meningitis.
I. Illness Reporting
J. General Safety for All Employees
K. Reporting Injury on the Job
L. Worker's Compensation

3. Policies of Administrative Personnel


A. Director of Public Relations
B. Director of Human Resources
C. Chief Transcriptionist
D. Admissions Coordinator
E. Medical Records Coordinator
F. Director of Maintenance and Safety
G. Physical Therapy - Admissions Coordinator
H. Transcriptionist
I. Insurance Coordinator
J. Admissions Clerk/Receptionist
K. Medical Records Clerk
L. Administrative Assistant


  4. Policies of Nursing Personnel

A. General Policies
B. Clinical Coordinator
C. Employee Health Nurse
D. Staff Nurse 
5. Policies of Professional Personnel
A. Clinical Director
B. Director of Psychology
C. Physical Therapist
D. Physical Therapy Assistant
E. Physical Therapy Technician
F. Radiologic Technologist
G. Physician’s Assistant
H. Nurse Practitioner 

6. Policies of Physician Personnel

A. Medical Director
B. Physician 

7. Ancillary Personnel

A. Statistician and Programmer
B. Janitor
C. Laundry Coordinator 
8. Education and Training
A. General Policies
B. Educational Profiles
C. Cardiopulmonary Resuscitation Certification
D. Continuing Education
 

VOLUME TWO
SECTION IV ENVIRONMENTAL SAFETY


1. Purposes

A. Principles
B. Environmental Security
C. Physical Facilities
D. Risk Management
E. Environmental Performance Improvement


2. Fire Safety

A. Introduction
B. Prevention of Fire in an Oxygen Enriched Atmosphere
C. Evacuation Procedures
D. Responsibilities, Admissions Coordinator

3. General Safety

A. Statement of Policy
B. Safety Education
C. Safety Surveillance Program

4. Environmental Control

A. Safety
B. Environmental Security
C. Departmental Safety: Business Office, Front Desk
D. Departmental Safety: Laundry
E. Departmental Safety: Laboratory
F. Departmental Safety: Medical Records
G. Departmental Safety: Nursing Department
H. Departmental Safety: Maintenance
I. Departmental Safety: Radiology
J. Department Safety: Physical Therapy and Psychology
K. Departmental Safety: Pharmacy
L. Medical Device Problem and Recall

5. Emergency Preparedness

A. Preface
B. Emergency Response
C. Bomb Threat
D. Earthquake
E. Explosions
F. Disaster Plan
G. Patient Flow in the Event of a Disaster
H. Cardiopulmonary Resuscitation Policy
I.  Cardiopulmonary Resuscitation Protocol
J.  Cardiopulmonary Resuscitation Procedure

6. Hazardous Materials Management

A . Hazardous Materials
B. Chemical Waste
 

SECTION V. PERFORMANCE IMPROVEMENT
 

1. Organizational Performance

A. The Program
B. Program Evaluation

2. Quality Management and Improvement

A. Objectives
B. Scope of the Program
C. Peer Review
D. Quality Improvement
E. Risk Management
F. The QMI Program
G. Utilization Review
H. Quality of Care
I. Sentinel Events Policy
J. Environmental Performance Improvement

3. Medical Records

A. Function
B. Protection and Availability
C. Authentication

4. Infection Control

A. Principles
B. General Rules
C. Hand Washing
D. Universal Precautions
E. Employee Infection Control
F. Disposal of Sharps
G. Housekeeping Procedures
H. Isolation Techniques
I. Needle Stick Protocol
J. AIDS/HIV Positive Guidelines
K. Biohazard Waste
K. Infectious Waste

5. Miscellaneous Policies

A. Professional Inquiries
B. Publishing Activities
C. Staff Improvement
D. Teaching
E. Patient Satisfaction Survey
 

SECTION VI PAIN MANAGEMENT PROGRAM

1. Purposes

A. Organization
B. Scope of Services
C. Program Description
D. Program Evaluation
2. General Rules and Regulations
A. Program Standards
B. Staffing
C. Scheduling
 

SECTION VII MEDICAL GROUP

1. Purposes
A. Organization
B. Scope of Services
2. General Rules and Regulations
A. Staffing
B. Scheduling
C. Patient Care Guidelines
 

SECTION VIII PHYSICAL THERAPY AND PSYCHOLOGY

1. Purposes

A. Organization
B. Program Description
C. Scope of Services
D. Physical Therapy Guidelines


2. General Rules and Regulations

A. Staffing
B. Scheduling
C. Patient Care Guidelines
 

3. Operational Policies and Procedures

A. Physical Therapy
B. Psychological Services
C. Program Admission Criteria
D. Physical Therapy Procedures

 

SECTION IX ANCILLARY SERVICES

1. Radiological Services

A. Principles
B. Radiation Exposure Monitoring
C. Contrast Reactions

2. Pharmaceutical Services

A. Principles
B. Expired Drug Policy
C. Narcotic Policy

3. Pathology and Clinical Services

A. Principles
B. Quality Control
C. Blood Drawing

Model Compliance Plan
Table of Contents

Preface 
 
Compliance Program Overview 
 
Key Documents to Review 
 
Duties of the Compliance Officer/Committee 
 
Reporting and Investigating Misconduct 
 
Disciplinary Protocol 
 
Document Retention/Destruction 
 
Introductory Letter 
 
Standards of Conduct 
 
Model Compliance Plan 
 
Sample Policies and Procedures 
 
Duties of the Compliance Officer 
 
The Compliance Committee and 
Its Powers and Responsibilities 
 
Responding to Compliance Telephone

Hotline or Other Reports 
 
Non-Retaliation Policy 
 
Exit Interviews 
 
Employee and Contractor Screening 
 
Document Retention Policy for 
Compliance Program Documents
and Documents Associated with
Claims Processing
 
Refunding Overpayments 
 
Compliance as an Element of
Performance Evaluations 
 
Documenting Discussions with Third Party Payors
 
Waiver of Co-payments and Deductibles
 
Vender-Promotional Training 
 
Responding to Government Investigations

 


All contents Copyright © 2008
American Society of Interventional Pain Physicians ®
81 Lakeview Drive, Paducah, KY 42001
Phone 270.554.9412, Fax 270.554.5394
E-mail asipp@asipp.org