How to write a standard operating procedure (SOP)

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The team in the break room is involved in a discussion: What is the correct way to handle a client’s question? What is the proper protocol for follow-up tests for a patient with a long-term illness? Is it necessary to get 2 approvals for a particular medical service? In most cases, the problem is not that the team is clueless; instead, the team has witnessed 2 or more versions of the “correct way,” and everyone wants to get on the same page. The team needs a standard operating procedure (SOP).

An SOP is a detailed, written set of instructions or guidelines that outlines the steps to complete a particular organizational task or process. SOPs are designed to ensure consistency, efficiency, safety, and compliance with regulations or standards. They are commonly used in various industries, including health care, manufacturing, finance, and hospitality, to document best practices and ensure that tasks are performed correctly, regardless of who executes them. SOPs typically include step-by-step instructions, safety precautions, quality control measures, roles and responsibilities, and references to relevant regulations or policies.

Creating SOPs

Writing SOPs for a practice can seem cumbersome. However, following specific steps and using a standard template can make the process effortless and ensure a document that helps the team maintain consistency, efficiency, and clarity in operations. The following is a comprehensive guide for writing and implementing an SOP.

Step 1

Understand the purpose and scope

• Define objectives: Clarify the purpose of the SOPs. Are they for clinical procedures or administrative tasks?
• Scope definition: Determine which processes or tasks will be covered by the SOPs. Identify the departments or individuals involved.

Step 2

Gather information

• Process identification: List all the processes that need SOPs. This may include patient intake, billing procedures, scheduling appointments, and handling medical records.
• Interview the team: Talk to the team members who perform these tasks to understand current practices, challenges, and potential improvements.

Step 3

Structure the SOPs

• Header: Include the title, date written, or the revision date (and revision number if applicable).
• Consistent outline: Provide a clear outline of the document’s contents for easy navigation—and use the same template for every SOP to ensure consistency.

Step 4

Writing the SOPs (template)

• Start with a clear objective/purpose: Define the goal of the procedure.
• Job levels: List the job titles of those who should be able to perform the task (eg, veterinarians only, technician/nurse and customer service representatives [CSRs], or all personnel).
• Definitions: Define any abbreviations used in the SOP, considering a new hire who may not be familiar with industry abbreviations.
• Health or safety warnings: Specify any safety protocols or precautions. Be sure to specify any material safety data sheets to follow.
• Equipment/materials/tools: Enumerate all necessary resources.
• Step-by-step instructions: Provide detailed instructions for each task using clear language and action verbs.
  • Include visual aids: Diagrams, flowcharts, or screenshots can enhance understanding.
  • Responsibilities: Clearly outline who is responsible for each step or task.
• Quality control measures: Include checks or validations to ensure accuracy.
• References: Provide citations for relevant regulations, guidelines, or policies. In other words, what are you basing your SOP on?

Step 5

Review and approval

• Internal review: Have the practice owner(s), medical director, and manager(s) review the SOPs for accuracy and completeness.
• Revision: Incorporate feedback from the team and make necessary revisions.

Step 6

Implementation and training

• Rollout plan: Determine how and when the SOPs will be implemented.
• Training: Conduct sessions to ensure the team understands and can follow the SOPs effectively.
• Documentation: Keep records of training sessions and ensure all team members acknowledge receipt of the SOPs.

Step 7

Maintenance and updates

• Regular review: Schedule periodic reviews to ensure SOPs remain relevant and up to date.
• Version control: Clearly label document versions and revisions.
• Feedback mechanism: Establish a system for the team to provide feedback or suggest improvements.

Step 8

Document control

• Storage: Store SOPs in an easily accessible location or digitize them and make PDF versions readily available on all computer stations throughout the hospital or accessible via an employee portal.
• Access control: Limit access to revise any SOP to authorized personnel only.
• Versioning: Maintain a clear version history to track changes.

Step 9

Continuous improvement

• Feedback loop: Encourage staff to provide feedback and suggestions for improving SOPs.
• Performance monitoring: Regularly assess adherence to SOPs and identify areas for enhancement.
• Benchmarking: Compare your SOPs with industry best practices and adjust accordingly. Consider resources, including American Animal Hospital Association guidelines, articles, textbooks, other veterinary publications, discussion board topics hosted by professional associations, feedback from conference attendees, and more.

Implementing SOPs

SOPs are helpful in many areas of the hospital. From stating treatment or testing protocols to handling client queries to clarifying team responsibilities, SOPs can provide the necessary clarification to a seasoned team member or guide a new hire. Regular reviews help rid a process of bureaucratic creep (ie, how many hoops one needs to jump through to finish a task) and update a process due to new technology or medical advancements.

Some examples of SOPs follow.

SOP for requesting new pharmaceuticals and/ or medical equipment

Purpose: Explore new pharmaceuticals and/ or medical equipment for improved patient care while preventing excess inventory with “old” pharmaceuticals or repeat pharmaceuticals similar to the latest addition.

Job level (who should be able to perform task): This task is the responsibility of veterinarians and managers. The SOP should include definitions or abbreviation, health or safety warnings, and equipment and supplies to be used.

Procedural steps:

1. Submit information regarding new pharmaceuticals or equipment to the inventory coordinator.
2. The inventory coordinator will obtain pricing and any additional information.
3. Information will be given to the chief medical officer for discussion with all the veterinarians.
4. Discussions are to include the following:
   1. Use of the new pharmaceutical or equipment
   2. What it will replace
   3. Cost
   4. Price to charge clients
   5. Amount of training the team will require
5. The chief medical officer will inform the inventory coordinator regarding ordering and what to phase out

Quality control and records management: These policies are set by the hospital’s owner, manager, etc.

Consequences: Establish steps to be taken when hospital policies are not followed. For example, what happens when an employee orders new pharmaceuticals or medical equipment without the proper approvals?

SOP for end-of-shift transfer

Purpose: Ensure thorough communication of information with the team and clients. Prevent errors in patient care. Reduce wasted time searching for information or calling the person who has left for the day.

Job level: SOPs for all team members, including veterinarian, lead technician, and lead CSR, should be established. These could include health or safety warnings, and notes about equipment and supplies.

Procedural steps:

• Identify who is leading the transfer.
• Identify who is required to attend the transfer meeting.
• Discuss in a quiet area that lacks patient and client traffic flow.
• The area must have computer access to review medical charts.
• Core issues to transfer include, but are not limited, to the following:
  • Urgent tasks for the incoming team, identifying who is undertaking the task
  • Changes in hospitalized patient conditions
  • Unstable patients and next steps
  • Client contact needed, identifying who is undertaking the task
  • Staffing concerns for the incoming shift
  • Equipment concerns

Consider quality control and records management, consequences, and industry standards as well as references and applicable regulations.

Takeaways

By following the steps for writing, updating, and implementing an SOP, you can create comprehensive and effective SOPs that contribute to the smooth operation of the veterinary hospital. Remember that SOPs should be living documents, subject to periodic review and refinement, to ensure they remain relevant and valuable.