How to Develop a Surgery Center Policy and Procedure Manual

A surgery center needs more than skilled staff and shiny tools. It needs structure. That structure begins with a clear Surgery Center Policy and Procedure Manual. This manual isn’t just a stack of documents—it’s the backbone of your operations. It guides your team, protects your patients, and keeps your center compliant. Without it, things can quickly fall apart.

Start with the Foundation

Start simple. Define who you are and what your surgery center does. Include your mission, the services you offer, and your staff structure. This section helps everyone—from new hires to inspectors—understand how your center works. Keep your language easy to follow. You’re not writing for a lawyer—you’re writing for your team.

Organised by Department

Now, break the manual into clear sections. Don’t throw all your policies into one big mess. Organise it by department. For example, have sections for Administration, Clinical and Nursing, Infection Control, Pharmacy, Emergency Response, and Billing. Each department should have its playbook. And each policy should include real steps, not just rules. Say what needs to happen, when, and who is responsible. This makes it easy for your team to follow.

Align with Medicare Rules

If your surgery center bills Medicare, your manual must meet Medicare’s requirements. And let’s be honest—they don’t make it easy. Missing a single step could mean denied payments or a failed inspection. That’s why Surgery Center Medicare Consulting is so important. At Accredia, we help you make sure every section of your manual meets Medicare’s rules. We remove the guesswork and keep your center audit-ready.

Use Simple Language

Many centers make one big mistake—they write their manual like a legal document. Don’t do that. Your team actually needs to understand the manual. Use short sentences and everyday words. Instead of writing, “Initiate sterilization protocols per standardized documentation,” just say, “Clean and log all tools after surgery.” Simple language helps people follow steps quickly—especially when time matters.

Train Your Team

Creating the manual is step one. Teaching it is step two. Don’t let the manual sit on a shelf. Make sure every team member knows it. Walk them through it. Hold training sessions. Run drills. Ask questions. A policy is only useful if your team can put it into action. Training turns rules into habits.

Update It Every Year

Your manual shouldn’t be static. Healthcare changes constantly—new technology, rules, and staff. What worked last year might not work today. That’s why you should update your manual at least once a year. Review each section. Remove anything outdated. Add anything new. This keeps your center safe and current.

Need Help? Accredia’s Got You

Writing a manual from scratch can be overwhelming. That’s where Accredia comes in. We help you build custom Surgery Center Policies and Procedures that make sense for your team. Our Surgery Center Medicare Consulting ensures everything meets the latest standards. Visit www.accredia.shop to get started. Let’s build something solid—together.