Before learning about SOP, you get the basics right, first, we should understand what is mean by policy, processes and procedure. We should learn how a policy, processes and procedure are connected to a standard operating procedure. So allow me to explain policies, processes and procedure first before getting into the details of standard operating procedure aka SOP.

Policies

• Policies are decision-making guideline which helps to achieve rational outcomes. If management wants to run an organization rationally, there should be several policies that ensure that the decisions taken in the organization is rational, ethical and also comply with the national and international standards and widely accepted good practices.
• Policies help in avoiding subjective bias
• Implementation of policies is generally achieved through standardized procedure or protocol. When a standard operating procedure is prepared, all relevant policies must be taken into consideration.

Understanding processes

• Process means transforming inputs to outputs. It is a set of interrelated or interacting activities that transform inputs into outputs (ref. ISO 9000:2000)
• Process variables (PV) – When we talk about process, we should also understand what is meant by process variables. Process variables are resources need for transformation activities of the process, such as people, infrastructure, work environment, information, materials, supplies, equipment etc
• Product – The result of a process is called a product. It can be a product or service. In the case of Hospital, our product is a service.
• If you understand what is meant by procedure, you will realize why there is no standard procedure for creative work. For example, you cannot set up a procedure for painting. Because there is no defined one way of painting. It is up to you and how you unleash your creativity. But that is not the case when you are working as a receptionist in the front office department in a Hospital. As a receptionist, if you unleash your creativity in a front office in a hospital, it will bring chaos to the Hospital.

Procedure

• A combination of processes is called a procedure. When each process is aligned sequentially with an expected outcome, it becomes a procedure. The more the number of processes, the more complicated the procedure becomes and to standardize the same we create SOPs.

SOPs

• Nothing happens on a reliable, sustained basis unless we build a system to cause it to happen. SOPs just do the same for any industry or organization. SOP stands for standard operating procedure
• When we talk about the hospital industry, SOPs give more important as the process is more complex. Many departments usually get involved in a single procedure and the expertise of individuals working in each department will be different. For the same reasons, having an SOP for each procedure will standardize the entire chain of processes.
• SOPs help in making sure that the important elements of a process are performed consistently in the best-known way. SOP help to describe what should be done for an expected outcome and for that we will include information like who should do what and when, where and how it should be done.
• Changes in the SOPs are made whenever there is a new alternative possible which is better than the existing one. Any revision in the existing process is updated in the SOP.
• Standardization helps us in

1. Increased reliability
2. Reduced cost
3. Improved employee performance
4. Increase safety
5. A process that remains in control
6. Continuous improvement
7. A framework that can be quickly changed and communicated to all employees, allowing for rapid response to changing organization, staff and customer needs

• When an SOP is published or distributed to a department or organization, the management expects the employees to comply with the defined SOP in their daily job. SOPs are a type of written agreement between the management and staff.

Purpose of SOP

• The purpose of an SOP is to gather information on the best practices available in the industry and put it in a written form to make it easier for everyone to do his/her work
• It helps in such a way that even employees who are not fully trained or newbies can use this document to understand the standard process followed in the hospital
• The points are written in detail that the employee can follow what is written in the document to ensure that he/she is doing the task given in a standardized manner
• It helps to prevent variation – Especially for experienced staff who had followed different practices and methods in different hospitals. When they come together to work for a different organization, always there will be a clash on which process to be followed or which

practice is best for the patient, staff and organization. SOPs remove all these variations and confusions.

• It provides clear instruction to all stakeholders on what is expected from them
• SOPs provide a basis for training new people
• It acts as a document to trace problems
• To ensure compliance with standard
• To ensure that the procedure will not result in any kind of adverse event
• To ensure the safety of the person who performs the procedure
• To ensure the safety of the person who receives the product or service
• To ensure the credibility of the organization
• To adhere to a defined TAT and waiting time
• To prevent errors and variation
• To ensure repeatability and reproducibility

Steps to make a Standard Operating Procedure

Step 1: Make it a team effort

• A good SOP can be prepared only if it is a collaborative effort. Experienced stakeholders/department HODs from different disciplines should come together to develop an SOP.
• Call the team together and discuss with them how they think this job should be done. Make sure that most of the members of the team are those who are going to ask to adhere to the final SOP. This helps to ensure that all the necessary tasks are included. At the same time, ensure that some team members are from outside the department who are aware of the process and are representatives of the management ex. Quality department.

Step 2: Process mapping

• Process maps are a key type of documentation used in standard practices
• If you are making an SOP for a new hospital, you should do process mapping based on the best practices in the industry that can be customized after considering the present organization’s capability and limitations. Whereas, if you are working for an existing hospital, you should first map the current process and from there, you should look for opportunities to improve the process, discuss the same with all stakeholders, understand the infrastructure requirement and present the same to the approval authorities and if the revised process gets approved, make changes in the existing process and accordingly develop a revised standardized operating procedure.

Step 3: Identify your audience

• Knowing your audience helps you determine how you should write your SOP document.
• Consider reader’s existing knowledge, how familiar they are with the organization and the procedures, do we expect them to know all the terminologies and what are their language skills? If they are not good in a common language like English, you may want to use more pictures than words.
• If most of the employees are new, your SOP documents need to be very detailed and training-oriented
• If the document is meant for many departments in an organization, with readers who are into different roles, you may want to write the procedures in a way that clearly defines who, or what role, performs each task. This helps your audience understand where they each fit into the process.

Step 3: Review of Literature

• During all these steps mentioned above try to refer to and use available pieces of literature. Most of the time, whatever you are planning to write would have already written by someone else. Do detailed research online and from libraries to ensure that you have enough basic data to start with. If the content is already available somewhere else, you can use the same as a reference and customize it according to the requirement of your organization.

Step 4: Begin with a table of content

• Identify the heading and subheading first. This will help you in separating the complete SOP into different subcategories. This will help you in focusing on one topic at a time and write about it in detail.
• For each heading, try to make subheading as much as possible. This helps you to ensure that no major points are missed while preparing the SOP.
• Finish writing about all subheadings identified under the main heading and once you are done, move to the next heading. Like this, complete the entire table of content which will help you to come up with a structured draft document of SOP.

Step 5: Choose a standard format

Write a draft of your standard operating procedure and consider including some of the following elements to make all the SOPs in your organization a standardized one.

• Name and logo of the organization
• The title of the document
• Document number
• Issue date and number
• Revision date and number
• Names and signatures of those who prepared, reviewed, approved and issued the document
• Details of amendment if any
• Table of contents – Give links in the table of content to all heading and subheading. You need a table of content only if the document is large.
• A description of the scope and purpose of the SOP, its limits, and how it should be used.
• Roles and responsibilities of the major members in the department specific to the SOP
• The reporting structure of the department
• Clarification of terminology, including acronyms and phrases that may not be familiar to your reader
• Explanation in detail about all the points mentioned in the table of content
• Details of forms and registers related to the SOP
• Reference literature that used to make the SOP and for further reading

Step 6: Review, test, edit, repeat

• After you have written your standard operating procedure document, send a draft of the SOP to team members for review. Have them note grammatical and technical errors
• Give some of the user end staff to read through the document to ensure that the language is clear and can be easily followed
• Incorporate relevant edits and suggestions as required to improve the document
• Repeat these steps until the document is approved and accepted by all stakeholders

Implementation of SOPs

Distribution and accessibility

• It is important to ensure that the SOPs developed in an organization is accessible to all stakeholders.
• Just sharing and making it accessible is not enough. It should be ensured that all staff have gone through the document thoroughly and they understood what is exactly expected from them.
• It is preferable to do this activity the moment a staff is newly recruited especially with in the first week of joining. This should be a part of the induction program. Department HOD should ensure this activity and there should be a process by which the HR department of any organization ensures the compliance of this process.
• As we expect that for a newbie, as everything is new for him/her, we should ensure that he/she will spend enough time going through the SOP
• In the case of experienced staff, he/she should unlearn what was practised earlier and should try to read and understand the SOP that is followed in the new organization with a fresh mind.

Training

When you have completed the documentation, you need to make sure that everyone using the process is trained in the new methods. Even experienced employees need to be trained in the new methods. Training ensures that all process users perform in the same way that results in repeatability and reproducibility.

• Do not try to develop a single training session to teach people everything they need to know about their job
• Focus on the most critical aspects of the SOP
• When you make changes to process, explain the reasons behind the changes; people resist change for change’s sake
• Do not expect everyone to learn everything at once

Monitoring

• It is not enough to put an effective solution in place, the solution must be maintained over time. This requires management action to monitor key measures, review work methods and procedures and take appropriate action when a problem occurs. You should review the SOP at a pre-defined interval or as necessary to identify areas where it can be improved and to reflect any changes that have been made to current procedures.