Sexually Transmitted Diseases  >  Program Guidelines  >  Medical and Laboratory Services

Program Operations Guidelines for STD Prevention
Medical and Laboratory Services

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• CLINIC MANAGEMENT STRUCTURE
• CLINIC MANUALS
• CLINIC ROLES AND PERFORMANCE STANDARDS
• STANDARD PRECAUTIONS

CLINIC MANAGEMENT STRUCTURE

Clinics should have one person (usually the clinic manager) who has the authority to develop and implement clinic goals, policies, and procedures, as well as to manage personnel, orchestrate all clinic functions, and ensure quality of care. Delegation of clinic manager functions depends on clinic resources, staffing, and space. Working as part of the clinic management team, the medical director supports and complements the efforts of the clinic manager by carrying out a number of special medical duties. The interrelationship between management staff members (clinic manager, medical director, laboratory director, DIS supervisor, and other supervisory staff members) is critical to accomplishing STD prevention program objectives.

Clinic Manager

At a minimum, job qualifications for clinic manager should include: 1) adequate medical knowledge to make valid comparisons between observed clinician performance and clinic protocols, 2) specialized STD training (see Clinician Performance Standards), 3) clinic management training, 4) public health experience or an orientation toward STD intervention concepts and activities to understand the needs of DIS supervisors and staff, and 5) understanding of standard laboratory procedures and methods to coordinate clinical and laboratory functions effectively.

The clinic manager needs to have the necessary training and authority to carry out various personnel management responsibilities. These include: 1) development of accurate job descriptions and reasonable performance standards for clinicians, 2) providing staff orientation, familiarity with work plans, and knowledge of performance expectations, 3) arranging for adequate staffing to care for the patient population (even when vacations are scheduled), and assuring staff training and updates in STD patient management and universal precautions.

The clinic manager also ensures that 1) clinic policies and procedures for all aspects of clinic operations are developed, implemented, and updated, 2) the clinic manual is current and accessible to all employees, visiting clinicians, and clinicians-in-training, 3) information is communicated to all staff through regular staff meetings and that staff members are encouraged to make suggestions about policies, 4) standard blood and body fluid precautions are observed by all personnel, 5) patient flow is optimal including developing policies for triage, quality assurance procedures for the clinical aspects are implemented and maintained, 7) the clinic facility, including equipment and supplies, is adequate for the patient population, 8) that appropriate medical oversight is available as needed, 9) quality assurance functions related to clinic operations are performed at regular intervals and the results are used to modify operations manuals .

Medical Director

The responsibilities of the medical director include: 1) ensuring the best use of non-physician providers within the limits of state and local regulation, 2) signing standing orders for non-physician clinicians and acting as the final authority on medical care in the clinic, 3) being available, or arranging for other physician coverage in the director's absence, for consultation with non-physician clinicians during all clinic hours, 4) identifying and assisting with the training of clinicians to improve clinical practice and learn new techniques, 5) assisting the clinic manager in clinician performance evaluations by observation and chart reviews, 6) assuring that clinic manuals are up-to-date and appropriately used by the clinic manager to guide clinic activities, 7) routine auditing of medical records to ensure quality clinical care and that clinic protocols are followed, 8) ensuring that the quality assurance committee's recommendations concerning medical care are implemented, 9) seeing patients in the STD clinic on a routine basis.

CLINIC MANUALS

Clinic manuals should include all policies and procedures that relate to the operation of the clinic. This should include personnel policies and medical protocols that are followed in the local area, as well as any emergency or injury protocols. Current and signed standing orders for non-physician clinicians should be included if required or not prohibited by state laws and regulations (medical practice acts). Standing orders are the signed instructions of a licensed physician which outline the medical assessment, appropriate testing, and treatment that a clinician may perform or deliver on behalf of the physician. In some states, non-physicians are authorized to perform assessments and prescribe medications independently. Standing orders also serve to standardize the clinical care practiced by all clinicians.

CLINICIAN ROLES AND PERFORMANCE STANDARDS

The use of non-physician clinicians is critical to STD medical management. Non-physician clinicians can manage most STDs and can provide HIV prevention counseling. Nursing and physician assistant roles should not be limited to history taking, assisting physicians, and dispensing medication. Having a single clinician manage each patient lessens the patient's sense of fragmentation and impersonal interaction; it also improves patient flow and patient satisfaction. Patients' perceptions and experiences during the examination can influence their willingness to comply with staff instructions at any step in the process. The extent to which various categories of non-physicians can function as clinicians is defined in medical practice statutes and legal precedent in each state or locality. Clinicians who perform HIV prevention counseling or partner services should receive specific skill training and should be evaluated regularly in those skills.

At a minimum a clinician must have the appropriate licensure or credentials required by the state or locality. New clinicians should have a preceptorship before caring for patients independently. Specific training for clinicians inexperienced in STD examinations should include completion of the Comprehensive or Intensive STD Clinician Course at a STD/HIV Prevention/Training Center or a similar course; completion of an AIDS Update Course, or equivalent, that includes clinical and epidemiologic information about HIV infection; a course in HIV client centered counseling, if this service is a clinical care responsibility; and certification or special training in Mantoux skin testing for tuberculosis (when testing is provided in the clinic).

The manner in which clinicians relate to patients, especially in a STD clinic, is critical to patient acceptance and follow through on treatment, behavioral intervention, and prevention of transmission to others. Clinicians should present an image of sensitivity and competence to the patient. The importance of good interviewing, counseling, and education skills on the part of the clinician cannot be overstated. All relevant medical history, risk assessment, examination, diagnosis, and treatment should be accurate and noted in the medical record. Counseling messages should be specific, clear, and allow the patient time to ask questions. Clinicians should strictly adhere to standard (formerly known as universal blood and body fluid standards) precautions. Clinicians should facilitate a seamless transfer of the case to other team members such as DIS when appropriate.

STANDARD PRECAUTIONS

Standard Precautions are a set of protocols designed to reduce the risk of (or prevent) transmission of pathogens. Standard precautions synthesize the major features of Universal (Blood and Body Fluid) Precautions (designed to reduce the risk of transmission of bloodborne pathogens) and Body Substance Isolation (designed to reduce the risk of transmission of pathogens from moist body substances). Under standard precautions blood, all body fluids, and all body substances of patients are considered potentially infectious (CDC, 1997).

Standard precautions should be observed by all clinical personnel for all patients as part of routine infection control. Clinicians, laboratory technicians, phlebotomists, and other health care professionals routinely come into contact with blood and body fluids during the course of examination and testing. Blood is the single most important source of infection with HIV and viral hepatitis in the workplace. The potential for hepatitis transmission in the clinic is greater than for HIV. Health care workers should be particularly alert to the need for preventing tuberculosis transmission in settings in which persons with HIV infection receive care.

Federal regulations on preventing the spread of bloodborne pathogens are contained in the final rule (Department of Labor, Occupational Safety and Health Administration, Occupational exposure to bloodborne pathogens; final rule (29 CER 1910.1030) Federal Register, pp. 64004-64182, Dec. 6, 1991.) These regulations, which took effect on March 6, 1992, outline in detail what employees must be taught about the hazards of working with potentially infectious materials and what precautions must be taken to prevent or minimize exposure to such materials. The regulations are summarized below.

• Every employer is required to have a written exposure control plan designed to eliminate or minimize worker exposure. The document must include all job classifications and job tasks in that place of employment that could lead to occupational exposure and the names of workers at risk for exposure to infectious materials. The written exposure control plan must have a record keeping element that includes a training records section and a medical records section.
• Training records must include the date, content outline, trainer's name and qualifications, and names and job titles of all persons attending the training sessions.
• A medical record must be established for each employee with occupational exposure. This record is confidential and separate from other personnel records. The medical record contains the employee's name, social security number, hepatitis B vaccination status, including the dates of vaccination and the written opinion of the health care professional regarding the Hepatitis B vaccination. If an occupational exposure occurs, reports are added to the medical record to document the incident and the results of testing following the incident.
• Any employee whose job requires contact with blood or other body fluids must receive free biosafety training during working hours, followed by annual refresher courses.
• All workers to whom standard precautions apply should be offered and should strongly consider receiving hepatitis B vaccine.
• Each clinic in which persons with HIV infection receive care should have a policy for Mantoux tuberculin skin testing of all health care facility workers (not just those interacting with patients). A baseline skin test administered within 2 weeks of employment and a follow-up based on the prevalence of tuberculosis in the patient population and community is suggested.

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