Chapter 1: Introduction

1.1 About this Toolkit

This toolkit includes the policies and procedures for [YOUR CLINIC NAME] and replaces all previous manuals and directives.  The web and template versions will be maintained and updated by ​the provincial divisions office. ​Customized toolkits will be maintained and updated by designated staff members in [YOUR CLINIC NAME].

If you have any feedback on the contents of the web or template versions of this toolkit, please provide comments using this form. If you have any feedback on the contents of [YOUR CLINIC NAME]'s customized toolkit please let your Toolkit Coordinator know, and he/she will take any necessary action.

In the web version, use the left menu to look for topics, or use the website search function. If you have any questions, use the Table of Contents to look up subjects, or press CTRL+F to bring up the find tool, and search for topic of your choice.


1.2 Making This Toolkit Your Own

This toolkit is designed to be modified to fit the needs of your individual practice. To make this toolkit your own, refer to the editing guide for easy to follow directions. D​ivisions of Family Practice provincial office will maintain the links provided to you in this document. Please watch for updates posted ​in the right-hand sidebar.


1.3 Changes to this Toolkit

Our philosophy is one of continuous improvement, using the Plan – Do – Study – Act quality improvement process.  We expect frequent changes to this toolkit as we continuously implement improvements in our policies and processes. The Editing Guide can be used to guide you through making changes if any formatting is unclear.

Roles for policy and process development:

  • [Medical Director/Practice Manager] approves any changes to policy or procedures.
  • The Toolkit Coordinator facilitates policy and procedure change requests, document changes, and update this document.
  • Anyone may develop a policy or process for consideration by the doctors.
  • Everyone should be looking out for and communicating improvements to the way we work.



[Clinics may develop their own clinic blurb. You may want to consider include points such as:

  • When the clinic opened
  • Clinic location
  • Number of doctors and other support staff
  • Special programs or services
  • Number of patients/panel size (e.g. number of patients under regular care or number of patients seen in a year…)
  • Other pertinent info such as ambulance services, urgent care, etc.

OR – if you have a clinic website with this information, include a link in this section.]

The following is an example:

The Everyone’s Healthy Medical Clinic (EHMC) opened on November 28, 2007 when the Westside Family Medical Clinic and the Northwest Medical Centre joined as a single clinic.

EHMD is located in Southern Vancouver Island’s West Shore and serves rural areas. The area includes a culturally and age diverse population of about 14,000. 

EHMC includes six family physicians.  The clinic hosts itinerant specialists and family practice residents and provides an urgent care clinic for the general public on evenings and weekends.

The EHMC doctors estimate that almost 70% of the area’s population are on the clinic roster, while their urgent care clinic serves the rest of the population for immediate care issues.

The area is also served by the BC Ambulance Services and a number of Vancouver Island Health Authority Services including Home and Community Care based in Esquimalt, public health services, and an Environmental Health Officer.

The closest hospital is Victoria General Hospital approximately 25 km away.



[YOUR CLINIC NAME] is a group family medicine clinic based on the following ideals:

The following is an example:

For everyone on the team:

  • Patient centered focus for planning and care
  • Supportive, inclusive, multidisciplinary team approach to Family Medicine
  • Respect for all roles in the multidisciplinary team, and tolerance of our differences
  • Open and clear communication among all team members
  • Recognition of and respect for all team members’ private lives
  • Mindfulness in delivering efficient and cost effective services.

For the doctors:

  • Shared on-call responsibilities
  • Cross-coverage of each other’s practices when needed
  • Consensus decision making, based on a structured, consistent approach
  • Physicians as a resource to the larger community
  • Collaborative approach to teaching responsibilities of medical residents, students
  • Rotating community roles, e.g._______________
  • Needs-based planning (services based on community needs and capacity, not simply previous activities or physician interests)


1.6 C​linic Organization

The diagram below explains the organizational structure of [YOUR CLINIC NAME].

The following is an example:

organizational structure.JPG