Annual competence reviews for AHPs

Competence evaluations for allied health professionals (AHP) is not onerous. For Joint Commission–accredited organizations, the HR standards require that AHPs have the same education, training, and competence requirements as their employed equivalents. For example, if the hospital employs surgical technicians/assistants and it allows medical staff members to bring their own surgical technicians/assistants in to assist them in the operating room, the credentialed surgical technicians/ assistants and the employed surgical technicians/assistants have equivalent requirements. Typically, medical staff services departments will collaborate with the HR department to align job descriptions and competence requirements. If there is not an employed equivalent to a credentialed AHP, then the hospital is responsible for creating an appropriate description of the individual’s responsibilities and required qualifications. The HR department would typically involve the requesting physician, pertinent medical staff leaders (such as the department chair or section chief), the credentials committee, and/or an AHP committee (if one exists).

The Joint Commission also requires that the competence evaluation for an AHP is equivalent to that of an employed equivalent. Most organizations review their employees’ performance on an annual basis; therefore, AHP evaluations should align with what the organization does for its employees.

For the competence evaluation of AHPs, at a minimum, organizations should ensure that the AHP and his or her sponsoring physician(s) review the position/job description annually to ensure that there have been no changes. The medical staff services department should also obtain a clinical evaluation from the sponsoring physician. Feedback can also be obtained from administrative supervisors for the area in which the AHP is providing services; for example, for a dental assistant who accompanies a dentist to the operating room, the nurse supervisor for the operating room can likely attest to whether the dental assistant complies with operating room policies and procedures, such as sterile technique, and whether he or she works collegially with other staff.

Source: The Medical Staff’s Guide to Overcoming Competence Assessment Challenges