Ask the expert: Should allied health professionals have their own manual, policies, and procedures?

Yes, this may be an acceptable arrangement. But first, it is important to understand that the term allied health professional (AHP) means different things to different people, and AHPs go by different names in different organizations. In general, AHPs are usually not members of the medical staff.

There are two distinct groups of AHPs. One consists of the practitioners who must be granted privileges through the medical staff process. These practitioners are perhaps better described as advanced practice professionals (APP). An APP is an individual, other than a licensed physician, dentist, clinical psychologist, or podiatrist, who provides direct patient care services in the hospital under the supervision of a medical staff member with clinical privileges. APPs include physician assistants and advanced practice registered nurses, such as nurse midwives, nurse practitioners, clinical nurse specialists, and nurse anesthetists. 

The second group of AHPs consists of individuals the hospital does not need to privilege through the medical staff. Instead, they are approved by the hospital’s HR department. These individuals provide services that are consistent with a scope of care approved by the medical staff and the board and should perhaps be called clinical assistants (CA). CAs provide patient care services in a clinical or supportive role. Surgical assistants/technicians, registered nurse first assistants, private duty scrub technicians, perfusionists, and occupational and physical therapists may be considered CAs.

Since APPs must be credentialed and privileged in accordance with Joint Commission standards, some medical staff bylaws create a “parallel staff” or “adjunct status” category to accommodate this requirement. Other medical staffs grant APPs privileges without placing them in any category and then create a separate AHP manual to address the specifics.

Joseph Cooper, MD
Consultant
The Greeley Company