Ask the expert: Who owns the process of developing a policy regarding clinical assistants and advanced practice professionals?

How should an organization proceed in developing or revisiting a policy covering clinical assistants and advanced practice professionals? To simplify matters, if a policy doesn’t currently exist, the best place to begin is to evaluate the current scope of practitioners allowed to practice within the facility. If the organization wants to expand the services offered, it should evaluate the additional disciplines that the leaders may wish to consider adding and include these disciplines in the policy.

From there, creation of a policy should be a board-level activity. This may require that the organization create a task force with representation from the governing board, hospital administration, medical staff, and community leaders, as appropriate.

Organizations must create and adhere to policies. Organizations often make the mistake of consulting the organized medical staff about the inclusion of specific allied health disciplines, but officially, this route could lead to charges of antitrust activities. For example, sometimes physicians who wish to have their employee assist them within the hospital will request permission to include particular clinical assistants or advanced practice professionals during a medical staff meeting.

If organizations follow a policy, they can quickly grant permission if the healthcare provider is included in the listing of those already authorized to provide clinical services. If the individual is not listed, the organization should not grant permission to the medical staff member to use this support person within the hospital setting. However, if the organization is interested in the practitioner’s request, it should place a moratorium on the request and refer the issue to a board-level task force.
 

This week’s question and answer are from The Medical Staff Leader’s Practical Guide, Sixth Edition by William K. Cors, MD, MMM, FACPE, CMSL; Mary J. Hoppa, MD, MBA, CMSL; and Richard A. Sheff, MD, CMSL.