Washington has a rule that does more work than its length suggests.
Under the Washington Medical Commission’s rules on nonsurgical medical cosmetic procedures — WAC 246-919-606, made under RCW 18.71 — a physician must be fully and appropriately trained in the procedure before performing it or delegating it.
Read that as an operator. The physician whose name is on your protocol has to be trained on the thing your staff are doing. Not trained in medicine generally. Trained in that procedure. A physician who has never used your device, or never injected the product you carry, cannot lawfully authorise someone else to.
Why this is the most useful sentence in the batch
Most states approach the absentee medical director indirectly — through supervision standards, availability requirements, or a board’s disapproval after the fact. Washington makes it a precondition. The question “are you trained on this?” is answerable before anything happens, and it is a question a prospective director either can or cannot answer.
It also gives you a clean test when you add to the menu. New device, new product category, new procedure: is the delegating physician trained on it? If not, the delegation for that item is not available until they are, whatever the existing agreement says.
The protocol contents are prescribed
Washington does not leave the written office protocol to your imagination. It must include, at minimum:
- The identity of the physician responsible for the delegation of the procedure.
- Selection criteria to screen patients for the appropriateness of treatment.
- A description of appropriate care and follow-up for common complications, serious injury, or emergencies.
The third of those is the one most protocols we are shown handle badly. “Refer to the emergency department” is not a description of appropriate care for a vascular occlusion.
Who may receive the delegation
A physician meeting the requirements may delegate a nonsurgical medical cosmetic procedure to a properly trained physician assistant, registered nurse or licensed practical nurse. Note that the rule names the licences; “properly trained” qualifies who within those licences, it does not extend the list.
Read the nursing side too
The Washington Board of Nursing has published an advisory opinion on medical, aesthetic and cosmetic dermatological procedures, and the Department of Health has run a Med Spa and Esthetic Services Work Group with published guidance for businesses offering esthetic services. Those sit alongside the Medical Commission rule and are not identical in emphasis. If your staffing is nurse-heavy, the nursing materials are the ones your team will be measured against.
Related reading
Frequently asked questions
Can a Washington physician delegate a procedure they have not performed?
No. WAC 246-919-606 requires the physician to be fully and appropriately trained in the procedure before performing or delegating it.
Who may perform delegated cosmetic procedures in Washington?
A properly trained physician assistant, registered nurse or licensed practical nurse, under a compliant written office protocol.
What must the written office protocol contain?
At minimum the identity of the physician responsible for the delegation, patient selection criteria, and a description of appropriate care and follow-up for common complications, serious injury or emergencies.
Does the Board of Nursing have its own position?
Yes. It has published an advisory opinion on medical, aesthetic and cosmetic dermatological procedures, and the Department of Health has published med spa guidance. Read them alongside the Medical Commission rule.
General information about Washington delegation rules, not legal advice. Confirm your obligations with healthcare counsel licensed in Washington.