On Infection Prevention & Control

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Granting Privileges to Volunteer Licensed Independent Practitioners

04/01/2020

Robert Campbell, PharmD, director, clinical standards interpretation for hospital/ambulatory programs 

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here. All examples are for illustrative purposes only.

In my blog post yesterday, I illustrated the screening requirements for volunteers who are NOT licensed independent practitioners (LIPs). Today, I wanted to further explain requirements for granting privileges in a disaster for ambulatory care organizations.

The requirements that address disaster privileging are found in the Emergency Management (EM) chapter of the Ambulatory Health Care Accreditation Manual at standard EM.02.02.13. Disaster privileges can only be granted to volunteer licensed independent practitioners when an organization’s emergency operations plan has been activated.  

A disaster is an emergency that, due to its complexity, scope, or duration, threatens an organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.

Providing outpatient elective surgery or treating non-life-threatening illness would NOT apply. 

Before granting emergency privileges, the organization must:
Obtain a valid, government-issued photo ID (e.g. driver’s license, passport) and at least one of the following:

 

  • A current picture identification card from a health care organization that clearly identifies professional designation.
  • A current license to practice.
  • Primary source verification (PSV) of licensure.  NOTE:  PSV of licensure occurs as soon as the disaster is under control or  within 72 hours from the time the volunteer LIP presents him- or herself to the organization, whichever comes first (see also standard EM.02.02.13, EPs 8 and 9 for additional information).
  • Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal response organization or group.
  • Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment or services in disaster circumstances.
  • Confirmation by a LIP currently privileged by the organization or by a staff member with personal knowledge of the volunteer practitioner’s ability to act as a LIP during a disaster.

Once the above information has been confirmed, disaster privileges are then granted in accordance with the process defined in the emergency management plan.

 

The medical staff must have a process in place to oversee the performance of each volunteer LIP. Based on its oversight of each volunteer LIP, the  organization determines,  within 72 hours of the practitioner’s arrival, if granted disaster privileges should continue.

 

The requirements for assigning disaster responsibilities to volunteer practitioners who are NOT LIPs, but who are required by law and regulation to have a license, certification, or registration, are found in Ambulatory Health Care Accreditation Manual at standard EM.02.02.15. Examples of such practitioners may include, but are not limited to: 

  • nurses
  • physician assistants
  • nurse practitioners
  • respiratory therapists

Robert Campbell, PharmD, is director, Clinical Standards Interpretation Hospital/Ambulatory Programs and director, Medication Management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.