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Emergency Management - Requirements for Granting Privileges During a Disaster

What is required in order to grant privileges to volunteer licensed practitioners in an emergency or disaster situation?

Any examples are for illustrative purposes only.
 
The requirements for disaster privileging are found in the Emergency Management (EM) chapter at EM.12.02.03.  
Disaster privileges can only be granted to volunteer physicians and other licensed practitioners (such as APRNs and PAs) when the organization's Emergency Operations Plan has been activated.  A disaster is an emergency that, due to its complexity, scope, or duration, threatens the organization's capabilities and requires outside assistance to sustain patient care, safety, or security functions. 

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 of licensure. (^) NOTE:  Primary source verification of licensure occurs as soon as the disaster is under control or within 72 hours from the time the volunteer licensed practitioner presents to the hospital, whichever comes first. (see also EM.12.02.03 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 licensed practitioner currently privileged by the hospital or by a staff member with personal knowledge of the volunteer practitioner's ability to act as a licensed independent practitioner during a disaster 
Once the above information has been confirmed, disaster privileges are then granted by the individual(s) identified in the medical staff bylaws (see MS.01.01.01 EP 14).  Examples of such individuals may include, but are not limited to: the CEO/COO or designee, VP of Medical Affairs, Chief Medical Officer, etc.   

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

Note: The requirements for assigning disaster responsibilities to volunteer practitioners who are NOT licensed practitioners, but who are required by law and regulation to have a license, certification, or registration, are found in the Hospital and Critical Access Hospital Accreditation manual at EM.12.02.03. Examples of such practitioners may include, but are not limited to: Nurses, Physician Assistants, Nurse Practitioners, Respiratory Therapists, etc. 

Organizations that use Joint Commission accreditation for deemed status purposes should monitor the CMS website as waivers are being approved frequently and may include state-specific waivers.
 
(^) Organizations that use Joint Commission accreditation for deemed status purposes may use information from another CMS-certified entity's PSV of licensure as long as the documentation includes evidence that licensure was verified via PSV or via a Credentials Verification Organization (CVO).
 
(^) Organizations that do not use Joint Commission accreditation for deemed status purposes (such as the VA, DoD, children's hospitals) may use information from another like entity as long as the documentation includes evidence that licensure was verified via PSV or via a Credentials Verification Organization (CVO).  
Manual: Critical Access Hospital
Chapter: Emergency Management EM
New or updated requirements last added: June 13, 2022. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: June 13, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on June 13, 2022 with update notes of: Reflects new or updated requirements Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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