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Emergency Management - Requirements for Granting Privileges During a Disaster (AHC)

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

Any examples are for illustrative purposes only.

The requirements that address disaster privileging are found in the Emergency Management (EM) chapter of the Ambulatory Health Care Accreditation Manual at EM.02.02.13. Disaster privileges can only be granted to volunteer licensed independent practitioners 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.

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 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 independent practitioner presents him- or herself to the  organization, whichever comes      first. (see also EM.02.02.13 EP 8 & 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 licensed independent practitioner currently privileged by the  organization 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 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 licensed independent practitioner, the  organization 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 independent practitioners, but who are required by law and regulation to have a license, certification, or registration, are found in Ambulatory Health Care Accreditation manual at EM.02.02.15. Examples of such practitioners may include, but are not limited to:  Nurses, Physician Assistants, Nurse Practitioners, Respiratory Therapists, etc.

Last updated on July 26, 2021
Manual: Ambulatory
Chapter: Emergency Management EM

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