Emergency Management - Requirements for Granting Privileges During a Disaster
What is required in order to grant privileges to volunteer licensed practitioners (LP) 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 Hospital and Critical Access Hospital Accreditation Manuals at EM.12.02.03.
Disaster privileges can only be granted to volunteer licensed 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.
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:
Before granting emergency or disaster incident privileges, the organization must have a documented staffing plan for the management of volunteer licensed practitioners when the hospital is unable to meet its patient needs. The plan outlines the following:
The requirements that address disaster privileging are found in the Emergency Management (EM) chapter of the Hospital and Critical Access Hospital Accreditation Manuals at EM.12.02.03.
Disaster privileges can only be granted to volunteer licensed 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.
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:
Before granting emergency or disaster incident privileges, the organization must have a documented staffing plan for the management of volunteer licensed practitioners when the hospital is unable to meet its patient needs. The plan outlines the following:
- Verifies and documents the identify of all volunteer licensed practitioners
- Completes primary source verification of licensure as soon as the immediate situation is under control or within 72 hours from the time the volunteer licensed practitioner presents to the organization
- Provision of oversight of the care, treatment, and services provided by the volunteer licensed practitioner
- Note: If primary source verification of licensure cannot be completed within 72 hours, the hospital documents the reason(s) it could not be performed
The hospital identifies those responsible for granting disaster privileges to volunteer physicians and other licensed practitioners and has a process for granting these privileges. This is documented in the medical staff bylaws, rules and regulations, or policies and procedures.
Manual:
Critical Access Hospital
Chapter:
Emergency Management EM
New or updated requirements last added: May 11, 2023.
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: May 11, 2023
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: March 14, 2020
This Standards FAQ was first published on this date.
This page was last updated on May 11, 2023
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.