Emergency Management - Requirements for Granting Privileges During a Disaster

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 Hospital and Critical Access Hospital Accreditation Manuals 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.

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 hospital, 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 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
(*) 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). 
 
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 LIP. Based on its oversight of each volunteer licensed independent 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 independent 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.02.02.15. Examples of such practitioners may include, but are not limited to :  Nurses, Physician Assistants, Nurse Practitioners, Respiratory Therapists, etc.

Additional Resources:
FAQ:  Credentialing and Privileging - Temporary Privileges
Last updated on March 20, 2020
Manual: Hospital and Hospital Clinics
Chapter: Emergency Management EM

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