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Emergency Management – Reappointment and Re-privileging Time Period During a Disaster

Are there any circumstances under which The Joint Commission will permit an extension to medical staff reappointment time frames, such as during a disaster ?

Any examples are for illustrative purposes only.

If an established provider's privileges are scheduled to expire during the time of the declared national emergency,  The Joint Commission will allow an automatic extension of medical staff reappointment beyond the 2-year period under the following conditions:
  • A national emergency has officially been declared
  • The organization has activated its emergency management plan
  • Extending the duration of providers' privileges during an emergency is NOT prohibited by State Law
     
After the state of emergency ends (national, federal, or local level depending upon which allows the most time to address), organizations have 60 days to complete these requirements.  The organization determines how the extension will be documented.



 
Manual: Hospital and Hospital Clinics
Chapter: Medical Staff MS
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 18, 2020 This Standards FAQ was first published on this date.
This page was last updated on May 23, 2023 with update notes of: Review only, FAQ is current 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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