To address the COVID-19 national emergency, hospitals throughout the country are seeking to bolster their ranks of health care providers. Under the CMS Conditions of Participation, hospitals should have an emergency plan that guides “[t]he use of volunteers in an emergency and other emergency staffing strategies.”

This alert provides a refresher to Joint Commission-accredited hospitals on common questions regarding the Standards that apply to temporary and disaster privileges, which, depending on the circumstance, hospitals may grant to providers to combat the COVID-19 virus.

What are temporary privileges?

The Joint Commission addresses temporary privileges in the Medical Staff Chapter, Standard MS.06.01.13. For Joint Commission-accredited hospitals, temporary privileges can be granted for a limited duration to fulfill an important patient care, treatment, or service need. The Joint Commission notes in a “Frequently Asked Question” about temporary privileges that a justified need includes situations where the patient care volume exceeds the level that can be handled by currently privileged practitioners and additional practitioners are needed to handle the volume. Temporary privileges also can be granted to applicants for new privileges under certain circumstances that do not depend on patient care need.

What are disaster privileges?

The Joint Commission addresses disaster privileges in the Emergency Management Chapter, Standard EM.02.02.13. For Joint Commission accredited hospitals, disaster privileges are temporary privileges a hospital may grant if the hospital has activated its Emergency Operations Plan, or disaster plan, and the hospital is unable to meet immediate patient needs. According to the Joint Commission, “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.” Your hospital will have its own process for declaring a disaster in its Emergency Operations Plan.

How do I know if my organization permits temporary or disaster privileges?

Most medical staff bylaws provide for temporary and disaster privileges. Your bylaws should describe the process for granting privileges and any limitations on the privileges. You should also consult your hospital’s Emergency Operations Plan.

Who may authorize temporary or disaster privileges?

Typically, the hospital’s governing body or hospital board is the only entity authorized to appoint members to the medical staff and grant privileges. However, Standard MS.06.01.13, EP4 and EP5, provides that all temporary privileges are granted by the chief executive officer or authorized designee, on the recommendation of the medical staff president or authorized designee. With disaster privileges, Standard EM.02.02.13, EP2, provides that the medical staff bylaws identify those individuals responsible for granting disaster privileges, and does not limit it to the chief executive officer or require medical staff recommendations. Examples of individuals that the bylaws can identify may include, but are not limited to: the CEO/COO or designee, VP of Medical Affairs, and the Chief Medical Officer.

Who may receive temporary or disaster privileges?

Your bylaws should specify who is eligible to receive temporary or disaster privileges. Generally, these are “licensed independent practitioners” from professions that are eligible for medical staff privileges at your institution. “Licensed independent practitioners” are those professions whose scope of practice under state law allows them to provide care, treatment, and services without direction or supervision. This may vary from state to state (for example, in some states, nurse practitioners are licensed independent practitioners; in other states, they are not).

In addition to allowing hospitals to grant disaster privileges to volunteer licensed independent practitioners, Joint Commission Standard EM.02.02.15 allows hospitals to grant disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license. The organization must follow its Emergency Operations Plan in determining any qualifications that must apply.

How do I credential applicants for temporary privileges?

When granting temporary privileges to fulfill an important patient care need, Joint Commission Standard MS.06.01.13, EP 2 requires hospitals to verify the provider’s current licensure and competence. The hospital must also document the patient care need that justifies granting the privileges in the provider’s credentialing file. This documentation may be, for example, a written recommendation from the Chief of Staff, or designee, to the hospital administrator granting privileges. The hospital should also request an NPDB report regarding the provider. Other, more detailed requirements apply when granting temporary privileges for an applicant for new privileges.

What oversight responsibilities does the hospital have regarding providers with temporary privileges?

The hospital is ultimately responsible for the quality of care provided to patients. Each hospital’s medical staff must have a process in place to oversee the performance of providers granted temporary privileges. The Joint Commission standards do not specifically address what type of oversight the medical staff must exercise over providers with temporary privileges, but the oversight generally involves the same type of oversight and ongoing professional practice evaluations that apply to members with traditional staff privileges. This includes, for example:

• Periodic chart review
• Direct observation
• Monitoring of diagnostic and treatment techniques
• Discussion with other individuals involved in the care of each patient

How do I credential applicants for disaster privileges?

Joint Commission Standard EM.02.02.13, EP 5 requires organizations granting disaster privileges to document the provider’s government-issued photo ID and at least one of the following:

• A picture identification card from a health care organization that clearly identifies professional designation;
• A current license to practice;
• A primary source verification of licensure;
• 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.

After granting disaster privileges, the hospital must attempt to verify a provider’s licensure using primary sources within 72 hours after the provider arrives, or as soon as circumstances permit. If, due to the emergency, the hospital is unable to complete the verification within 72 hours, it should document the reasons why verification was not performed.

What oversight responsibilities does the hospital have regarding providers with disaster privileges?

Joint Commission Standard EM.02.02.13, EP 6 requires the medical staff to oversee the performance of each volunteer licensed independent practitioner with disaster privileges, but does not dictate who provides the oversight. Many medical staffs delegate that responsibility to the relevant department chair or to a medical staff officer. The medical staff must have a process for overseeing the providers with disaster privileges. The Joint Commission requires hospitals to reassess after 72 hours whether disaster privileges should continue, based on the medical staff’s oversight of the care provided and its recommendation to the hospital.

Quickly-Evolving Issues May Lead to Additional Guidance

Temporary and disaster privileges are two options to help hospitals meet the dramatically increased need for health care providers in response to the COVID-19 emergency. For more information on both types of privileges, see the Joint Commission’s recently-published Frequently Asked Questions on Temporary Privileges and on Disaster Privileges. The Joint Commission recently informed hospitals that it was suspending all regular surveys, so as “not interfer[e] with the work you are doing to prepare and care for your patients during this pandemic.” Given the quickly-evolving nature of the pandemic, accrediting organizations and government regulators may take further action to ensure hospitals have the flexibility they need to meet the expected unprecedented healthcare demands. If hospitals have questions about whether measures they adopt are compliant with legal or accreditation obligations, they should consult legal counsel.