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The Boy Scout motto of “be prepared” resonates strongly for healthcare organizations at the time of a disaster.  Hospitals need to have a well-defined procedure for when non-privileged practitioners need authorization to provide patient care when the hospital has activated its Emergency Operations Plan.

Recognizing that an organization’s routine credentialing and privileging process is not a practical manner to expeditiously obtain additional clinical resources to meet community and patient needs in a disaster, the Joint Commission allows for a streamlined alternative to the full credentialing process. EM 02.02.13 provides for volunteer licensed independent practitioners (LIPs) to be authorized to care for patients through a process that will protect the patient and quickly expand critical resources. This standard defines the circumstances under which disaster privileges may be granted as: 1) when the hospital’s emergency management plan has been activated, and 2) the organization is unable to meet immediate patient needs.

Two integral pieces of the usual credentialing and privileging process must be in place:

  1. Verification of licensure, and
  2. Oversight of the care provided by the volunteer practitioner.

In addition, volunteers considered eligible to act as LIPs and professional staff members in the organization must, at a minimum, present valid government-issued photo identification (e.g., driver’s license or passport) and at least one of the following:

  1. A current picture hospital ID card that clearly identifies professional designation.
  2. A current license to practice (for LIPs) or a current license, certification, or registration for professional staff members (non-LIPs).
  3. Primary source verification of the license (for LIPs), or primary source verification of the license, certification, or registration (if required by law and regulation to practice a profession).
  4. 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.
  5. Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances.
  6. 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 LIP during a disaster.

Primary source verification of licensure begins as soon as the immediate situation is under control and is completed within seventy-two (72) hours from the time the volunteer practitioner presents to the organization.

If primary source verification cannot be completed in seventy-two (72) hours (e.g., there is no means of communication or there is a lack of resources), it is expected that it be done as soon as possible.  If this occurs, there must be documentation of the following:

  1. reasons why primary source verification could not be performed in the required time frame;
  2. evidence of the volunteer practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services; and
  3. evidence of the hospital’s attempt to perform primary source verification as soon as possible.

Primary source verification of licensure would not be required if the volunteer practitioner has not provided care, treatment, and services under the disaster responsibilities or privileges.

Other accrediting organizations e.g., HFAP, DNV GL have similar emergency management standards – for complete information, we suggest you visit their website.

Greeley’s core mission is to help hospitals deliver high-quality, cost-effective patient care. For more information on how Greeley can partner with your organization during this challenging time, please email info@greeley.com or call 888.749.3054. 

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