Manual:
Hospital and Hospital Clinics
Chapter:
Emergency Management EM
Topic:
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.
Last updated on May 11, 2023
with update notes of: Reflects new or updated requirements
First Published Date: March 14, 2020
Last Reviewed Date: May 11, 2023
Last Major Update: May 11, 2023