Disaster or Emergency Management Plan Privileges

Question 1

TJC
Disaster or Emergency Management Plan Privileges

Answer 1

• During disasters, disaster privileges may be granted to licensed practitioners when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs
• If the organization’s usual credentialing and privileging processes can’t be performed due to the disaster, a modified credentialing and privileging process can bused on a case-by-case basis
• Medical staff bylaws must identify the individual(s) responsible for granting disaster privileges
• The medical staff must have a documented mechanism for oversight of the professional performance of volunteer physicians and other licensed practitioners who received disaster privileges, which can be accomplished through direct observation, mentoring, and/or clinical record review
• There must be a mechanism to identify volunteer physicians and other licensed practitioners functioning under disaster privileges in order to be considered for disaster privileges, the organization must obtain, at a minimum, present a valid government-issued photo ID from a state or federal agency, such as a driver’s license or passport, and at least one of the following
• Current picture hospital ID card with professional designation
• Current license to practice
• PSV of licenses
• Identification indicating the volunteer is a member of a Disaster Medical Assistance Team, the Medical Reserve Corps, the Emergency System for Advance Registration of Volunteer Health Professionals, or another recognized federal, state or, municipal entity
• Identification indicating that the individual has been granted authority to render patient care, treatment, and services during disaster by a federal, state or municipal entity OR
• Identification by a current hospital employee or medical staff member with personal knowledge of ability of the volunteer to act independently during a disaster

Question 2

NCQA
Disaster or Emergency Management Plan Privileges

Answer 2

Not specifically addressed

Question 3

ACHC Acute Care Hospitals
Disaster or Emergency Management Plan Privileges

Answer 3

• The Medical Staff Bylaws provide for a Medical staff chief and/or the CEO to grant emergency privileges to a practitioner to accomplish lifesaving procedures, within the scope of their license during such times that reasonably suggest that a staff member who is a credentialed practitioner with appropriate privileges is not available
• Temporary privileges can be used in time of emergency and/or disaster
• The hospital has a plan for dealing with clinical volunteers during emergency/disaster. This plan should provide for primary source ID from the volunteer’s hospital (a documented phone call is acceptable). This hospital should use volunteers as appropriate within the scop of their license/certification

Question 4

Medicare Hospital COPS and Interp Guidelines
Disaster or Emergency Management Plan Privileges

Answer 4

Interpretive Guidelines 482.41(a)
The hospital must coordinate with Federal, Sate, and local emergency preparedness and health authorities to identify likely risks for their area (e.g., natural disasters, bioterrorism threats, disruption of utilities such as water, sewer, electrical communications, fuel; nuclear accidents, industrial accidents, and other likely mass casualties, etc) and to develop appropriate responses that will assure the safety and well-being of patients [this includes]
- Qualifications and training needed by personnel, including healthcare staff, security staff, and maintenance staff, to implement and carry out emergency procedures

Question 5

DNV NIAHO for Hospital
Disaster or Emergency Management Plan Privileges

Answer 5

MS.7 SR.4
Bylaws must include a process for approving practitioners for care of patients in the event of an emergency or disaster

Question 6

URAC Health Plan
Disaster or Emergency Management Plan Privileges

Answer 6

not specifically addressed

Question 7

AAAHC Ambulatory Health Care
Disaster or Emergency Management Plan Privileges

Answer 7

• Under the Facilities and Environment standards, a comprehensive written emergency and disaster preparedness plan to address internal and external emergencies is present
• Under the Quality of Care standards, when hospitalization is needed due to emergencies or unplanned outcomes the organization may have a policy for credentialing and privileging physicians and dentists who have admitting and similar privileges at a nearby hospital