Guidance on the Joint Commission’s Temporary and Disaster Privileging Policies

As COVID-19 increases the demand for healthcare personnel, hospitals are activating their emergency plans to quickly onboard practitioners to meet patient demand. In the current national emergency, the Secretary of Health and Human Services has modified certain CMS requirements, including Conditions of Participation, by invoking 1135 Waivers. This enables hospitals to amend their credentialing and onboarding processes to quickly accommodate more practitioners. The Joint Commission provides the following guidance on temporary and disaster privileging for such emergencies through Medical Staff Chapter, Standard MS.06.01.13.

Temporary Privileges
Per Medical Staff Chapter, Standard MS.06.01.13, Joint Commission-accredited hospitals may grant temporary privileges to quickly increase its number of privileged practitioners when the current number of privileged personnel cannot meet patient volume.

Disaster Privileges
The Joint Commission refers to Emergency Management Chapter, Standard EM.02.02.13 protocol to enable its accredited hospitals to provide temporary privileges once their governing body or hospital board activates their emergency operations plans and need to increase privileged personnel to meet patient demand.  According to Standard EM.02.02.13, EP2 refers to the hospital’s medical staff bylaws to identify the personnel responsible for issuing disaster privileges. In designated emergencies, accredited hospitals may also privilege volunteer licensed independent practitioners.

Typically, those who are licensed independent practitioners in professions that a hospital medical staff recognizes and privileges can practice without supervision. MSPs should refer to their hospital bylaws and state licensure laws to confirm supervision requirements.  State licensure law will also provide guidance on practitioner supervision requirements.

Through Standard EM.02.02.15, the Joint Commission also enables its accredited hospitals to privilege volunteer practitioners who are not licensed independent practitioners, but required to have a license, certification, or registration.

Credentialing and Privileging for Temporary Privileges
The Joint Commission requires its accredited hospitals to verify a practitioner’s current license and competence, as well as document the current need for granting temporary privileges via the MSO Chief of Staff or designee recommendation, in the practitioner’s credentialing file.  MSPs should also query the NPDB before granting temporary privileges.

All hospitals that provide temporary or disaster-related privileges must have protocol for overseeing these practitioners. The Joint Commission provides more logistical guidance on credentialing practitioners during disasters, as well as overseeing practitioners with temporary or disaster-related privileges.

Additional COVID-19 Hospital Resources:
• The Joint Commission’s COVID-19 Page.
• NAMSS
• American Hospital Association
• Arent Fox