2019-Novel Coronavirus (COVID-19) Resources
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CREDENTIALING AND PRIVILEGING
DURING THE COVID-19 PANDEMIC
Q-1: For new practitioners, can we use Emergency Privileges?
A-1: Emergency privileges are not the best fit. Instead, temporary or disaster privileges could be used.
Regarding emergency privileges, the Rationale for Joint Commission MS.06.01.13 provides: “Medical staff bylaws or other documents may stipulate that, in an emergency, any medical staff member with clinical privileges is permitted to provide any type of patient care, treatment, and services necessary as a life-saving measure or to prevent serious harm—regardless of his or her medical staff status or clinical privileges—provided that the care, treatment, and services provided are within the scope of the individual’s license.” Thus, emergency privileges are used to allow individuals who are already Medical Staff members to do whatever is needed to save the life of a patient or prevent serious harm.
Emergency privileges are very rarely used and are intended to be very limited. For example, emergency privileges might come into play when a physician sees a visitor in distress in need of immediate help, the physician could do whatever is necessary to save the visitor even beyond the privileges the physician had been granted.
There are two other options for practitioners who do not have privileges and those are temporary privileges for an important care need and disaster privileges.
(a) Temporary privileges for an important patient care need
Temporary privileges for an important care need are typically used for short term situations such as care of a specific patient, proctoring, and locum tenens. As stated in The Joint Commission Standard MS.06.01.1, the only requirements that must be met before granting temporary privileges for non-applicants are:
- a National Practitioner Data Bank (“NPDB”) query;
- confirmation of current licensure; and
- confirmation of current competence.
Many hospitals do more before granting this kind of temporary privileges. These privileges are time-limited, and the limit should be stated in Bylaws. Most commonly we see these temporary privileges limited to 120 days. For DNV GL hospitals, NIAHO accreditation requirements at MS.15, SR 5, allow six months for locum tenens “or similar temporary medical service.” While the grant of these privileges is not intended to be used as a way around the more thorough credentialing process used for initial applicants, this might be an appropriate option in the case of COVID-19 because the process is more thorough than the process followed in granting disaster privileges.
If you are part of a system, even if there is not a unified medical staff, you could pass a resolution allowing for the grant of temporary privileges for an important patient care need to any physician, or other practitioner, who has been fully credentialed by any hospital within the system. The only verification that would be necessary would be confirmation from the medical staff office or credentialing verification office that the individual maintains appointment and clinical privileges within the system. Additionally, as with any other grant of clinical privileges, you would have to query the NPDB. This query should be made before the physician starts to work, if possible, or as soon as possible thereafter. Under the circumstances, prior approval by the hospital board is not essential. However, it would be prudent to present a list of practitioners who were granted temporary privileges at next board meeting for ratification
(b) Disaster Privileges
The granting of disaster privileges is anticipated to be for volunteers (those who do not have clinical privileges in the hospital). There is no limit on the number of days disaster privileges may be in effect but rather are designed to last for the duration of the disaster. The Joint Commission standards (EM.02.02.13) require activation of the hospital’s Emergency Operations Plan in response to a disaster. Thereafter, disaster privileges can be granted when the hospital is unable to meet immediate patient care needs.
According to The Joint Commission, disaster privileges can be granted, on a case-by-case basis, using a modified process as described in the Medical Staff Bylaws or related policies. Before granting disaster privileges, the hospital must verify the identity of the volunteer and the licensure of the volunteer.
A volunteer’s identity may be verified through a valid government-issued photo identification (i.e., driver’s license or passport). A volunteer’s license can be verified in number of ways including (i) current hospital picture ID; (ii) current license to practice; (iii) primary source verification of the license; (iv) identification indicating that the volunteer has been granted authority to render patient care in disaster circumstances or is a member of a Disaster Medical Assistance Team, the Medical Resource Corps, the Emergency System for Advance Registration of Practitioner Health Professionals, or other recognized state or federal organizations or groups; or (v) identification by a current hospital employee.
Per The Joint Commission, verification of licensure is to be completed within 72 hours. If this is not possible, there should be some documentation explaining why and the efforts taken to complete this function.
The Joint Commission standards also require the Medical Staff oversee the performance of each volunteer granted disaster privileges and, based on this information, determine if privileges should continue.
There is a similar process to follow for volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification, or registration (e.g., nurses, physician assistants, nurse practitioners, respiratory therapists). According to the standards, verification of licensure, certification or registration is required, so too is the “oversight of the care, treatment, and services provided.” For individuals who are not granted clinical privileges (such as nurses), the hospital must identify “in writing” who may assign disaster responsibilities to these individuals.
As a practical matter, it is imperative to confirm the identity of any volunteer practitioner before he or she starts to practice. Thereafter, efforts to verify the volunteer’s licensure, registration or certification should be completed as soon as possible.
It is also advisable to have some mechanism, even if perfunctory, to confirm that the volunteer is providing adequate care. This could be done by direct observation, mentoring, and/or medical record review. If possible, these efforts should be documented.
A FAQ on “Emergency Management – Requirements for Granting Privileges During a Disaster” issued by The Joint Commission can be found here:
Q-2: How can we authorize currently privileged practitioners to provide expanded care?
A-2: It depends on whether the currently privileged practitioner is seeking to (1) use basic medical skills to assist with the disaster; or (2) perform specialized functions that would require a grant of additional clinical privileges.
(a) Using Basic Medical Skills
Many elective procedures are being cancelled or postponed due to the pandemic. This may leave specialists available to participate in the provision of care when resources are strained, and some frontline professionals are ill themselves. While the specific tasks that are needed to be performed may not be expressly included in the delineation of privileges for specialists, the needed skills are basic and medical professionals should be competent to perform them. Examples may include performing an H & P, preparing discharge summaries, and otherwise helping the attending physician (who would remain ultimately responsible).
It would be time consuming, burdensome, and unnecessary to process individual requests for additional privileges. Thus, the Medical Executive Committee could adopt a resolution authorizing currently privileged practitioners to assist in whatever ways are reasonably determined by the attending physician, or designated leaders in the Emergency Department, ICU, or other areas. The Medical Executive Committee might choose to define the privileges that are likely to be needed in treating patients during the pandemic.
The authorization in this resolution would not depend on the implementation of the disaster plan but would rather serve as a global authorization to assist in the care of patients, using the skills of trained professionals, to meet the urgent needs of patients in the community. The resolution should be limited to the duration of the COVID-19 national, state, or local emergency.
In considering such a resolution, care should be taken to carve out any practitioner who is currently subject to an adverse recommendation, under investigation, or subject to a performance improvement plan. A practitioner in any of these categories would be ineligible for the global authorization or would be handled on a case-by-case basis.
Also, the resolution should make clear that practitioners are being authorized to perform only functions that require basic medical skills (with examples being provided).
(b) Grant of Additional Privileges
In contrast, some privileged practitioners may have voluntarily limited their practice but remain qualified to perform additional specialized functions that require clinical privileges. For such individuals, disaster privileges or temporary privileges could be granted (see Question 1 for additional information).
Q-3: What if we can’t process reappointment applications within normal time frames?
A-3: According to a FAQ published by The Joint Commission, if an established member’s clinical privileges are going to expire during the national emergency, The Joint Commission will allow an automatic extension so long as the following conditions are met.
First, a national emergency must have officially been declared. As we know, this happened by proclamation dated March 13, 2020.
Second, your organization must have activated its emergency management plan. This activation should be documented.
Finally, state law must not prohibit extending the duration of privileges during an emergency. Most states are issuing broad emergency orders allowing for flexibility in the health care arena to respond to COVID-19, so this last factor won’t serve as a prohibition.
According to The Joint Commission, the duration of the extension cannot exceed 60 days after the state of emergency has ended and the organization should “determine how the extension will be documented.” Exhibit A to these FAQs is a sample resolution that addresses both extending the term of reappointment and the grant of disaster privileges.
The Joint Commission’s FAQ “Emergency Management – Reappointment and Re-privileging Time Period During a Disaster” can be found here:
Q-4: We are in an “all hands-on-deck” mode. There are several members of our medical staff who have recently had their appointment and privileges relinquished because they failed to satisfy our threshold eligibility criteria. Does COVID-19 create a reasonable basis to waive the criteria?
A-4: The answer to this question is “it depends.” While the national emergency created by the COVID-19 pandemic might, in some circumstances, justify waiving the threshold criteria, you should be careful. For instance, if a physician was ineligible for continued appointment due to a finding of clinical incompetence or egregious behavior, for example multiple counts of sexual abuse of minors, that is not the kind of person you should bring back under any circumstances
However, if a physician was ineligible for continued appointment because the state board had placed conditions on her license which required her participation in the Physician’s Health Program, and physician is complying with her recovery requirements, you might consider a waiver. Depending on the underlying issue, you may want to make the waiver time limited to synch with the duration of the COVID-19 national emergency and/or the implementation of the hospital’s emergency management plan.
Disasters like this have a way of bringing the best out in people. They also have a way of bringing the worst out in people. We are already seeing physicians who have recently been subject to discipline applying at new hospitals perhaps in the hope that they can slide in when the credentialing standards are lower. You need to stay vigilant even during the pandemic.
Q-5: In an effort to curtail the spread of COVID-19, we are trying to reduce patient visits to our primary care physician and, when possible, provide ambulatory services via telemedicine. Our employed physicians have all been granted “ambulatory privileges.” Do we need to grant “telemedicine privileges” to these providers too?
A-5: HHS recently published a “Notification of Enforcement Discretion for Telehealth” in which HHS expressly stated: “We are empowering medical providers to serve patients wherever they are during this national public health emergency…. ” The Notification also stated that penalties for noncompliance with regulatory requirements under HIPAA Rules against health care providers in connection with the good faith provision of telehealth during COVID-19 would not be imposed. Enforcement: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
Additionally, The Joint Commission, in a recently published FAQ, expressly provided: “Licensed Independent Practitioners (LIP) CURRENTLY credentialed and privileged by the organization, who would now provide the same services via a telehealth link to patients, would not require any additional credentialing or privileging. The medical staff determines which services would be appropriate to be delivered via a telehealth link. There is no requirement that ‘telehealth’ be delineated as a separate privilege.” (Emphasis added.) https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/emergency-management-em/000002276/
In light of this guidance, there is no need to grant telemedicine privileges to physicians or other practitioners who have already been granted clinical privileges simply because they are going to be delivering services via telehealth. Because of the requirement that the “medical staff determines which services would be appropriate to be delivered via a telehealth link,” you may want to have the Medical Executive Committee address this issue.
PRACTITIONER CREDENTIALING DURING THE COURSE
OF THE COVID-19 NATIONAL EMERGENCY
WHEREAS, the COVID-19 national emergency has caused widespread closure and/or personnel strain at health care facilities, universities, and government agencies, and has resulted in the cancellation of many activities underlying practitioner credentialing (e.g. board certification examinations, basic life support, and other certifications) and disruption of the Hospital’s ability to obtain primary source verification of certain practitioner credentials during the course of processing applications for initial appointment to the Medical Staff and Advanced Practice Clinician Staff (“appointment”), for the grant of clinical privileges, and for the processing of applications for reappointment to the Medical Staff and Advanced Practice Clinician Staff (“reappointment”);
WHEREAS, the COVID-19 national emergency may create a need for the Hospital to grant clinical privileges to practitioners whose credentials are not in accordance with those required in non-emergency periods, as outlined in the Medical Staff Bylaws, Medical Staff Credentials Policy, and related policies, procedures, and privilege delineation forms;
NOW, THEREFORE, BE IT RESOLVED THAT the Board has determined that immediate, temporary credentialing methods are necessary to ensure that the Hospital can continue to meet the needs of the community during the course of the COVID-19 national emergency. As such, the credentialing methods set forth in this resolution are hereby authorized for individuals seeking appointment, reappointment, and clinical privileges, for the duration of the COVID-19 national emergency and for the immediate time period thereafter up to 60-days following the conclusion of the COVID-19 national and/or local emergency declarations)
BE IT FURTHER RESOLVED THAT during the course of the COVID-19 national emergency, the procedures for disaster privileging may be followed to grant clinical privileges to those specifically responding to the COVID-19 national emergency, as well as to applicants for initial appointment or initial clinical privileges, or applications for additional privileges from practitioners already practicing at the Hospital, insomuch as the credentialing of such individuals is disrupted by the COVID-19 national emergency.
BE IT FURTHER RESOLVED THAT during the course of the COVID-19 national emergency, the Chief of Staff is authorized to extend the reappointment and clinical privileges of any practitioner who is currently appointed with privileges at the Hospital as of March 13, 2020 (the date the COVID-19 national emergency was declared). Unless otherwise determined by the Chief Executive Officer, the extension of reappointment and clinical privileges will last until 60-days following the conclusion of the COVID-19 national emergency or until such time as the individual’s application for reappointment and renewal of clinical privileges can be processed, whichever occurs sooner.
ADOPTED by the Board, March _____ 2020.
Chairperson, on Behalf of the Board of Trustees/Directors
 The guidance provided in these FAQs apply to physicians and other advanced practice professionals who are or must be granted clinical privileges.