QUESTION: We used emergency, alternative credentialing methods to grant privileges to additional practitioners at the outset of the COVID-19 pandemic — and to grant additional privileges to practitioners who were already members of our Medical Staff but willing to work beyond their normal scope of practice in order to help us best respond to community needs. Now, as we are winding down some alternative care sites and trying to find ways to get elective surgeries and treatments back on track, we are facing new dilemmas. For example, we need to offer some elective procedures at alternative care sites because certain facilities in the health care system are still dedicated to COVID care. If we want to have a practitioner from hospital A exercise his or her privileges in hospital B or an affiliated ambulatory surgery center, do they have to apply for Medical Staff appointment and privileges? We’ll never get that done on time. Can we continue to rely on temporary privileges and disaster privileges to get those individuals privileged and “up and running” at the other sites — even though they are not treating COVID patients (on the basis that the shifting of sites is nevertheless related to the COVID-19 pandemic)?
ANSWER: Just because the initial crisis is passing does not mean that the COVID-19 emergency is over — nor that the solutions for dealing with the emergency are unavailable to credentialers. You should, of course, check the Medical Staff Bylaws and/or Credentials Policy of the organization where an individual is to be privileged to determine what they say about temporary privileges for an important patient care need and/or disaster privileges. But, in all likelihood, both of these options will be available to you to help you solve the conundrum about how to temporarily get elective (but still necessary) procedures back on the schedule and underway, to meet the needs of your community. It’s important to remember, in the case of disaster privileges, that they can continue to be granted for so long as the emergency management plan is activated (which, in the case of most hospitals dealing with COVID-19, will probably be for quite some time). Of course, disaster privileging has its limitations (including that the institution that grants them is supposed to implement some method for monitoring those who have been granted disaster privileges and then periodically reviewing — perhaps every 72-hours for Joint Commission accredited hospitals — whether they should be continued). In this scenario, temporary privileges may provide a better option, since they can generally be granted for a longer time period initially (up to 120 days, pursuant to most Medical Staff Bylaws and related documents) and can be granted again and again if need be.
Of course, if the practice arrangement goes from a short-term arrangement to a long-term arrangement, then it would make sense to start full credentialing of the practitioners who have now been privileged to provide services at the alternative site. But, many organizations may find that as the COVID-19 pandemic passes, most practitioners are happy to get back to their usual places of practice and, in turn, full credentialing at the alternative site may not end up being necessary.
QUESTION: We expect to have a surge of coronavirus patients in the next week or two, so we are currently credentialing and privileging practitioners to help with the patient volume. Should we rely exclusively on disaster privileges for this, or should we consider temporary privileges instead? What about emergency privileges?
ANSWER: Emergency privileges are not an ideal tool for dealing with a pandemic. Emergency privileges are intended for scenarios where a patient experiences a sudden emergency and a physician rushes to help. For example, imagine a circumstance where a (seemingly healthy) patient is visiting your hospital and collapses suddenly. Emergency privileges would authorize a physician to provide emergency care at the scene that goes beyond the scope of his or her clinical privileges. That authorization would last only until the emergency was under control.
Consequently, the main question is whether you should grant temporary privileges (for an important patient care need) or disaster privileges. If you have a week or two to prepare for a surge in patient volume, then it may be optimal to consider temporary 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.
Disaster privileges can be used if you need to onboard someone very quickly. Generally speaking, disaster privileges can be granted after you verify a volunteer’s identity and licensure. Accreditation standards place certain timelines on the verification of licensure. Note that the Joint Commission also requires an oversight process for volunteers who are licensed independent practitioners and who have been granted disaster privileges. Specifically, based on the oversight, the hospital must determine within 72 hours if disaster privileges should continue. A similar process must be followed for volunteers who are not licensed independent practitioners but who are “required by law and regulation to have a license, certification, or registration” (e.g., respiratory therapists).
This is a rapidly evolving topic, and it is important to consider your own unique needs and circumstances when evaluating these options.
QUESTION: I noted that one of the cases that was in this week’s HLE arose as a result of a hospital granting temporary privileges to an applicant for medical staff appointment. While we do not routinely grant temporary privileges, they are useful from time to time. How much risk is there in granting temporary privileges?
ANSWER: While temporary privileges should not be routinely granted, it is not unusual for a hospital’s medical staff bylaws to state that temporary privileges may be granted to applicants for initial appointment whose complete application is pending review by the Medical Executive Committee and the Board. In order to be “complete” there must be verification of licensure, training or experience, current competence, and an ability to perform the privileges requested. In addition, the bylaws should state that in order to be eligible for temporary privileges, an applicant must (i) have had no current or previously successful challenges to licensure or registration, (ii) have not been subject to involuntary termination of medical staff membership at another organization; and (iii) have not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges. The bylaws may include other criteria that must be met before temporary privileges are granted.
Additionally, the hospital must query and evaluate information from the National Practitioner Data Bank and check the Office of Inspector General’s List of Excluded Individuals/Entities before temporary (or any privileges) can be granted. Finally, the grant of temporary privileges should be time limited consistent with the standards of the applicable accreditation organization. According to The Joint Commission standard “Temporary privileges for applicants for new privileges are granted for no more than 120 days.”
It is not clear, but it appears from the facts of the case described above, that the hospital’s hospitalist group had such a need for the nocturnist that it wanted to use temporary privileges to rush a candidate through the hospital’s credentialing process. The temporary privileges were granted and rescinded in 2012, but the litigation did not end until 2019. In this case, not only did granting temporary privileges fail to fill the nocturnist position, but also caused the hospital years of litigation.
The best way to avoid these kinds of situations and the endless litigation that sometimes ensues is only to grant temporary privileges to applicants after a thorough vetting, after confirmation that there are no red flags and only under the above-described circumstances.
QUESTION: A department chair instructed our Medical Staff office to provide an application to someone who was formerly on our staff but who has not practiced in a hospital setting for several years. The application contained no recent peer references. This applicant was persistent, and has now asked for temporary privileges. What should we do?
ANSWER: This application is incomplete! So, temporary privileges cannot be provided! (Many applicants do not recognize this.) Hospitals are required to verify from primary sources information regarding every applicant’s education, training, practice history and current competence for all privileges requested. These requirements are found in accreditation standards, the Medicare Conditions of Participation and, in many states, hospital licensing requirements.
The courts in most states have adopted the doctrine of negligent credentialing/hospital corporate negligence. Hospitals must, in order to meet the standard of care in credentialing, obtain relevant information related to an applicant’s satisfaction of all qualifications. You must confirm practice history following the applicant’s tenure on your staff, as well as current competence.
Every applicant has the burden of demonstrating satisfaction of all qualifications and of resolving any doubts. Incomplete applications cannot be processed. (If you don’t have language to this effect in your Bylaws or Credentialing Policy, add it soon!) So you should write a letter stating that the application is incomplete and that it cannot be processed unless and until complete information is provided and verified, demonstrating current competence for all privileges requested. If your bylaws have a time frame for the provision of this information or else the application is deemed to be withdrawn, add that as well. (No NPDB report is required for withdrawal of an incomplete application.) Assume that this letter is aimed at multiple audiences, so it makes sense to provide some education about accreditation, regulatory and legal standards.
And — finally — it would make sense to have a process whereby applications are provided only by the Medical Staff Office in response to a written request, and then on authorization of the Medical Staff professional and the CMO/VPMA. That way, if an applicant pressures a department chair, the chair can state that the standard process requires a written request to the Medical Staff Office. (The once-common practice of using a pre-application eligibility questionnaire has declined for many reasons, but every application should be scrutinized for eligibility before it is processed.)