Credentialing & Privileging

Be prepared when disaster strikes

Credentialing Resource Center Connection, April 26, 2007

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

 

Dear credentialing colleague:

 

The Boy Scout's motto, "be prepared," resonates strongly for healthcare organizations during times of disaster. Hospitals that grant disaster privileges must have a well-defined policy in place that accomplishes all of the following:

  • Provides for volunteer licensed independent practitioners (LIPs) to care for patients expeditiously
  • Is as risk adverse as possible
  • Protects the patient

The Joint Commission recognizes that disaster privileges are necessary for practitioners who must be immediately available to provide patient care, treatment, and services- and, consequently, who cannot be subject to an organization's routine credentialing and privileging process. For that reason, under MS.4.110, The Joint Commission allows for a streamlined privileging process for LIPs that maintains two integral pieces of the usual process: verification of licensure and oversight of the care provided.

 

MS.4.110 defines the circumstances under which a healthcare organization may grant disaster privileges as: When the hospital's emergency management plan has been activated and the organization is unable to meet immediate patient needs. 

 

In addition, the elements of performance (EPs) for MS.4.110 define:

  • The responsibilities of the organization and the medical staff
  • Methods for confirming that the individual is an LIP
  • The requirements for primary source verification of licensure

As a result of this standard and its accompanying EPs 1-8, Joint Commission-accredited organizations must formulate their disaster privileging policies and revise their medical staff bylaws accordingly.

 

Recent disasters have prompted many states and organizations to work together to coordinate a more efficient disaster privileging process that reduces duplicated efforts. Recently, members of the New Hampshire Association of Medical Staff Services (NHAMSS) were part of the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) Hospital Implementation Committee. Patty Roberts, president of NHAMSS, shares the goal of the initiative and the results.

 

Roberts writes:

 

"The ESAR-VHP is a project that was created by Congress in the days following the September 11 attacks. Through the oversight of the Department of Health and Human Services' Human Resources and Services Administration (HRSA) each state is responsible for establishing a system capable of maintaining verifiable, up-to-date information on each volunteer's identity, licensing, credentialing, and privileging. New Hampshire began development of the ESAR-VHP database in June of 2005."

 

"In addition to creating a database to ensure an adequate and competent volunteer force of health professionals, it was important to begin looking at how these health professionals would be able to assist hospitals during a time of disaster. A Hospital Implementation subcommittee began meeting in August of 2006. The committee consists of several NHAMSS members, as well as other representatives from the New Hampshire ESAR-VHP Advisory Committee. The goal is to develop a consistent approach to disaster privileging at every hospital throughout the state. We recognize that not all hospitals are Joint Commission-accredited, but we feel that the policies, procedures, and forms that have been developed represent a "best-practice" scenario and are appropriate for everyone to use.

 

"To date, the committee has created a disaster privileges policy template, which outlines the purpose of the policy and procedures for healthcare organizations to follow. The committee has also developed a disaster privileges coordinator duties template and an initial review and requirement log template to be completed by the disaster privileges coordinator in conjunction with the medical director and the incident commander. Each hospital should modify each of the documents to suit the organization's practices and needs.

 

"In addition, the committee has created a template outlining the method we would like to see information sent back to each hospital from the New Hampshire Homeland Security and Emergency Management office once assistance hospitals have requested assistance. We are working with the ESAR-VHP Advisory Committee to finalize this format, and a list identifying the disaster privileges coordinator at each of the state's 37 hospitals has also been compiled.

 

"It is the committee's belief that the more we collaborate on this project and commit to using the same (or similar) processes and procedures, the better prepared we will all be in the event of an actual emergency."

 

Remember, credentialing has no other master than the patient.

 

That's all for this week.

 

All the best,


Sally J. Pelletier, CPMSM, CPCS

http://www.greeley.com/consulting.cfm



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