Considering that COVID may be with us for the long haul, organizations who are credentialing new physicians or are recredentialing active medical staff members may have difficulty obtaining information from outside sources for primary source verification. Many are wondering how the Joint Commission surveyors will be scoring organizations who have incomplete or expired credentialing paperwork.
The Joint Commission recommends those who are working under their emergency operation plan consider utilizing EM.02.02.13 which states that “during disasters, the hospital may grant disaster privileges to volunteer licensed independent practitioners”. They define a disaster as “an emergency that due to its complexity, scope or duration, threatens the organizations capabilities and requires outside assistance to sustain patient care, safety or security functions”.
During a disaster, two pieces of the credentialing process are required to determine qualifications and competence. Those are (1) verification of licensure, certification or registration is required to practice a profession and (2) oversight of the care, treatment, and services provided.
For new credentials, if the organization is not in their emergency operations plan they should document all efforts to obtain information and continue to attempt to obtain the information, ensure State Law doesn’t require the information, and move forward with the process with the information they have.
For recredentialing, if an established provider’s privileges are scheduled to expire during the time of the declared national emergency, The Joint Commission will allow an automatic extension of medical staff reappointment beyond the 2-year period under the following conditions:
• A national emergency has officially been declared
• The organization has activated its emergency management plan
• Extending the duration of providers’ privileges during an emergency is NOT prohibited by State Law
The duration of the extension cannot exceed 60 days after the declared state of emergency has ended.
The organization determines how the extension will be documented.
Reference: The Joint Commission, Re-Appointing and Re-Privileging During a Disaster