New Client Welcome! 

Barrins & Associates welcomes our new client Apollo Behavioral Health Hospital located in Baton Rouge, Louisiana.  Apollo Behavioral Health Hospital is a new hospital and will be seeking initial Joint Commission accreditation. They provide inpatient, partial hospitalization and intensive outpatient services. We are pleased to be working with Apollo Behavioral Health Hospitalon on achieving Joint Commission accreditation.

It looks like disaster privileging is back on the TJC radar screen. During recent  surveys, we have noticed an increased focus by surveyors on the hospital's disaster privileging process. Some hospitals have been cited for their medical staff bylaws not adequately addressing how they handle disaster privileges. Others have been found lacking for not having a process in place for the non-LIP volunteers.

The requirements for disaster privileging are contained in the Emergency Management chapter of the Hospital Manual. Standard EM.02.02.13 outlines the requirements for volunteer licensed independent practitioners (LIPs). There are a few key points to keep in mind when designing your disaster privileging process:

• Disaster privileges are only to be assigned when the hospital has activated its Emergency Operations Plan in response to a disaster.
• The medical staff bylaws must identify who can grant disaster privileges.
• There must be a written description of how the medical staff will oversee the performance of volunteer LIPs who are granted disaster privileges. (This could be contained in the medical staff bylaws, medical staff rules/regulations or in a policy.)
• The volunteer LIP must present a government issued ID plus one or more of the following:
• A current picture hospital/health organization ID card
• A current license to practice
• Identification showing that he/she has been granted authority to render patient care in disasters (granted by a federal, state, or municipal entity.)
• Confirmation by an LIP or staff member at your hospital of the volunteer's ability to act as a volunteer during a disaster
• Primary source verification of licensure should occur within 72 hours if possible
• Remember: Disaster privileges and emergency privileges are not the same thing. Disaster privileges are used when practitioners outside of your own medical staff require privileges to treat your patients due to a disaster in your community. Emergency privileges are granted to existing practitioners on your medical staff. The emergency privileges allow LIPs to perform functions outside of their existing privileges in order to save a patient's life.

TJC Hospital standards also outline a similar process for assigning disaster responsibilities to volunteer practitioners who are not LIPs but who are required by law to have a license, certification or registration. This is detailed in standard EM.02.02.15.  Some non-hospital behavioral health organizations have adopted this process to assign disaster responsibilities to volunteers even though the Behavioral Health standards do not contain requirements to do so. 

To assist with designing your disaster privileging process, we are sharing the following resources that we have found helpful:

• A Sample Disaster Privileging Policy (originally developed by the Greater NY Hospital Association)
• A Sample Application for Disaster Privileges (originally developed by the Wisconsin Hospital Association)