CPCS Disaster and Emergency Privileging 1 — Questions and Answers
Question 1: During activation of a hospital's emergency management plan, who is authorized to grant disaster privileges to volunteer practitioners?
- The CEO or designee (Correct answer)
- The credentials committee chair
- The department chief
- The state medical board
Correct answer: The CEO or designee
Under Joint Commission Standard MS.13.01.01, the CEO or designee is authorized to grant disaster privileges when the hospital's emergency management plan has been activated.
Question 2: Which Joint Commission standard specifically governs the granting of disaster privileges to volunteer licensed independent practitioners?
- MS.13.01.01 (Correct answer)
- MS.06.01.03
- LD.04.01.01
- EC.04.01.01
Correct answer: MS.13.01.01
Joint Commission Standard MS.13.01.01 directly addresses the process for granting disaster privileges when the normal primary source verification process cannot be performed.
Question 3: What is the minimum documentation required to grant disaster privileges to a volunteer practitioner when normal credentialing processes cannot be followed?
- A government-issued photo ID plus evidence of current licensure (Correct answer)
- A completed credentialing application only
- A letter of good standing from the practitioner's primary hospital
- Verbal confirmation from two hospital staff members who know the practitioner
Correct answer: A government-issued photo ID plus evidence of current licensure
Joint Commission requires at minimum a government-issued photo ID (driver's license or passport) combined with evidence of current licensure such as a current hospital ID badge, license copy, or primary source verification from another accredited hospital.
Question 4: What is 'credentialing by proxy' in the context of disaster privileging?
- Relying on another accredited hospital's primary source verification to support a privileging decision (Correct answer)
- Allowing practitioners to self-certify their own credentials during a disaster
- Delegating all credentialing functions to an outside CVO during an emergency
- Using NPDB query results as the sole basis for granting disaster privileges
Correct answer: Relying on another accredited hospital's primary source verification to support a privileging decision
Credentialing by proxy allows a receiving hospital to rely on the primary source verification already performed by another accredited hospital when making a disaster privileging decision.
Question 5: After a disaster declaration ends, what must the hospital do regarding practitioners who received disaster privileges?
- Complete primary source verification or terminate those privileges (Correct answer)
- Convert disaster privileges to standard temporary privileges automatically
- Retain the privileges until the next reappointment cycle
- Notify the NPDB of all practitioners who were disaster-privileged
Correct answer: Complete primary source verification or terminate those privileges
Once the emergency ends, the hospital must complete full primary source verification for any practitioner whose privileges it wishes to continue, or those privileges must be terminated.
Question 6: Which document within a hospital organization should formally outline the process for granting disaster privileges?
- The emergency management plan and/or medical staff bylaws or policies (Correct answer)
- The annual credentials committee report
- The hospital's NPDB self-query form
- The CMS Conditions of Participation survey instrument
Correct answer: The emergency management plan and/or medical staff bylaws or policies
Hospitals are required to document their disaster privileging process within the emergency management plan and/or medical staff bylaws or policies so the process is defined before an emergency occurs.
Question 7: A volunteer practitioner arrives during an activated hospital emergency. The credentialing specialist has collected a valid driver's license and a copy of a current state medical license. What is the appropriate next step?
- Proceed with granting disaster privileges per the hospital's policy and notify medical staff leadership (Correct answer)
- Require a full credentialing application before any privileges are extended
- Query the NPDB before allowing the practitioner to see any patients
- Defer the decision to the credentials committee at its next scheduled meeting
Correct answer: Proceed with granting disaster privileges per the hospital's policy and notify medical staff leadership
A government-issued photo ID plus a current state license satisfies the Joint Commission minimum documentation standard; the credentialing specialist should proceed per policy and ensure medical staff leadership is notified.
CPCS Disaster and Emergency Privileging 1
During activation of a hospital's emergency management plan, who is authorized to grant disaster privileges to volunteer practitioners?