ED Accreditation Update: JCAHO changes standards for credentials in a disaster
ED Accreditation Update
JCAHO changes standards for credentials in a disaster
You have 72 hours to verify primary source
Standards have been added and revised in the accreditation manuals for the Joint Commission on Accreditation of Healthcare Organizations to address the verification of credentials and assignment of responsibilities for volunteers who are not licensed independent practitioners during disasters, as well as licensed independent practitioners.
The principle additional burden placed on ED physician leadership relates to the task of quality oversight of emergently credentialed volunteer practitioners, says Timothy Seay, MD, regional medical director of Greater Houston (TX) Emergency Physicians. "The credentialing process for these volunteers is not onerous for the hospital, requiring proof of licensure and a picture ID, followed up within 72 hours some primary source verification, much or all of which is available online in most states," he says. "There is even a provision for the inability to complete primary source verification in the event that the disaster is of sufficient import to preclude it [HR.1.25.B.6]."
Obviously, you have to attend to patients first, says John Herringer, RN, MS, associate director of the Standards Interpretation Group. The Joint Commission's expectation is that you would complete the task within 72 hours unless the communication systems are completely down, he says. "Then you have to document that it's out."
Reason for the revision
The new and revised standards are applicable to the hospital, critical access hospital, and ambulatory care programs. Hospital standard MS.4.110 already included an abbreviated process for privileging licensed independent practitioners when the facility's emergency management plan is activated and the organization cannot handle the immediate needs of its patients. Because there was not a similar process in the critical access hospital's manual and the ambulatory care manual, standard HR.4.35 was added. Among other requirements, standards HR.1.25, MS.4.110 and HR.4.35 establish that, even in a disaster, two parts of the usual process for determining qualifications and competence must be maintained: verification of licensure, certification, or registration; and oversight of the care, treatment, and services provided.
All of the changes were effective July 1, 2006.
Standards have been added and revised in the accreditation manuals for the Joint Commission on Accreditation of Healthcare Organizations to address the verification of credentials and assignment of responsibilities for volunteers who are not licensed independent practitioners during disasters, as well as licensed independent practitioners.Subscribe Now for Access
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