Temporary and Emergency Privileges: When They Apply

Understanding the Critical Role of Temporary and Emergency Privileges

In the high-stakes environment of hospital administration, the medical staff services department (MSSD) serves as the gatekeeper of patient safety. Typically, the credentialing and privileging process is a deliberate, multi-month marathon involving primary source verification, peer review, and committee approvals. However, medicine is rarely predictable.

When a hospital faces a surge in patient volume, a sudden vacancy in a specialized surgical department, or a regional disaster, the standard 90-to-120-day credentialing timeline becomes a liability. This is where temporary and emergency privileges become vital tools for facility leadership.

While these accelerated pathways allow providers to begin treating patients quickly, they are not a "shortcut" around National Practitioner Data Bank (NPDB) checks or patient safety standards. Understanding the nuances between temporary, emergency, and disaster privileges is essential for practice managers and hospital executives to maintain compliance with The Joint Commission (TJC) and CMS.

What are Temporary Privileges?

Temporary privileges are granted for a limited time and for a specific, focused purpose. According to TJC standard MS.10.01.01, there are two distinct scenarios where temporary privileges are clinically and operationally appropriate:

1. Urgent Patient Care Need

This occurs when a specialty gap exists that poses a risk to patient outcomes. For example, if a hospital’s only neurosurgeon is suddenly unavailable and a patient requires immediate intervention, a qualified outside physician may be granted temporary privileges to manage that specific case or cover the service for a short duration.

2. New Applicant Pending Medical Staff Review

This is the more common "administrative" use of temporary privileges. It applies to practitioners who have submitted a complete application that has been fully verified and is currently awaiting the final "stamp of approval" from the Medical Executive Committee (MEC) and the Governing Board.

To grant temporary privileges in this scenario, the hospital typically must verify:

• Current licensure.
• Relevant training or experience.
• Current competence.
• A clean NPDB report.
• A lack of "red flags" (e.g., previous involuntary termination of medical staff membership).

Emergency Privileges vs. Disaster Privileges

The terms "emergency" and "disaster" are often used interchangeably, but in the realm of hospital privileging, they serve different legal and regulatory functions.

Emergency Privileges

Emergency privileges apply to individual patient life-safety situations. Most hospital bylaws contain a provision stating that in an emergency, any member of the medical staff is authorized to do everything possible to save a life, limb, or organ—even if the specific procedure is not on their approved privilege list. These are usually self-extinguishing once the emergency has passed or a more qualified specialist arrives.

Disaster Privileges

Disaster privileges are triggered when a hospital activates its Emergency Operations Plan (EOP). This occurs during mass casualty events, pandemics, or natural disasters (hurricanes, earthquakes).

During a disaster, the hospital may allow physicians who are not members of the medical staff to provide care. However, the facility must still perform a simplified verification process, which includes:

• A valid photo ID issued by a state or federal agency.
• Identification from the practitioner’s home hospital or a license to practice.
• Confirmation by a current medical staff member with personal knowledge of the practitioner’s ability.

The Regulatory Framework: CMS and The Joint Commission

Regulatory bodies are highly sensitive to the use of temporary privileges because they circumvent the standard peer-review process.

The Joint Commission (TJC) Limits

TJC generally limits temporary privileges for "new applicants" to a maximum of 120 days. Use beyond this timeframe without a formal board decision can result in survey citations. Furthermore, TJC emphasizes that temporary privileges should never be the "standard" way of onboarding; they should be the exception, not the rule.

CMS Conditions of Participation (CoP)

CMS requires that the governing body of the hospital remain legally responsible for the conduct of the medical staff. If temporary privileges are granted without the required primary source verification (PSV) of certain elements (like licensure), the hospital risks its Medicare reimbursement status.

Risk Management and the "Red Flag" Rule

Granting temporary privileges is a high-risk activity for the Hospital Board. Because the full vetting process hasn't been finalized, the facility assumes higher vicarious liability.

To mitigate this, Credentialing Coordinators must look for "Red Flags" that should immediately disqualify a candidate from temporary status:

• Gaps in Work History: Any unexplained gap longer than 30 days.
• Multiple State Licenses: A history of jumping from state to state frequently.
• Malpractice History: Any pending or settled claims that suggest a pattern of poor clinical judgment.
• Disciplinary Actions: Any prior sanctions from a State Medical Board or OIG exclusion.

If a practitioner has any of the above, they should undergo the full, traditional credentialing process—no matter how urgent the staffing need.

The Role of FPPE in Temporary Privileges

Just because a provider is working under temporary privileges doesn't mean they are exempt from Focused Professional Practice Evaluation (FPPE). In fact, FPPE is even more critical for temporary providers.

The hospital must implement a process to monitor many of the practitioner's initial procedures or patient interactions. This can be achieved through:

• Proctoring: A current staff member observes the temporary provider in the OR or at the bedside.
• Chart Review: Timely review of the provider’s documentation and orders by a peer.
• Direct Supervision: Required for high-risk procedures until competence is established.

How to Streamline the Process

For practice managers, the goal is to avoid the need for temporary privileges by managing the credentialing pipeline efficiently. However, when the need arises, following a structured checklist ensures compliance:

1. Draft a Formal Request: The department chair should submit a written justification for the temporary privileges.
2. Verify Vital Credentials: At a minimum, verify licensure, DEA, and NPDB before the provider touches a patient.
3. Bylaws Review: Ensure the specific request aligns with the "Temporary Privileges" section of the Medical Staff Bylaws.
4. Set an Expiration Date: Automated alerts should be set to ensure temporary privileges do not exceed the 120-day (or board-defined) limit.

Conclusion

Temporary and emergency privileges are essential safety valves for the healthcare system. They allow hospitals to remain agile and responsive to patient needs while maintaining a high standard of care. However, because they bypass parts of the traditional vetting process, they require rigorous oversight, strict adherence to bylaws, and a proactive approach to risk management.

By understanding the distinctions between these categories and the regulatory expectations surrounding them, hospital leaders can ensure that "fast" doesn't become "unsafe."

Key Takeaways

• Two Use Cases: Temporary privileges are primarily for an "urgent patient care need" or for qualified "new applicants" awaiting board approval.
• 120-Day Limit: The Joint Commission generally caps temporary privileges for new applicants at 120 days.
• Disaster Privileges: Only applicable when the hospital's Emergency Operations Plan is officially activated.
• Verification is Mandatory: Even for temporary status, licensure and NPDB checks must be completed before the provider begins work.
• High Risk: Temporary privileges carry higher liability; practitioners with "red flags" in their history should not be granted accelerated status.
• FPPE Requirement: All providers on temporary privileges must still undergo monitoring via Focused Professional Practice Evaluation.
• Paper Trail: Every instance of temporary privileging must be documented, justified by a department chair, and approved by the CEO or authorized designee.