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One commonly overlooked requirement in The Joint Commission’s 2026 Hospital Accreditation Standards involves the management of Volunteer Licensed Practitioners (VLPs) during a disaster.
Under NPG.03.02.03, hospitals must have a written process for granting disaster privileges when the Emergency Operations Plan (EOP) is activated, and additional licensed practitioners are needed to meet patient care demands. The standard requires hospitals to verify and document the practitioner’s identity, perform primary source verification of licensure within 72 hours of the practitioner’s arrival (or document why this timeframe could not be met), provide oversight of the practitioner’s professional performance, and determine within that same 72-hour period whether disaster privileges should continue.
Just as importantly, NPG.03.02.03 requires the hospital to identify the individual(s) authorized to grant disaster privileges. This authority must be documented in the Medical Staff Bylaws, Rules and Regulations, or Medical Staff policies and procedures. In addition, MS.14.01.01 requires the Medical Staff Bylaws to define the organization’s credentialing and privileging processes. Together, these standards emphasize that disaster privileging is not solely an Emergency Management function, but also a Medical Staff governance responsibility.
Where the Gap Shows Up
One of the most common compliance gaps occurs when the Emergency Operations Plan describes a disaster privileging process that differs from the Medical Staff governance documents. Surveyors frequently review both and expect them to be fully aligned. The authority to grant disaster privileges, the credentialing process, practitioner oversight, and documentation requirements should be consistent across all governing documents.
Best Practice: What Your Process Should Clearly Identify:
- Who is authorized to grant disaster privileges.
- How volunteer practitioners’ identities will be verified.
- How and when primary source verification will be completed.
- Who will provide clinical oversight of the volunteer practitioner.
- How disaster privileges will be documented and when they will be terminated.
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