Healthcare regulatory bodies have responded to the challenges of the coronavirus by relaxing standards with which hospitals must comply. Among them, the Joint Commission (“TJC”) and DNV GL, an international accredited registrar and classification society, have issued guidance for hospitals that addresses concerns regarding the timeliness of reappointments during the declared national emergency related to COVID-19.
According to a FAQ posted under TJC’s Emergency Management Standards, TJC will permit hospitals to grant an automatic extension of the two-year reappointment period to established medical staff members whose appointments and privileges are scheduled to expire during the time of the declared national emergency so long as the following conditions are met:
- A national emergency has officially been declared;
- The organization has activated its emergency management plan; and
- Extending the duration of providers’ privileges during an emergency is not prohibited by state law.
The FAQ further clarifies that the extension may not exceed 60 days after the declared state of emergency has ended and that the organization must determine how to document the extension.
The first condition, that a national emergency must have been declared, was satisfied by President Trump’s March 13, 2020 “Proclamation Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak.”
The second condition is met only after an organization has activated its emergency management plan. Presumably, most, if not all, California hospitals have done so.
The third condition, which requires that the extension of privileges not be prohibited by state law, has been met. In California, the two-year appointment period is mandated by Title 22 of the California Code of Regulations (“CCR”) section 70701 (a)(7), an accompanying regulation to the licensing requirements for general acute care hospitals. On March 4, 2020, California Governor Gavin Newsom issued a Proclamation of a State of Emergency in which he issued the following order:
“To ensure hospitals and other health facilities are able to adequately treat patients legally isolated as a result of COVID-19, the Director of the California Department of Public Health may waive any of the licensing requirements of Chapter 2 of Division 2 of the Health and Safety Code and accompanying regulations with respect to any hospital or health facility identified in Health and Safety Code section 1250.... Any waivers granted pursuant to this paragraph shall be posted on the Department's website.”
On March 20, 2020, Heidi Steinecker, Deputy Director of the California Department of Public Health, issued an All Facilities Letter (“AFL”) addressed to General Acute Care Hospitals. (AFL 20-26.) The AFL states, “CDPH is temporarily waiving licensing requirements and suspending regulatory enforcement of all licensing requirements for hospitals.” The waiver has exceptions, none of which preclude the waiver of the two-year appointment extension.
In contrast, DNV GL issued an advisory notice on March 27, 2020 stating “DNV GL requirements already permit a 3-year appointment cycle, where approved by the medical staff and permitted by state law. In the current situation, we will accept extensions in 60-day increments to routine credentialing requirements.” (DNV GL Advisory Notice, Notice No. 2020-HC08.)
Although TJC, DNV GL, and the State of California have allowed hospitals to extend appointment and reappointment periods, most medical staff bylaws (“bylaws”) do not allow for extension of appointments. To avoid being in noncompliance with the bylaws, the hospital’s governing body may wish to pass a board resolution addressing the extension of appointment and privileges. We would be pleased to be of assistance in drafting such a resolution.
Cindy Rodriguez has an extensive background in medical staff operations and is well versed in all aspects of physician credentialing and privileging. Her expertise extends to all aspects of medical staff governance, including ...
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