The Importance of Establishing a Disaster Credentialing Policy

The Importance of Establishing a Disaster Credentialing Policy
Senior Director of Marketing

It’s 2AM and a devastating natural disaster has just stricken your city. Power is down in most areas. Massive flooding has obstructed major routes in and out of town, limiting the availability of emergency resources to affected locations. Hundreds are in need of immediate medical attention from first responders, emergency care providers, and physicians. Your facility is nearing capacity, and caregivers are struggling through the chaos to triage and treat the injured. Your hospital is in need of more physicians and surgeons. Immediate additional resources are needed at various locations around the city. What do you do?

The question posed is not a rhetorical one. The scenario submitted is very real, played-out in cities across the country every year. In January 2011, for example, Joplin hospitals in Missouri were challenged to meet an overwhelming patient surge after an EF-5 tornado wiped out the area. While the details may differ from place to place, the primary concern is always the same: Saving Lives. When disaster strikes, a viable emergency credentialing policy is an absolute necessity to assure rapid deployment and delivery of emergency resources. You will significantly increase your organization’s disaster response time and improve patient outcomes by following these three steps: Plan, Drill, Execute.


The Joint Commission requires that all medical care facilities have a process in place for granting clinical privileges to volunteer practitioners and providers who are not members of Medical or Allied Health Professional staff in the event of a disaster situation. Your plan should include provisions for the following:

  • A method for obtaining documentation of the officially declared disaster and suspension of licensing requirements issued by government officials
  • A primary source verification method
  • A method for collecting identifying information from volunteer practitioners (drivers license, passport, etc.)
  • A method for obtaining at least one certifying document verifying a volunteer’s professional designation (hospital ID card, current license, certificate, or registration, DMAT identification, etc.)
  • A practical timeline for obtaining additional critical documents (DEA and State Controlled License certificates, etc.)
  • A designee or designees authorized to grant disaster privileges
  • A method of disseminating names and demographic information of those granted privileges to appropriate channels within the organization
  • A method for designating a volunteer’s area of service based on current licenses and qualifications, and a department chairperson of their specialty to work under
  • A method for gathering patient names and medical record numbers of each patient treated by individual volunteers
  • A peer review process to assess performance and qualifications of assigned volunteers
  • A process for revoking disaster privileges once granted
  • A timeline for the termination of disaster privileges once the disaster situation subsides


It is important that your organization plan regular mock-disaster drills on a quarterly basis. During these drills, senior personnel will activate the emergency credentialing initiative. It is up to the credentialing specialist and designees to find, recruit, and verify the licensure of surgeons, physicians, and volunteers. The disaster drill will help your organization begin to more efficiently gather information regarding a volunteer’s areas of privilege. It will also better prepare you to quickly assign essential personnel with specialized skills to appropriate areas within a disaster zone. Areas of focus for your disaster drill should include:

  • Establishing a clear chain of command
  • Effective communication and dissemination of vital information to mission critical personnel
  • Identification of appropriate channels for primary source verification
  • Delineation of individual areas of responsibility in the event of a disaster situation (all runners, designees, and mission critical personnel)
  • Storage and dissemination of mission critical documentation
  • Normalization efforts when disaster conditions cease.


With proper planning, regular drills, and effective communication among key performers, a sound disaster credentialing policy will provide insightful crisis management guidance within your organization. Key members of your team should have access to copies of your updated disaster credentialing procedures at all times. This will ensure that when the time comes to enact your plan, mission critical personnel will be armed with the authoritative information they need to put the right people in the right places at the right time.

Example of an Award-Winning Disaster Credentialing Policy

In March 2010, HCPro ran a contest on their Credentialing Resource Center Blog for medical staff services professionals who shared their disaster credentialing policies. If you would like access to a sample disaster credentialing policy, Kelly Emrich, RHIT, a credentialing specialist in the medical staff services department at St. Mary's - Good Samaritan, Inc., was their March winner. Click here to visit HCPro's Blog and download Kelly's contest-winning disaster credentialing policy.

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