Public Health Emergency Preparedness

Chapter 4 (continued)

4.8 Licensing, Credentials, and Privileging Issues⁵⁷

4.8.1 Background

In the event of a disaster, health professionals may be called to work outside their normal place of employment, possibly even outside their State of licensure, in less than ideal working conditions. Physicians and nurses may have to triage patients, use unapproved drugs or treatments, and/or care for patients in unusual circumstances or surroundings. In extreme circumstances, certain health professionals may be required to function outside their normal scope of practice, e.g., dentists or veterinarians assisting with triage.

Issues around the need to quickly verify professional licenses and credentials and to provide protection from liability to those delivering care need to be explored. State laws vary regarding scope of practice and professional liability in emergency situations, as are seen in what are commonly referred to as Good Samaritan laws. States also differ in the extent to which State laws and regulations may be waived in emergency situations. Under normal circumstances, the hospital or facility in which an individual practices is liable for the actions of health-care professionals on their premises.⁵⁸  Health systems and their medical staffs may be held liable for damages if they permit an unqualified practitioner to practice in the organization or if they allow even a qualified practitioner to provide special clinical services that he or she has not been deemed competent to perform within that health system.⁵⁹

State laws require that potential surge hospital staff members—physicians, nurses, nurse aides and nurse practitioners, dietitians, physician assistants, pharmacists, respiratory therapists, emergency medical technicians (EMTs), paramedics, and social workers—be licensed or certified by the State in which they practice. Responding to an emergency in another State would require licensure or certification in that State, unless the health professional is a member of a Federal disaster team (in which case the person may be federalized) or the disaster State has agreement(s) in place to recognize the licenses and certifications of other designated States. Training requirements for licensing and certification may vary from State to State, complicating the option for States to grant reciprocity to other States.

Credentialing is the process used to validate professional licensure, clinical experience, and preparation for specialty practice. Credentials include proof that the practitioner has completed an accredited training program, specific patient care activity, or a defined number of specific patient care activities under the supervision of an expert.⁶⁰ In 1989, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established standards that required health-care organizations to perform credentialing functions.⁶¹ Credentialing ensures competence in a broad area, but lacks specificity for specific patient care functions. Credentials to ensure competence in one health-care organization or region may not be adequate to ensure competence in a different area.⁶² Under normal nondisaster circumstances, this information is checked directly with the medical school and specialty board. Clinical competence is verified through communication with individuals familiar with the physician, nurse practitioner, or  physician assistant.

Privileging is the process to grant to a specific practitioner the authorization to provide specific patient care services. Privileging ensures that the individual requesting privileges is capable of providing patient care services in accordance with the standard of care of the facility granting the privilege. In a November, 2004 memo, the Director of the Centers for Medicare and Medicaid Services wrote that, "The hospital's governing body must ensure that all practitioners who provide a medical level of care an/or conduct surgical procedures in the hospital are individually evaluated by its medical staff and that those practitioners possess current qualifications and demonstrated competencies for the privileges granted... Board certification, certification or licensure in and of itself is not recognized as an appropriate basis to bestow or award any or all of the privileges included in a particular practitioner's category."⁶³

Verification of Licensing

Even if the State licensing requirement were waived, licenses and certification would still need to be verified by the surge hospital. Under normal circumstances, the verification of a license may take several weeks. States may have access to electronic databases of current licensees for some professions but not for all professional groups or for other States.  Physician licenses may be verified using information from either the American Medical Association Physician Master File, the Educational Commission for Foreign Medical Graduates, or the American Osteopathic Association.³³ In Massachusetts, the license (or certification) for a physician, nurse, social worker, respiratory therapist, occupational therapist and assistant, physical therapist and assistant, dentist and dental hygienist, pharmacist, pharmacy technician, physician assistant, emergency medical technician, paramedic, and veterinarian may be verified on-line. Guidelines for the verification of emergency medical technicians, for example, caution that searches must use exact spellings, and/or city/town listings, and/or zip code listings. Even though the system is updated monthly, the instructions state that due to the frequency of name changes, address changes, and legibility of application information they recommend that anyone seeking information contact the Office of Emergency Management in writing for official verification of the status of any individual EMT.

The Massachusetts Board of Registration in Nursing uses an online nurse license verification system, Nursys® (Nurse System) provided by the National Council of State Boards of Nursing. Nursys® receives regular updates of nurses' personal (name, address, etc.) and license information from participating boards of nursing.⁶⁵ All boards of nursing, including nonparticipating boards have access to information within Nursys® and are able to enter and edit discipline information.

The Massachusetts Board of Registration in Medicine provides on-line physician credential verification. The following information is provided as part of a physician profile:

• Education.
• Training.
• Medical specialties.
• Professional demographics, including business address, insurance plan, hospital affiliations, and available translation services.
• Professional or community awards received.
• Research or publications by the physician.
• Malpractice claims paid in the past 10 years.
• Hospital discipline in the past 10 years.
• Criminal convictions in the past 10 years
• Disciplinary actions of the Massachusetts Board of Registration in Medicine in the past 10 years.
• License information (license number, renewal date and date renewal received) available to "health-care entities." Anyone seeking physician license information must submit a request on institution letterhead and on approval will receive a username and password.
• Verification of the certification of Massachusetts nurse aides is not available online but through the Nurse Aide Registry Automated Voice Response System, which may be accessed 24 hours a day, 7 days a week by those facilities and agencies with Registry access codes.

Except for members of DMATs and US&R teams who can be federalized in a declared disaster and thus able to practice anywhere in the United States, potential surge hospital workers from outside the State would have to have credentials, licenses and/or certification verified in the limited time prior to surge hospital opening.³⁵ Except for verification of licensure, which may be available through a database, the credentialing and privileging processes appear to be much more labor intensive and subject to the review of more than one individual. Advance research on State regulations regarding verification of licensure, credentials and privileging, any reciprocal agreements between the State and other States as well as the waiving on such verification requirements in the event of a disaster for each professional type would be extremely advantageous.

Mutual Recognition

Mutual recognition is a system that allows licensed professionals to practice across State lines, similar to the current driver's license model. Under a mutual recognition system, any licensed professional may practice in other States on the basis of their home State license. Participating States enter into an interstate compact that allows licensed professionals to practice in any of the participating States without obtaining licenses for each individual State, a costly and time consuming process. As of December 2004, 18 States have entered into the Nurse Licensure Compact (Arizona, Arkansas, Delaware, Idaho, Iowa, Maine, Maryland, Mississippi, Nebraska, New Mexico, North Carolina, North Dakota, South Dakota, Tennessee, Texas, Utah, Virginia, and Wisconsin).⁶⁷ A nurse licensed in one compact State is allowed to practice in another compact State provided he or she adheres to the practice laws and rules of the State in which the patient receives care. The existence of similar interstate pacts for other health professionals has not yet been determined.

4.8.2 Verification Requirements by Staff Types

Physicians, Nurse Practitioners and Physician Assistants

According to a policy statement in the Annals of Emergency Medicine, physicians responding as volunteers in a disaster situation will need one or more of the following:

• Current hospital identification card.
• Current license to practice and valid picture ID issued by State, Federal or regulatory agency.
• Identification showing individual is a DMAT team member.
• Identification indicating that the individual has been granted authority to render patient care in disaster circumstances, such authority having been granted by a Federal, State or municipal entity.
• Presentation by current hospital or medical staff member with personal knowledge regarding the practitioner's identity.⁶⁸

When practical, the following should also be verified:

• Current and unencumbered medical license verification.
• Drug Enforcement Administration and State narcotics registration verification.

Nurse practitioners and physician assistants will need current professional license and picture identification. Credentials and privileges should be verified at his or her home hospital.

Nurses, Nurse Aides, and Allied Health Workers

Presentation of current professional license or certificate, picture identification, and current CPR card if available, should be sufficient verification to practice in most States.

4.8.3 Volunteer Protection Laws

The Federal Volunteer Protection Act of 1997 provides immunity for volunteers serving nonprofit organizations or governmental entities for harm caused by their acts or omissions if:

• Volunteer was acting within the scope of his/her responsibilities.
• Volunteer was properly licensed, certified or authorized to act.
• Harm was not caused by willful, criminal or reckless misconduct or gross negligence.
• Harm was not caused by volunteer operating a motor vehicle, vessel, or aircraft.

A volunteer in the context of the law is defined as an individual who performs a service for a nonprofit organization or government entity and does not receive compensation (or anything of value in lieu of compensation) in excess of $500 per year. The law includes as volunteers directors, officers, trustees, and direct service providers. Federal law preempts State law to the extent that the State law is inconsistent with the Federal law. The State may provide greater protection to volunteers than that allowed in the Federal law, but not less protection.

Most States have enacted some form of Good Samaritan or volunteer protection law. These laws vary in terms of whom or what entities constitute a volunteer organization and the situations in which the granted immunity may not apply. For most States, only uncompensated volunteers are protected. A definition of compensation, however, may differ from State to State. In about one-third of States, protection is limited to directors, officers, and trustees of an entity, and volunteers in general are afforded no special protection. The type of entity covered also varies in terms of tax status, organization under State law, and specified types of service or interest of the nonprofit organization. In some States hospitals and governmental entities are included in the scope of protection in addition to nonprofit organization. Lastly, States vary in specifying situations in which the immunity does not apply. Generally, immunity is not granted for conduct that is "willful and wanton." Some States also add conduct that is "grossly negligent, reckless, malicious, in bad faith, fraudulent, or intentionally tortuous or that is a knowing violation of the law."⁶⁹

As an example, Massachusetts State laws provide immunity for EMTs, fire and police who render first aid in the course of their jobs.⁷⁰ The law also states that no physician, physician assistant, or nurse who renders emergency care or treatment as a volunteer without fee other than in the ordinary course of his or her practice, shall be liable in a suit for damages as a result of his acts or omissions.⁷¹ Lastly, Massachusetts' law also protects physicians and nurses administering immunizations or other protective programs under public health programs. The law states that they shall not be held liable in a civil suit for damages as a result of any act or omission.⁷²

Organizations are advised to:

1. Review their State statutes to determine if (or which) sections provide greater or lesser protection than the Federal law.
2. Review compensation arrangements with volunteers, especially members of governing boards, to verify that compensation is within the $500 maximum allowed amount.
3. Ensure that volunteer duties are clearly defined so that all volunteers are acting within their scope of duties and hence protected under the law.⁴²

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4.9 Orientation and Training

Given that the individuals staffing the surge facility will likely come from a variety of sources with varying levels of clinical expertise and current experience, it would be advantageous for at least some proportion of physicians and nurses to come from an acute care hospital local to the surge facility. These individuals, if dispersed among the clinical staff, would provide leadership and support to those with less current training and experience. All staff should receive training on the mission of the surge facility and orientation to the building, standard operating procedures, and responsibilities for each staff type. This may occur prior to or during their first shift on duty. Staff should be oriented, at a minimum, to the following:

• Personal protective measures, including standard precautions, location of personal protective equipment, disposal of infectious waster, etc.
• Standard operating procedures.
• Standard reporting procedures.
• Response to outside requests for information.
• Patient confidentiality.

In the Incident Command System, the records/planning director, along with the medical operations directors, is responsible for making sure that training occurs. Clinical staff will need additional orientation to their unit including:

• Leadership and chain of command.
• Location of medications, patient care supplies and equipment.
• Procedures for ordering medications, supplies and equipment.
• Admission and discharge procedures.
• Ordering patient tests and procedures.
• Patient records and charting requirements.
• Procedures for contacting physicians, nurse practitioners, physician assistants.
• Care delivery system (e.g., primary care; team nursing; and use of nonclinical staff, students, and volunteers).

4.9.1 Job Action Sheets

The Incident Command System uses job action sheets to identify roles and responsibilities for all personnel. Job action sheets are organized by position and include simple checklists, which include whom the person reports to; the responsibility of the position; and immediate, intermediate, and extended job responsibilities. These sheets provide guidance to new, likely stressed workers in unfamiliar surroundings. Sample job action sheets for clinical (medical operations director and nursing subunit supervisor) and nonclinical (housekeeping unit leader and maintenance unit leader) positions are included in the Appendix.

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4.10 Summary

Although many shuttered hospitals have limited staff on site, that staff can not be expected to be available for use during a surge event.  Aside from possibly the security staff, almost all staff would have to be brought in from outside. The two scenarios may have somewhat different staffing needs, but in either case the four main types of staff that will be needed are physicians and physician extenders, nursing staff, allied health staff, and other types of staff such as security, laundry, and kitchen staff. Some skills could be delegated from nurses to allied health staff. It will be important to use a highly standardized organizational system that outlines individual and team responsibilities such as the HEICS. It will also be important to assign responsibilities in advance so that all parties know their roles. Both Federal and Massachusetts State regulations on nursing coverage and nurse-to-patient ratios are general and in a surge event could probably be waived or relaxed.

Ideally, surge facility staff would:

• Have current or recent acute care experience but no current employment obligation (or flexibility to be absent from current obligations).
• Live locally (to minimize housing and licensing requirements).
• Have no (or delegated) responsibilities for children, elderly parents, or pets.
• Be available to work within several days for at least several weeks.

Ideally, these individuals would have worked together previously as a team. The nursing and physician leaders would, in an ideal situation, come from an acute care hospital local to the surge facility.

Individuals currently volunteering on Federal disaster or urban search and rescue teams would be preferred staffing candidates as they would be federally credentialed in a disaster situation, have up-to-date clinical skills and be available in time. Those serving with the U.S. Public Health Service would also be available within hours but would not be experienced working together and may not have current clinical skills. Private groups such as the American Red Cross appear to be a good source for mental health workers. Students (medical, nursing, and allied health) are available, at least in this area, but because of licensing issues would be restricted to nursing assistant or nonclinical tasks. Their instructors, however, may be a very good source of clinicians with up-to-date skills and few other employment responsibilities. Volunteer organizations are plentiful and may be sources for nonclinical staff, but level of expertise, readiness, and availability would certainly vary across the various groups. Some "residential" teams such as AmeriCorps NCCC seem like a promising source for nonclinical staff based on their numbers, reported availability, and experience working together as teams on disaster-related projects.

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