What are the requirements for granting temporary privileges ?

^Note: Applicant for new privileges includes an individual applying for clinical privileges at the hospital for the first time; an individual currently holding clinical privileges who is requesting one or more additional privileges; and an individual who is in the reappointment/re-privileging process and is requesting one or more additional privileges.

The medical staff bylaws at MS.01.01.01 EP 14 must include a description of the privileging process including temporary and disaster privileges (see EM.02.02.13). The description of temporary privileges would need to include the elements of performance outlined at MS.06.01.13 for the two acceptable reasons, i.e., important patient care need and new applicant temporary privileges.

As noted at MS.06.01.13, new applicant temporary privileges are granted when the applicant is awaiting review and approval by the organized medical staff, or if delegated to the MEC, etc. Temporary privileges for applicants for new privileges are granted for no more than 120 days.

The second, and most common reason for use of temporary privileges is to meet an important patient care need. The need must be documented in the credentials file at the time privileges are granted. It typically appears as a recommendation from the medical staff president or designee to the CEO who grants the privileges. It could also appear in a statement by the CEO as to the reason for granting the temporary privilege(s).

• The care of a patient requires specialized skills that no currently privileged practitioner possesses
• A currently privileged practitioner will be absent from the organization and someone is needed to cover the associated patients during the absence (commonly termed locum tenems)
• The patient care volume exceeds the level that can be handled by currently privileged practitioners and additional practitioners are needed to handle the volume

Failure to process a practitioner's reappointment application in a timely manner is not a reason for the use of 'important patient care need' temporary privileges. To grant temporary privileges in such a situation, the organization would need to justify and document that requiring the practitioner to stop practicing at the time of reappointment for failure to submit the application in a timely manner - or failure to process the application in a timely manner - would result in an important patient care need situation. Examples may include, but not limited to:

• Requiring an anesthesiologist to stop practicing at reappointment, when the organization only has three anesthesiologists which results in a backlog of surgeries, would be an important patient care need issue and would justify the use of temporary privileges at reappointment.
• However, requiring a pediatrician to stop practicing at reappointment, when the organization has ten other pediatricians that could admit the children, would probably not result or meet the definition of an 'important patient care need', therefore, may not justify the use of temporary privileges at reappointment.

The determination would need to be made on an applicant-by-applicant / case-by-case basis and not as a routine basis for all re-appointments that are not submitted or processed in a timely manner.

When temporary privileges are granted, whether awaiting governing body approval of full privileges, or to meet an important patient care need, the period of FPPE begins at the time temporary privileges are granted. For example, if temporary privileges are granted on July 1, 2021, however, the governing body does not meet until September 15, 2021, the period of FPPE starts July 1, 2021.

Last reviewed by Standards Interpretation: May 10, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).

This page was last updated on September 13, 2022 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.