What You Need to Know About Reappointment Amid the Pandemic Blog Feature

By: Maureen Clarke on September 30th, 2020

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What You Need to Know About Reappointment Amid the Pandemic

Credentialing compliance | Provider reappointment

As COVID-19 quickly spread, hospitals shifted priorities on the fly. Two pressing new demands were establishing work-from-home medical staff offices and expanding telemedicine privileges. Resources typically focused on practitioner reappointment, in particular, took a backseat for some during the pandemic. In response, The Joint Commission (TJC) took the extraordinary step of allowing reappointment extensions under certain circumstances during the pandemic. 

It’s best practice to queue reappointment notifications approximately 3-6 months before the practitioner’s existing privileges are up. But if your healthcare organization experienced shifting orders or the unfortunate loss of staff, you may be playing catch-up. Here’s what you need to know to ensure you’re on track and in compliance regarding practitioner reappointment.

What the Joint Commission’s extension means long term

On March 18, 2020, a TJC FAQ stated that “if an established provider’s privileges are scheduled to expire during the time of a declared national emergency, TJC will allow an automatic extension of a medical staff reappointment beyond the two-year period under [specific] circumstances...” The criteria were:

  • A national emergency has been declared
  • An organization has activated its emergency management plan
  • The state in which the organization is located does not have laws prohibiting extension of provider privileges during an emergency

Importantly, the FAQ stated, “The duration of the extension cannot exceed 60 days after the declared state of emergency has ended.” Further, the extension covered only those providers whose privileges expired during the emergency. 

The extension of privileges wasn’t the only reprieve TJC provided during the pandemic. The accreditor also suspended all regular, onsite surveys of hospitals and other healthcare organizations from mid-March through June 2020. While surveys have resumed, TJC put into place new safety protocols and stated that, “Our survey will focus on a thorough assessment but will not retroactively review compliance.” 

However, if your organization took the extension or is behind with recredentialing, a risky domino effect could occur if your reappointment volume is large or your organization is still being affected by shifting priorities due to COVID-19.

Important considerations if you took the extension

If your organization is Joint Commission accredited and extended the reappointment cycle of some or all providers up for renewal, take heed of the following guidance to remain on track going forward. 

Document everything while it’s fresh

Which providers were extended? What were their effective dates before and after the official TJC extensions? Were any in progress when halted, and at what step (application, verification, department chair review, committee review, etc.)? What special circumstances related to reappointment are worth noting in the file (e.g., the provider was a volunteer at another organization during the disaster).

Determine (new) committee schedules

If your organization was hard-hit with patient volume due to COVID-19, committee meetings that occur monthly or bimonthly were likely cancelled or postponed. If so, enlist medical staff leadership’s help in rescheduling meetings and/or calling additional ones. Perhaps a return to the normal, in-person committee meeting schedules will jeopardize deadlines and compromise compliance. If so, explore options to hold virtual meetings to get through reappointment backlogs. 

Identify blocks to getting back on track

Check availability of medical staff leadership/the board, and access to any other internal groups against your revised deadlines for each practitioner or batch of reappointments. Consider, too, that any additional delays might be caused by factors outside your control. They might include:

  • Outside organizations relied on for verifications
  • Other hospitals/providers for references, etc.
  • The applicants themselves not responding to requests 


Communicate the resumption plan as needed

Let affected providers know if their effective dates passed during the emergency and that they have been extended. Provide the TJC data so they understand the parameters and can assist in responding in a timely way. There’s no reason to alert unaffected providers, and in fact doing so may cause you additional work.

Lean on technology to get back on track 

It’s critical to have a plan to return to normalcy, and your best bet to accelerate any workflow includes tapping into all available credentialing technology. Shortcuts and automation that your integrated platform should provide include the ability to:

  • Use application auto-fill technology
  • Process multiple practitioner tasks simultaneously using batch processing for recredentialing and verifications.
  • Use web crawler technology to increase accuracy and efficiency by mirroring the steps a user would follow to complete verifications, including the capture of text and images while on the URL hosting the necessary data.
  • Give providers access through an online portal that connects them with your database for data entry or read-only access.
  • Generate customizable verification and correspondence letters.
  • Sync with quality, case/peer review data (including OPPE/FPPE) to paint a complete picture of the practitioner’s current competence.
  • Set up auto-exports to get data out to reappointment applicants. 
  • Create scheduled import processes for data you’re collecting from external sources and ability to decide where the new data will go within your system.
  • To tap into outside support that is expert in your database.


Maintaining quality in healthcare starts with reappointing the most qualified providers and making the process smooth for all parties. While accreditors may have extended reprieves during the pandemic, ensuring that quality remains high through rigorous reappointment practices is essential.

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