JCAHO Surveys to Focus on Emergency Management
Accreditation Monthly
January 9, 2006
Dear Colleague,
Beginning January 1, 2006 JCAHO is ramping up their assessment of hospital compliance with the emergency management standards found at EC.4.10 and 4.20. The new survey process, in effect for hospitals with 200 beds or more, includes an estimated two-to-four-hour meeting with the emergency management team to occur in your command center, followed by random interviews with staff throughout your hospital.
The meeting begins with a thorough review of the hospital's emergency management plan. The surveyor is looking to determine if the hazard vulnerability analysis is current and whether it includes hazards germane to your particular region and organization. Organizations need to demonstrate that local, regional or state community emergency management agencies and the hospital's medical staff leadership were involved in the EMP preparation. The surveyor will likely ask to see evidence that hospital staff received education on their role in an emergency, including the method used to validate staff competency.
Given the lessons learned in recent years in the aftermath of actual emergency management events, surveyors will likely focus on a number of common denominator vulnerabilities that have surfaced in hospitals around the country. For example, does your plan address the adequacy of internal and external communications and information management systems, including provisions for backup capability and results of periodic reliability testing?
Additionally, hospitals in the path of Hurricane Katrina were at times overrun with patients, visitors, and the news media, so you'll likely need to explain your plan to escalate security (as necessary) at your facility and how media relations are to be handled. Your hospital is expected to be self-sufficient for generator fuel, food, water, and other supplies for at least 24 hours with 72 hours seen as best practice.
Other topics tested in this session could include your plan for evacuation to alternate care sites along with your mutual aide agreements, staffing plans, and infection control plans, including the ability to continually decontaminate and clean/sterilize equipment, handle red-bag waste and isolate patients as necessary during an emergency event.
The surveyor then chooses a detailed, predetermined disaster scenario based on the facility's hazard vulnerability analysis. The scenarios could include natural disasters such as floods, hurricanes, tornadoes, snow or ice storms, and earthquake. Man-made occurrences could include a chemical spill, radiation release, transportation accident, construction accident, terrorist act or bombing.
As part of this "table-top tracer" exercise, the surveyor will head out to departments to determine whether hospital staff understands their role in the selected scenario. After all, the true test of effective emergency management planning and preparation is how well individual staff responds to the emergency. Scoring of these standards focuses heavily on how well staff perform in these random interviews that test not only their knowledge of the plan, but how well they are able to apply that knowledge to an HVA scenario.
I also want to call your attention to a new resource available on the JCAHO Web site (click here to view the document) that explores the need to improve hospital "Surge Capacity" in our communities. It describes what surge hospitals are, how to establish one, and who should be responsible for their establishment and operation. The report uses case studies prepared in the aftermath of Hurricane Katrina and provides excellent instruction to hospitals of the challenges involved in providing patient care under these conditions.
Sincerely,
John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company
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