The Joint Commission – Emergency Management 2010 & Beyond

Yusuf A. Rahman, BA, RRT, CHECGeorgia Hospital Association

Objectives

Overview of changes to 2009 & 2010 JC standards

Primary stumbling blocks for most hospitals

Provide tools and resources to help with future JC reviews

Share experiences and best practices

Primary Focus AreasLife Safety (LS)

Environment of Care (EC)

Emergency Management (EM)

GENERAL CHANGES

2008– Joint Commission involvement in aftermath of

recent disasters–Katrina Focus on sustainability–Identification of opportunities for

improvement

2009– Emergency Management & Life Safety Code

become stand alone chapters– Emphasis on documentation

EM.01.01.01

“The organization engages in planning activities prior to developing its written Emergency Operations Plan.”– HVA– Community partners– Community communication– Mitigation & preparedness– Incident command– Inventory

COMMUNITY PARTNERS

Determine critical community partnersHVA reviewed & prioritized with communityCommunicate needs & vulnerabilitiesAt annual review of plan & when needs

change

HAZARD VULNERABILITY ANALYSIS

Consider possibility of cascading eventsWorst-case scenarios

– Surge of infectious patients– IT vulnerabilities / failures– Loss of utilities or other critical

infrastructure

Define mitigation & preparedness

Rationale

Emphasize a “scalable” approach to help manage the variety, intensity, and duration of the disasters that can affect a single organization, multiple organizations, an entire community, or region

Importance of planning for emergencies in which the local community cannot support the healthcare organization

STAND ALONE CAPABILITY

Identifies capabilities & establishes response efforts when organization cannot be supported by community for

> 96 hours– does NOT require stockpiles– does NOT require the ability to stand

alone for 96 hours

POTENTIAL RESPONSES

Maintaining or expanding servicesConserving resourcesCurtailing servicesSupplementing resources from outside

communityClosing hospital to new patientsStaged or total evacuation

EM.03.01.03

“The organization evaluates the effectiveness of its EOP.”– Emergency exercises– Stress capabilities– Realistic & relevant– Identify lessons learned and opportunities

for improvement– Implement corrective actions

REQUIREMENTS

Twice annually (unchanged)– FSE/FE vs. tabletops

Influx of patients (unchanged)One exercise annually to evaluate ability

to stand alone without community support– Community portion can be tabletop

One community-wide exercise annually

The “Critical Six” Functions

CommunicationsResources and AssetsSafety & SecurityStaff ResponsibilitiesUtilities Management Patient Clinical & Support Activities

Most Problematic StandardsPublished in

November 2009 Perspectives– % of hospitals

that received a Requirement for Improvement (RFI)

Most Problematic StandardsLS.02.01.20 (45%) The hospital

maintains the

integrity of the means of egress

LS.02.01.10 (43%) Building and fire protectionfeatures are designed and maintained to minimizethe effects of fire, smoke, and heat

EC.02.03.05 (38%) The hospital maintains firesafety equipment and fire safety building features

LS.02.01.30 (36%) The hospital provides and maintains building features to protect individualsfrom the hazards of fire and smoke

Most Problematic Standards

Egress includes corridors, stairways, and doors so avoid blocking hallways with carts, x-ray machines, laundry carts, equipment, or supplies– Surgery areas particularly susceptible

WOWS/COWS should only be in hallways when in use– Not unattended while charging

Most Problematic Standards

Resources

Resources

ResourcesStandards questions can also be submitted

by phone, mail or fax

Standards Interpretation Group (SIG) – 630 792-5900

Fax questions to 630 792-5942By mail:

SIG, The Joint Commission

One Renaissance Blvd

Oakbrook Terrace, IL 60181

Resources

http://blogs.hcpro.com/accreditationcenter/

www.jointcommission.org/Standards/FAQs/

GHA911LiveProcess JC standards crosswalks

DISCUSSION

QUESTIONS