emergency management pdate - jcrqsn.com · applies to all hospital and critical access hospitals....

Department of Engineering 2017 - 1 © C

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2017

EMERGENCY MANAGEMENTUPDATE

John Maurer, SASHE, CHFM, CHSPEngineering Department

The Joint Commission


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DISCLOSURE STATEMENT

Disclosure StatementThe following staff and speakers have disclosed that they do not have any

financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: John Maurer Leslie LaBelle George Riccio Steve Chinn

The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation

Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products.


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PUBLICATIONS AND RECORDRESTRICTIONS

The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited.


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PUBLICATIONS AND RECORDRESTRICTIONS

Copyright © 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22nd StreetSuite 1300W, Oak Brook, Illinois 60523.


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OBJECTIVES

Upon completion of this program, participants will be able to:

1) Understand the Emergency Management standards changes

2) Understand the Emergency Management most challenging standards


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CMS EMERGENCY MANAGEMENT FINAL RULE

Joint Commission focus on deemed settings: Deemed Home Health Agencies

Deemed Hospices

Deemed Hospitals

Deemed Critical Access Hospitals

Deemed Ambulatory Surgical Centers

Plus: Rural Health Clinics and Federally Qualified Health Centers


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Structure Emergency Plan

Policies & Procedures

Communication Plan

Training and Testing

Integrated Healthcare Systems (option)


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Applies to all hospital and critical access hospitals.

In most cases, a new EP was developed rather than revision of an existing EP

All new/revised content is indicated in red and is in draft status


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SURVEY FUNDAMENTALS APPLY

New content, but usual approach applies; confirm that: HVA was performed and is relevant to organization and

community

EOP covers critical areas and supports response to prioritized risks

Staff training aligns with response plans

Exercises test & stress the plan & surface gaps, weaknesses, opportunities for improvement

Exercises and responses to actual emergencies are reviewed and inform improvements to plan


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EMERGENCY OPERATIONS PLAN

Continuity of Operations (COOP)

“The plan must…address continuity of operations, including delegations of authority and succession plans” (Source: CMS)

“The health care organization’s COOP may be an annex to the organization’s EOP, and during a response should be addressed under the ICS” (Source: ASPR)


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EM.02.01.01, EP 12 For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan includes a continuity of operations strategy that covers the following:

- A succession plan that lists who replaces the key leader(s) during an emergency if the leader is not available to carry out his or her duties

- A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation


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EM.02.01.01, EP 13 For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant centers (see Glossary), the following must occur:

- A representative must be included in the development and maintenance of the emergency preparedness program

- Develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant center, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency


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EM.02.01.01, EP 14 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure to request an 1135 waiver for care and treatment at an alternative care site.Note: During disasters, organizations may need to request 1135 waivers to address care and treatment at an alternate care site identified by emergency management officials. The 1135 waivers are granted by the federal government during declared public health emergencies; these waivers authorize modification of certain federal regulatory requirements (for example, Medicare, Medicaid, Children’s Health Insurance Program, Health Insurance Portability and Accountability Act) for a defined time period during response and recovery.


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COMMUNICATIONS PLAN

EM.02.02.01, EP 20 For hospitals that use Joint Commission accreditation for deemed status purposes: As part of it communications plan, the hospital maintains the names and contact information of the following:

- Staff- Physicians- Other HAPs and CAHs - Volunteers- Entities provided arranged services- Relevant fed, state, tribal, regional and local EM- Other sources of assistance


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COMMUNICATIONS PLAN

EM.02.02.01, EP 22 For hospitals that use Joint Commission accreditation for deemed status purposes: The organization maintains documentation of completed and attempted contact with the local, state, tribal, regional, and federal emergency preparedness officials in its service area. This contact is made for the purpose of communication, and where possible collaboration, on coordinated response planning for a disaster or emergency situation.


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COMMUNICATIONS PLAN

EM.02.02.01, EP 22 - continued

Note: Examples of these contacts may be written or email correspondence; in-person meetings or conference calls; regular participation in health care coalitions, working groups, boards, and committees; or educational events sponsored by a third party (such as a local or state health department).


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COMMUNICATIONS PLAN

Incident Command Structure - Essential structure flexes to size of organization & type of emergency


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POLICIES & PROCEDURES

Current key requirement addressing organization policy:

LD.04.01.07, EP 1 Leaders review and approve policies and procedures that guide and support patient care, treatment, or services.


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POLICIES & PROCEDURES

Survey:

During document review evaluate EM plan for annual review and update.

Existing EM and LD requirements sufficiently cover the need for policies

To avoid possible redundancy or conflict with plans / procedures required in EM, EC, COOP & ICS, no additional policy EPs were added.


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TRAINING

EM.02.02.07, EP 13 For hospitals that use Joint Commission accreditation for deemed status purposes: Initial and ongoing training relevant to their emergency response roles is provided to staff, volunteers, and individuals providing on-site services under arrangement. This training is documented and then reviewed and updated annually and when these roles change.


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TRAINING

EM.02.02.07, EP13 - continuedStaff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.


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TESTING - EXERCISES

One of the two annual exercises must be operations based – with community or as individual organization

CMS requires documentation of attempt to participate in community exercise

An actual emergency response can suffice

Other annual exercise must be operations based –tabletop will not count toward this requirement


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INTEGRATED SYSTEM EM PROGRAM

Optional requirement for all settings

Applies to organizations that choose to be members of their systems’ integrated EM program.


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New Standard EM.04.01.01

For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is part of a health care system that has an integrated emergency preparedness program, and it chooses to participate in the integrated emergency preparedness program, the hospital participates in planning, preparedness, and response activities with the system.


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EM.04.01.01, EP 1 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital demonstrates its participation in the development of its system’s integrated emergency preparedness program through the following:

- Designation of a staff member(s) who will collaborate with the system in developing the program


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EM.04.01.01, EP 1 – continued

- Documentation that the hospital has reviewed the community-based risk assessment developed by the system’s integrated program

- Documentation that the hospital’s individual risk assessment is incorporated into the system’s integrated program


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EM.04.01.01, EP 1 – continued

- Documentation that the hospital’s patient population, services offered, and any unique circumstances of the hospital are reflected in the system’s integrated program

- Documentation of an integrated communication plan, including information on key contacts in the system’s integrated program

- Documentation that the hospital participates in the annual review of the system’s integrated program


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EM.04.01.01, EP 2 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has implemented communication procedures for emergency planning and response activities in coordination with the system’s integrated emergency preparedness program.


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EM.04.01.01, EP 3 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s integrated emergency management policies, procedures, or plans address the following:


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- Identification of the hospital’s emergency preparedness, response, and recovery activities that can be coordinated with the system’s integrated program (for example, acquiring or storing clinical supplies, assigning staff to the local health care coalition to create joint training protocols, and so forth)

- The hospital’s communication and/or collaboration with local, tribal, regional, state, or federal emergency preparedness officials through the system’s integrated program


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- Coordination of continuity of operations planning with the system’s integrated program

- Plans and procedures for integrated training and exercise activities with the system’s integrated program


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CMS EMERGENCY MANAGEMENT FINAL RULE –WEB INFORMATION

CMS sponsored portal https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

ASPR TRACIE https://asprtracie.hhs.gov/

Joint Commission Emergency Management Portal

https://www.jointcommission.org/emergency_management.aspx


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Most Cited EM Standards

2017 YTD 2016

EM.03.01.03 EM.03.01.03EM.02.02.13 EM.02.02.13EM.02.01.01 EM.01.01.01EM.01.01.01 EM.03.01.01EM.03.01.01 EM.02.01.01


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#1 - EM.03.01.03: EVALUATION

Hospital evaluates effectiveness of EOP Two drills annually, activate the EOP at each

site Actual events may apply

One required for business occupancies

Likely scenarios to evaluate the 6 critical areas

Escalating event


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#2 - EM.02.02.13: DISASTER VOLUNTEERS LIPS

Hospital may grant disaster privileges to volunteer Licensed Independent Practitioners (LIP) Identifies in bylaws responsibility for granting

disaster privileges

Prior to eligibility, obtains 2 forms of ID

Grants privileges when EOP is activated

Determines how volunteer LIPs are distinguished


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#3 - EM.02.01.01: PLAN REQUIREMENTS

Hospital has an EOP Identify capabilities for 96 hours

Leaders, including medical staff participate in development

Develops and maintains EOP

Process for initiating and terminating response and recovery


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#4 - EM.01.01.01 FOUNDATION

Hospital engages in planning activities prior to developing the EOP

Documented inventory of resources and assets

Conducts HVA

Works with and prioritizes HVA with community


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#5 - EM.03.01.01 EVALUATION

Hospital evaluates the effectiveness of the EOP

Annual review of inventory

Annual review of the EOP’s objectives and scope

Annual review of the HVA


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SURVEY PROCESS

Pre-Session Documents Emergency Operations Plan

All hazards approach Addresses the six critical areas Inventory of resources and assets

Identification of Potential Emergencies…..(aka, HVA) Mitigation and preparedness activities for the

identified risks

Disaster drill and real event evaluations Monitors and evaluates the six critical areas


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SURVEY PROCESS

Emergency Management topics are addressed in Leadership, Individual Tracers, and System Tracers

Scenarios not used Focus on all-hazards planning to sustain six

critical capabilities


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SURVEY PROCESS

Emergency Management Session Focus on mitigation and preparednessNo disaster scenarios

Use disaster critiques

Data collection Focused discussion on six critical areas Look at resources and assets inventory, if

present Appropriate storage Expirations Training


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Herman McKenzie, MBA, CHSPEngineer

Kathy Tolomeo, CHEM, CHSP Engineer

James Woodson, P.E., CHFMEngineer

Andrea Browne, PhD., DABRMedical Physicist

Kate Dolezal, MA, CRC, LPCTechnical Coordinator

DEPARTMENT OF ENGINEERING

John Maurer, SASHE, CHFM, CHSP

Acting Director


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THE JOINT COMMISSION DISCLAIMER

These slides are current as of 10/9/2017. The Joint Commission reserves the right to change the content of the information, as appropriate

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission