Revision to the Emergency Management Standards (EC 1.4 (2002)) Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)

The new Emergency Management standards for hospitals, long term care, behavioral health, and ambulatory care implemented on January 1, 2001 introduced concepts into existing standards and infused the concept of community involvement into the management process. The revised standards broaden the framework provided in the standards to assist organizations in preparing for, and managing, a variety of potential emergencies.

Tropical storm Allison in Houston, Texas and the terrorist attacks in New York City and Washington D.C. afforded the Joint Commission opportunities to learn how health care organizations respond to large scale disasters and provided arenas in which to review the adequacy of the scope of the revised emergency management standards.

Visits to hospitals, meetings with representatives of the cities of Houston and New York, and conference calls with northern Virginia hospitals that received victims of the Pentagon attack allowed Joint Commission staff to examine the emergency response of these institutions, evaluate the adequacy of the current emergency management standards, and develop a list of "lessons learned" to be disseminated throughout the country.

Based on the information obtained from these visits, as well as discussions with health care policy analysts, health care providers, administrators, and community responders, there have been editorial changes made to current standards and their intent statements in the Comprehensive Accreditation Manual for Hospitals (CAMH) to clarify that a wide variety of terrorist acts are among the hazards that are to be considered in an organization's hazard vulnerability analysis.

In addition, a revision to the intent statement of standard EC.1.4 in the CAMH requires cooperative planning among health care organizations that provide services to a contiguous geographic area. This new requirement is effective for hospital surveys January 1, 2002, but would be only consultative through 2002, and would be scored as part of the hospital accreditation survey beginning January 1, 2003.

A revision to the intent statement of EC.2.9.1 in the CAMH clarifies the requirement of the organization to participate in at least one community-wide drill yearly. While this drill can be organized and supervised by the local office of emergency preparedness or a similar authority, it is expected that the emergency(ies) responses practiced in the community is relevant to the organization's hazard vulnerability analysis. These drills should lead to improvements in the organization's ability to communicate, coordinate, and integrate their response with that of other health care facilities and of the community.

Revision to the Emergency Management Standards
Comprehensive Accreditation Manual for Hospitals

(revised language is underlined)

The organization has an emergency management plan.

Intent of EC.1.4

The emergency management plan comprehensively describes the organization's approach to responding to emergencies[1] within the organization or in its community that would suddenly and significantly affect the need for the organization's services, or its ability to provide those services. The plan addresses four phases of emergency management: mitigation,[2] preparedness,[3] response, and recovery. At a minimum, the emergency management plan is developed with the involvement of the hospital leaders, including those of the medical staff.

The planning process provides for

  1. The conduct of a hazard vulnerability analysis[4] to identify potential emergencies that could affect the need for the organization's services, or its ability to provide those services.
  2. The establishment, in coordination with community emergency management planning (where available), of priorities among the potential emergencies identified in the hazard vulnerability analysis for which mitigation, preparation, response and recovery activities will need to be undertaken.
  3. Identification of specific procedures to mitigate, prepare for, respond to, and recover from the priority emergencies.
  4. Definition of, and where appropriate, integration of, the hospital's role in relation to community-wide emergency response agencies, including identification of the command structure in the community.
  5. Definition of a common (i.e., "all-hazards") command structure within the organization for responding to and recovery from emergencies, that links with the command structure in the community.
  6. Cooperative planning among health care organizations that together provide services to a contiguous geographic area (for example, among hospitals serving a town or borough) to facilitate the timely sharing of information about:
    • Essential elements of their command structures and control centers for emergency response.
    • Names, roles, and telephone numbers of individuals in their command structures.
    • Resources and assets that could potentially be shared or pooled in an emergency response.
    • Names of patients and deceased individuals brought to their organizations to facilitate identification and location of victims of the emergency.
  7. Initiation of the procedures in the response and recovery phases of the plan, including a description of how, when, and by whom the phases are to be activated.
  8. Notification of external authorities of emergencies, including possible community emergencies identified by the organization (for example, evidence of a possible bioterrorist attack).
  9. Notification of personnel when emergency response measures are initiated.
  10. Identification of care providers and other personnel during emergencies.
  11. Identification and assignment of personnel to cover all necessary staff positions under emergency conditions.
  12. Management of the following under emergency conditions:
    • Patient care-related activities (for example, scheduling, modifying, or discontinuing services; control of patient information; patient transportation).
    • Staff support activities (for example, housing, transportation, incident stress debriefing).
    • Staff family support activities.
    • Logistics relating to critical supplies (for example, pharmaceuticals, medical supplies, food, linen, water).
    • Security (for example, access, crowd control, traffic control).
    • Communication with the news media.
  13. Evacuation of the entire facility (both horizontally and, when applicable, vertically) when the environment cannot support adequate patient care and treatment.
  14. Establishment of an alternative care site(s) that has the capabilities to meet the clinical needs of patients when the environment cannot support adequate patient care, and procedures that address, where applicable:
    • Transportation of patients, staff, and equipment to the alternative care site.
    • The transfer of patient necessities (for example, medications, medical records) to and from the alternative care site.
    • Patient tracking to and from the alternative care site.
    • Inter-facility communication between the organization and the alternative care site.
  15. Re-establishment of usual operations following an emergency.
The plan identifies:
  1. An alternative means of meeting essential building utility needs (for example, electricity, water, ventilation, fuel sources, medical gas/vacuum systems) when the organization is designated by its emergency management plan to provide continuous service during an emergency.
  2. Backup internal and external communication systems in the event of failure during emergencies.
  3. Facilities for radioactive, biological, and chemical isolation and decontamination.
  4. Alternate roles and responsibilities of personnel during emergencies, including who they report to within the organization's command structure, and when activated, within the command structure of the local community.
The plan further provides for:
  1. An orientation and education program for all personnel, including licensed independent practitioners, who participate in implementing the emergency management plan. Education addresses, as appropriate to the individual:
    • Specific roles and responsibilities during emergencies.
    • How to recognize specific types of emergencies (for example, the symptoms caused by agents that may be used in chemical or bioterrorist attacks).
    • The information and skills required to perform assigned duties during emergencies.
    • The backup communication system used during emergencies.
    • How supplies and equipment are obtained during emergencies.
  2. Procedures for an annual evaluation of the organization's hazard vulnerability analysis and of the emergency management plan, including its objectives, scope, functionality, and effectiveness.
Drills are conducted regularly to test emergency management.

Intent of EC.2.9.1

The response phase of the emergency management plan is tested twice a year, either in response to an actual emergency or in planned drills. Drills are conducted at least four months apart and no more than eight months apart.

Testing includes:
  1. For organizations that offer emergency services or are designated as disaster receiving stations, at least one drill yearly that includes an influx of volunteer or simulated patients.
  2. Participation in at least one community-wide practice drill yearly (where applicable) relevant to the priority emergencies identified by the organization's hazard vulnerability analysis, that assesses communication, coordination, and the effectiveness of the organization's and community's command structures.
  1. Tests of a and b may be separate, simultaneous, or combined.
  2. Drills that involve packages of information that simulate patients, their family, and visitors are acceptable.
  3. Tabletop exercises, though useful in planning or training, are not acceptable substitutes for test a.
  4. Staff in each freestanding building classified as a business occupancy, as defined by the Life Safety Code7, that do not offer emergency services nor are designated as disaster receiving stations need only participate in one emergency preparedness drill annually. Staff in areas of the building that the organization occupies must participate in such drills.
  5. In test b, "community-wide" may range from a contiguous geographic area served by the same health care providers, to a large borough, to a town, city, or region.

[1] emergency: A natural or man-made event that significantly disrupts the environment of care (for example, damage to the organization's building(s) and grounds due to severe winds, storms, or earthquakes); that significantly disrupts care and treatment (for example, loss of utilities, such as power, water, or telephones, due to floods, civil disturbances, accidents, or emergencies within the organization or in its community); or that results in sudden, significantly changed or increased demands for the organization's services (for example, bioterrorist attack, building collapse, or plane crash in the organization's community). Some emergencies are called "disasters" or "potential injury creating events" (PICE).

[2] mitigation activities: Those activities an organization undertakes in attempting to lessen the severity and impact of a potential emergency.

[3] preparedness activities: Those activities an organization undertakes to build capacity and identify resources that may be used should an emergency occur.

[4] hazard vulnerability analysis: The identification of potential emergencies and the direct and indirect effects these emergencies may have on the health care organization's operations and the demand for its services.

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