The 2008 Joint Commission emergency management standards were published in the June 2007 edition of Joint Commission Perspectives, allowing health care organizations six months to come into compliance before the standards become effective on Jan. 1.

Many of the concepts contained within these new standards are the same as in the current edition, but there are also many additional requirements. Even some of the existing concepts have been significantly expanded, resulting in the potential for additional compliance efforts.

While the Joint Commission Perspectives article underlines the totally new concepts for easy identification, the expansion of previous requirements is not so designated.

An obvious change

To start, an obvious change is the number of standards. Currently, one standard (EC.4.10) must be addressed with 21 elements of performance (EP) for emergency management. This has been expanded into eight standards (EC.4.11-4.18) with a total of 66 EPs. EC.4.20 retains the same number for 2008, moving from 16 to 19 EPs, but some of the changes made in mid-2006 are no longer applicable and have been replaced with new requirements.

Delving deeper into the content, The Joint Commission’s involvement in the aftermath of recent disasters involving health care organizations is evident. The opportunities identified for improvement in the health care response are incorporated into the new requirements, with a focus on sustainability. The influence of Hurricanes Katrina and Rita is apparent as is the influence of the National Incident Management System (NIMS).

In the introduction to emergency management, The Joint Commission identifies six critical areas to be addressed in order for an organization to effectively manage an emergency response. Each of these areas is associated with one of the subsequent emergency management standards as follows:

• Communication (EC.4.13);
• Resources and Assets (EC.4.14);
• Safety and Security (EC.4.15);
• Staff Responsibilities (EC.4.16);
• Utilities Management (EC.4.17); and
• Patient Clinical and Support Activities (EC.4.18).

Also new in the introductory material is a direct reference to five other standards in five other chapters of the accreditation manual that have a direct bearing on the emergency management activities of the organization. They are the following:

• IM.2.30: Continuity of information;
• IC.6.10: Influx or risk of infectious patients;
• LD.3.15: Patient flow;
• MS.4.110: Granting disaster privileges; and
• HR.1.25: Assigning disaster responsibilities.

It would therefore be prudent to include the concepts addressed in these standards in the organization’s emergency plans.

Emergency operations plan

The first two standards in The Joint Commission’s emergency management section address the general issues of emergency planning and the emergency operations plan (EOP).

For instance, EC.4.11 focuses on the planning process itself, calling for a comprehensive approach to risk identification in order to mobilize an effective response, within the organization itself and in its larger community. The planning process should continue to involve leadership from the health care organization and from the medical staff. As has been the case in previous editions, a hazard vulnerability analysis (HVA) is required to be completed, reviewed and prioritized with the community and evaluated annually. And a new requirement calls for the health care organization to communicate its needs and vulnerabilities to the community, leading to an identification of the community’s ability to meet those needs.

The four phases of emergency management (mitigation, preparedness, response and recovery) must be defined for each priority emergency on the HVA, and this may be done either in the “all hazards” portion of the plan or in plans to manage each type of event.

Although inventories are not new to health care organizations, there is a new EP calling for a documented inventory of on-site resources to manage an emergency event, including personal protective equipment (PPE), water, fuel, staffing, medical, surgical and pharmaceutical supplies (the latter two are only applicable to acute care and critical access hospitals). This inventory must be evaluated at least annually, and there must be a method established to monitor these supplies as they are used during an emergency event. This will require emergency planners to work closely with those in materials management to establish a process for compliance.

This standard also contains the requirement for the annual evaluation in terms of objectives, scope, performance and effectiveness, relocated from EC.9.10. One difference is that this evaluates the planning efforts as opposed to the plan itself.

And the plan itself has changed in focus. For many years, each organization has had to write an emergency management plan, which has been essentially an executive summary of Joint Commission compliance activities. Although it still may be a good idea to maintain, it is no longer officially required. It is replaced with the EOP, which may have been formerly called a “Disaster Plan” in many organizations. This document contains the policies and procedures to mount an emergency response. Alternative sites for the provision of care, treatment and services to meet the needs of the patients/residents should also be included in this plan.

In standard EC.4.12, there is a requirement for an all-hazards command structure to coordinate the six critical areas of emergency management. This document is usually written with incident-specific annexes with responses to specific types of events.

The incident command structure used by the organization must be integrated and consistent with that of the community. Neither compliance with  the National Incident Management System (NIMS) nor the Hospital Incident Command System (HICS) is mandated, but their use would certainly meet this requirement. Related to the use of incident command is the identification of how the response and recovery phases of emergency management are initiated and by whom.

A significant new requirement is that the organization identify its capabilities and establish its response efforts when it can’t be supported by the community for 96 hours or more. It is important to understand the context of this EP. It does not require that the organization stockpile supplies so it can stand alone for 96 hours, nor does it even mandate a 96-hour stand-alone time. Rather, it is important for the organization to understand its resources and supplies limitations to identify factors that define the stand-alone time and the point at which evacuation is necessary. Once established, this should be communicated to the organization’s leadership.

EC.4.13 calls for the establishment of emergency communications strategies, so that surveillance and communications channels can remain open. This involves backup communications processes and alternative technologies. Common terminology with other responders in the community is an important factor. Many of the requirements in this standard have been in existence previously, such as the notification of staff and external authorities and communication with the media. Those EPs that represent new information include the following:

• Ongoing communication to staff and external authorities;
• Communication with patients and families, particularly with regard to transfer to alternate care sites; and
• Communication with vendors of essential supplies.

The cooperative planning requirements with other health care organizations are located in this standard, with the additional reference to applicable law and regulation, such as the Health Insurance Portability and Accountability Act with respect to names and locations of victims of the event. Communication about patients to third parties, such as other health care organizations, the state health department, police, FBI and others is also addressed.

The concept of resource inventories established in EC.4.11 is carried over to EC.4.14, strategies to manage resources and assets. Concepts include the solicitation and acquisition of the resources from a range of providers, including vendors, other health care organizations and government resources. Considerations are events of long duration and a geographic scope beyond the immediate locality. To be addressed are how to obtain supplies at the onset of the event and replenish them throughout.

Staff and staff family considerations are included in this standard. Staff housing, transportation and incident stress debriefing are standard. Under staff family support, child care, elder care and communication are listed as examples, but this is not to be construed as mandating their provision.

The evacuation plan is contained here, and includes transportation of patients, medication, equipment and staff; the latter three being important considerations that were not previously addressed in the standards.

Safety and security

Safety and security management is addressed in EC.4.15. Factors to be managed will vary with the type of emergency and other local conditions. Internal safety and security operations must be defined, along with the role of community security agencies, such as the police requirement.

A new but common-sense requirement is for the management of hazardous materials and waste during an emergency, such as the collection and disposal of water from the decontamination process. What will be done with the regulated medical waste that can’t be picked up on schedule? Isolation and decontamination is addressed here, along with the identification of residents susceptible to wandering, a new requirement specific to long-term care.

Traffic and crowd control have been inherent with the management of security during an emergency. New language now calls for potential control of access into and out of the health care facility. While preventing egress is in violation of the Life Safety Code®, there may be some circumstances, such as quarantine, in which it is warranted. The Joint Commission recommends that this be managed as a risk assessment process as needed. Furthermore, a new EP calls for controlling movement within the facility, which may be manageable via electronic access control, other locking mechanisms or security staff.

Standard EC.4.16 on staff roles and responsibilities addresses issues of orientation and education as well as physician and other volunteer staff credentialing. Identification must be made of care providers assigned to specific areas, and there are a variety of ways to do this, ranging from the usual ID badges through vests worn to identify a role in the incident command structure.

Utilities management

Hospital utilities management during an emergency has long been an area of concern, and most concepts contained in EC.4.17 are consistent with conventional practice. The list of utilities to be managed has been expanded: Water has been broken down into potable and non-potable sources, and fuel for building operations and essential transport has been added. Fuel for the generator has usually already been considered, but now the organization must evaluate, via risk assessment, what it defines as essential transport and how to meet those fuel needs.

Clinical and support care activities are covered by standard EC.4.18 and are intended to include patient/resident care under changing situations, which are sometimes austere and include triage activities. Scheduling, modification and discontinuation of services is addressed as before. But the provision of services for vulnerable populations has not been previously included in the standards. This intends to include these populations who are already within the organization as well as those in the community.

Other patient care needs to be addressed have also been newly identified in the emergency management standards. They include the following:

• Patient personal hygiene and sanitation;
• Mental health needs;
• Mortuary services; and
• Documentation and tracking of clinical information.

Exercising the system

Moving to emergency exercises, EC.4.20 has not changed from the mid-2006 requirements for two drills annually without spacing requirements. Where applicable, one must include an influx of volunteer or simulated patients, and there must be a communitywide exercise. Where a tabletop drill is used for the latter, two “live” emergency drills must still be conducted.

There is a new requirement for a drill to test the organization’s ability to stand alone when it can’t be supported by the community. This exercise could begin as a live drill and shift to a tabletop drill to test the stand-alone phase.

The identified observer introduced in mid-2006 is still required, but the focus of those observations has changed to the six critical areas of emergency management as identified above.

Closing the loop on the exercises is critical. A multidisciplinary critique is conducted with the EOP modified based on identified issues. Those changes should be implemented and are evaluated during the next exercise. If resource limitations prevent the full implementation of the changes, they must be implemented incrementally.

Strengths and weaknesses in the organization’s performance are reported to the organization’s environment of care committee.

Ready or not

Some of the new requirements simply make sense in the new emergency management environment, and some activities are already being performed by the organization. Many will be met through the effective use of a standardized incident command system.

Some requirements will be more difficult to meet, such as the resource inventories, stand-alone capability and exercise and egress control. But, ready or not, Joint Commission-accredited organizations will be surveyed on these requirements at the first of the year.

Susan McLaughlin is president of SBM Consulting, Barrington, Ill., and a codes and standards consultant for the American Society for Healthcare Engineering. She can be reached via e-mail at sbmconsult@ameritech.net.

For more on HICS and community integration

To learn more about the Hospital Incident Command System (HICS), which can be combined with these Joint Commission emergency management standards to integrate a hospital’s plans with the surrounding community, check out last month’s Codes+Standards column.

This article first appeared in the November 2007 issue of HFM.

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