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What can be expected during the emergency management meetiing with surveyors?

Accreditation Connection, January 16, 2006

The meeting begins with a thorough review of the hospital's emergency management plan, Rosing says. The surveyor determines if the hazard vulnerability analysis is current and whether it includes hazards germane to your region and organization.

Surveyors will want to know if you included local, regional, or state community emergency management agencies and the hospital's medical staff leadership in the plan's preparation. Additionally, surveyors may ask to see evidence that hospital staff are educated on their role in an emergency, including the method to validate staff competency.

Surveyors may focus on a number of common denominator vulnerabilities that have surfaced in hospitals around the country, Rosing says, 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, you'll likely need to explain your plan to escalate security (as necessary) at your facility and how media relations are to be handled.

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, Rosing says, such as floods, hurricanes, tornadoes, snow or ice torms, earthquakes, chemical spills, radiation releases, transportation accidents, terrorist acts, or bombings. As part of this "table-top tracer" exercise, the surveyor will head out to departments to determine whether hospital staff understand their roles.

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.

Adapted from the January issue of Accreditation Monthly.

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