Accreditation

What to expect from the JCAHO's new EM session

Briefings on The Joint Commission, April 1, 2006

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Learning objectives: After reading this article, you will be able to

  • identify the six key emergency management (EM) standards
  • discuss which areas JCAHO surveyors will examine
  • list the disaster scenarios developed by the JCAHO

    Although the JCAHO has surveyed hospital disaster plans for years, in the wake of recent calamities such as Hurricane Katrina, a new focus on this matter has emerged.

    If you work in a hospital with 200 or more beds, the JCAHO will now evaluate your EM policies more stringently through a new effort that started in January. As part of this new process, surveyors will conduct special EM sessions in larger hospitals, which start with a discussion phase in the incident command center and then proceed to disaster plan tracers within the facility.

    Six standards in the core

    According to the JCAHO's Surveyor Survey Activity Guides, the EM session will focus on the following six standards from the environment of care (EC), infection control (IC), information management (IM), leadership (LD), and medical staff (MS) chapters of the Comprehensive Accreditation Manual for Hospitals :

  • EC.4.10 -Establishing and carrying out an emergency plan
  • EC.4.20 -Conducting emergency drills
  • IC.6.10 -Responding to an influx of infectious patients
  • IM.2.30 -Maintaining information continuity during a disaster, such as with patient records
  • LD.3.15 -Maintaining efficient patient flow
  • MS.4.110 -Granting temporary privileges to outside physicians during a disaster

    EC.4.20 will become even tougher as of July 1, when a significant revision takes effect. These changes apply to all hospitals, regardless of bed counts.

    • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on The Joint Commission.

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