Accreditation

Expect surveyor scrutiny of disaster management plans

Briefings on The Joint Commission, July 1, 2006

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.

Work with emergency management staff to prepare for a disaster-and for a survey

After reading this article, you will be able to

1. describe what's required in JCAHO standard EC.4.20

2. list ways to assess your emergency management plans

What will your hospital do if there's a community disaster? Although the JCAHO's new emergency management tracers--during which surveyors review disaster plans--apply to hospitals with 200 or more beds, the JCAHO has increased its focus on disaster planning in the wake of such highly publicized events as Hurricane Katrina (see "Emergency management survey basics" below).

So although your hospital may be small, or in an area that isn't prone to a disaster such as Katrina, it won't matter when surveyors show up, the JCAHO says.

If you don't identify anything in your hazard vulnerability analysis, surveyors will toss you a hypothetical scenario, JCAHO educators said during the accreditor's Hospital Accreditation Essentials education program in Chicago in May. And you will have to speak to that scenario, they added.

Emergency management standards are part of the environment of care (EC) chapter of the Comprehensive Accreditation Manual for Hospitals (CAMH).Consult your copy of the CAMH for the exact wording of standards and their elements of performance (EP).

For more about how to prepare for the emergency management session, refer to the April Briefings on JCAHO.

If you haven't already, the JCAHO recommends that you work with your emergency management staff to prepare not only for a possible disaster, but for the certain surveyor scrutiny of your hospital's disaster plans.

Assess your readiness

Changes to EC.4.20 take effect July 1 and affect all accredited hospitals. This standard requires that you conduct regular drills to test your emergency management. More importantly, the EPs for hospitals increased from five to 14.

"These are pretty significant changes to our standards," JCAHO Senior Engineer George Mills, FASHE, CEM, CHFM, said during an April audioconference presented by Joint Commission Resources (JCR), Inc. Hospitals should accordingly revise their emergency drill plans and goals ahead of their next test under EC.4.20. The standards also still require hospitals to conduct disaster planning tests twice per year.

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.

Most Popular

Related Articles