Accreditation

JCAHO Sentinel Event Alert

Accreditation Monthly, November 19, 2006

Dear Colleague,

On September 6, 2006, the Joint Commission announced a Sentinel Event Alert advising hospitals and other health care facilities to begin looking at the risks associated with the failure of emergency electrical power systems. You can see the details of the Alert at:
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_37.htm
Once again, I've asked Steve MacArthur, a consultant with the Greeley Company and our resident Environment of Care expert to assist me in analyzing the components of the Alert in this month's e-mail newsletter.

This Sentinel Event Alerts follows closely on the heels of the changes to the standard involving the testing of emergency generator(s) for a minimum of four continuous hours at least once every 36 months. This requirement, which is in addition to long-standing requirements for monthly testing, will be effective January 1, 2007, though organizations have until July 1, 2007 to conduct their first four-hour test, which is required to meet the standard for initial compliance.

As a bit of background, there is substantial indication, based on recent history (the 2001 floods in Houston, hurricanes Charlie, Frances, Ivan, and Jean in 2004 and Katrina and Rita in 2005), that the loss of normal power in the aftermath of these events had a significant and far-reaching impact on clinical operations in the healthcare facilities serving communities in the areas of impact. The focus thus becomes how can healthcare organizations become better able to respond to power-related disruptions, either external (loss of power supplied by the utility company) or internal (failure of one or more generators during an external disruption).

Now, there is well-established guidance for the testing and maintenance of emergency power systems within your four walls. This guidance comes in the form of several codes and standards developed by the National Fire Protection Association (NFPA). The intent of the NFPA codes and standards is to provide for immediate life safety - to complete a procedure where lives could be most or to provide an appropriately safe environment for the evacuation of a building in the case of fire. Clearly this level of preparation is not always sufficient in the event of a major catastrophe. As a result of this analysis, the Joint Commission is encouraging hospitals and other health care organizations to go beyond the minimum NFPA standards and to embrace a vulnerability analysis as their approach to planning and preparing for power disruptions.

At this point in the cycle of JCAHO surveys, all hospitals and healthcare organizations have completed a hazard vulnerability analysis as a function of preparing for disasters, emergencies, etc. What the JCAHO is encouraging now is effectively the conduction a thorough FMEA of your organization's capabilities in the event of a power disruption. The Alert (see link above) identifies a series of six recommended actions to assist in the prevention of adverse events caused by the failure of emergency electrical power. In brief, these are:

  1. Perform a gap analysis of your emergency power system that focuses on what systems and equipment would be supported over a long-term outage
  2. Maintain a complete, labeled inventory of all emergency power systems and the loads they serve (EC.7.10.13; EC.7.10.14)
  3. Provide competency training and testing for all operators and others responsible for system maintenance of the emergency power supply system (HR.2.30.2; HR.2.30.4; HR.2.30.7)
  4. Test generator fuel oil, track expiration dates, replace stale fuel oil
  5. Communicate emergency power system capabilities and limitations to administrative and clinical leadership
  6. Establish contingency plans for clinicians to follow during emergency power outages of varying durations (EC.7.10.12)

In several instances, there are already standards-based requirements that echo these "recommendations" (I have noted those with the applicable citation), which begs the question of how one should deal with these recommendations.

Our best advice is to work through this process as you would in managing any identified risk or improvement opportunity, be it clinical or environmental (and make no mistake, this has elements of both). As part of your FMEA, identify which, if any, of the risk reduction strategies identified in the Alert, might be applicable to your facility (they're all pretty reasonable) Then work your way through each of the six recommended steps (understanding that several should be in place to a substantial degree) and identify the improvement opportunities and upgrades. Once you have your "shopping list," prioritize the items (I'd love to be able to tell you that all this stuff is available "on the cheap," but that is a most unlikely scenario) and start moving forward.

As a final word relative to liability, I think that you would be hard-pressed during a survey or in the aftermath of a negative outcome during a power outage, to defend not working through this complete process. That being said, this should be an excellent learning process for involved staff - a process that can be extended into other areas of concern - there are more utilities that can be disrupted, especially in the event of a catastrophe. Our communities rely on us to be there to provide services regardless of the inherent difficulties in any given event. And we, in turn, must do everything in our power (small pun intended) to provide those services.

Speaking on behalf of my colleagues at The Greeley Company, any of us would be happy to assist you in fine-tuning your response to these changes and updates including helping to craft policies and effective processes designed specifically to fit your organization.  It may also be time to schedule an Unannounced Compliance Test-Run visit by one of our Greeley Company mock survey teams.  For more information please call Stacey Koch, Director of Client Relations at 888-749-3054, ext. 3193 or skoch@greeley.com.

Sincerely,

Steven A. MacArthur
Consultant
The Greeley Company

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