Nursing

JCAHO to check emergency plans: Hospitals with 200 or more beds subject to interviews

Nurse Leader Weekly, November 28, 2005

Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

Surveyors will scrutinize emergency management and preparedness plans for hospitals with more than 200 beds beginning in 2006, a JCAHO official said September 13.

Surveyors will meet with a hospital's emergency management committee for two to four hours at the hospital's incident command post, Standards Interpretation Group Engineer Jerry Gervais, CHFM, CHSP, told attendees during the Wisconsin Department of Health and Family Services Third Annual Statewide Partners' Conference on Public Health and Hospital Preparedness in Milwaukee.

"This is not, 'We're going to sit down and talk about this for 10 minutes,'" Gervais said. "We're going to be at this for a while."

Tracing emergency plans

A surveyor will interview members of the emergency management team and review plans to handle emergencies, Gervais said. All emergency personnel or their designated backups should be present during the interview, he said.

The bulk of the emergency preparedness meeting will occur when the surveyor picks a scenario to review with the team and interviews hospital staff about how they would respond to such an incident and what their roles would be, Gervais said.

Scenarios include transportation accidents, toxic spills, bioterror attacks, and natural disasters (e.g., hurricanes and tornadoes), Gervais said. Surveyors would select scenarios that would be realistic to a hospital's hazard vulnerability analysis, which identifies the risk of certain events occurring in a hospital's community and how prepared the organization is to handle them, he said.

Surveyors who work in hospitals with 200 or more beds will receive training on this interview process during their annual training in January, Gervais said.

Staff roles critical

Based on the average survey process for hospitals with 200 or more beds, the emergency management interview will take up almost half of a survey day, said Steve MacArthur, a safety consultant with Marblehead, MA-based The Greeley Company, a division of Briefings on JCAHO publisher HCPro, Inc.

MacArthur said most organizations he has seen have done a good job with their emergency management committees. The new interviews may shake hospitals that have yet to grasp the JCAHO's expectations of disaster drills, but that's not necessarily the intention, he said.

"The ultimate expectation is that each staff member should know what his or her role in the plan is and how [to] go about performing that role effectively," MacArthur said. "I think folks have a pretty good handle on that at the moment."

The JCAHO requires organizations to have two disaster drills per year. One drill must involve an influx of patients, and hospitals must also include the community in a drill, either in addition to the required two or as part of one.

One of the drills must also test some aspect of emergency response, including utility outages, bomb threats, or infant abduction, Gervais said.

Emphasis on coordination

The need to evacuate patients both before and after hurricanes Katrina and Rita, which struck the Gulf Coast within four weeks of each other, will place added emphasis on an organization's disaster planning and response, MacArthur said.

Recent events show the importance of communication and coordination between hospitals and communities in terms of disaster planning.

"I don't know of too many folks who are practicing community disasters at the hospital, as opposed to the fairgrounds or the high school football stadium or whatever," MacArthur said. "Generally, the hospital's role is one of providing support, as opposed to a scenario in which the hospital is the 'scene of the crime.'"

Source: This article is adapted from Briefings on JCAHO, November 2005, HCPro, Inc.



Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!

Most Popular

Related Articles