Safety

Tip of the week: Comply with new Joint Commission requirement for emergency exercises

Hospital Safety Insider, September 15, 2011

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EM directors should be aware of the new note that's been added to standard EM.03.01.03, says Marge ­McFarlane, PhD, CHSP, HEM, MEP, an independent safety consultant who runs Superior Performance, LLC, based in Eau Claire, WI.

To comply with Centers for Medicare & Medicaid ­Services (CMS) requirements, The Joint Commission added a new Note 4 under EM.03.01.03, element of performance (EP) 1. The new note states, "In order to satisfy the twice-a-year requirement, the hospital must first evaluate the performance of the previous exercise and make any needed modifications to its Emergency Operations Plan [EOP] before conducting the subsequent exercise in ­accordance with EPs 13-17."

"I think that's a good thing," says McFarlane. "This now very clearly says you need to take care of the items you identified prior to the next exercise."

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