Today’s blog post is the fourth in a series of posts of questions and answers from the JCR Annual Ambulatory Care Conference of November 2013. The Joint Commission panel of ambulatory experts responded to these questions regarding compliance issues during sessions held at the conference.
This fourth installment continues a focus on environment of care. We’re happy to welcome back John Maurer, SASHE, CHFM, CHSP. A member of The Joint Commission’s Department of Engineering, John provides support for customers seeking insights specific to the ambulatory care environment.
Q: Some Community Health Centers (CHCs) have school-based programs. What advice does The Joint Commission have for school-based programs in order to be compliant with the emergency management standards?
A: While the emergency management standards apply organization-wide, the planning activity should take into account site-specific locations (such as school-based programs) and the challenges each may present based on the organization’s analysis. Recent challenging requirements are based on leadership participation when developing the emergency management plan (EMP) in addition to understanding and documenting the role the organization may have with the community. When performing exercises, it is helpful that attention be given to the notes in the elements of performance (EPs) in EM.03.01.03. When response activity is evaluated for exercises and actual events, be sure to include the multi-disciplinary team in the organization (or all staff that had responsibility during the exercise or event) to effectively critique the response. Any modifications to the plan must be exercised in subsequent exercises.
Q: We are a business occupancy health care organization that will not be a receiving station for disasters. Are we required to conduct drills for utilities (e.g., a power outage) if that is a vulnerability according to our hazard vulnerability assessment (HVA)?
A: EM.03.01.03, EP 2 discusses the exercises required for organizations that are community-designated disaster receiving stations. This notes that an influx of simulated patients is required and if the organization is not a community-designated disaster receiving station, this EP will not apply. There is no exemption for utilities systems, or other risks, that may be identified in the HVA.
Q: We have two sites. One site provides primary and specialty care. The other site provides outpatient psychiatric services. Must we include the psychiatric clinic in the influx drill?
A: The need to include the psychiatric clinic in a required exercise for an influx of simulated patients should be determined in your EMP. Exercises are expected to be developed in accordance with the potential emergencies, or HVA, that may impact a facility and additional locations. If an organization’s EMP specifies actions for the ancillary site(s) when an emergency impacts the primary site, The Joint Commission would expect the organization to respond according to the plan and demonstrate the plan was initiated and acted upon accordingly.
Q: In organizations large enough to empower an emergency preparedness committee to administer the emergency management programs, do members of this group (typically the director and senior director) meet The Joint Commission’s definition of “leaders” or are “leaders” limited to chief or vice president level in the context of developing an HVA and subsequent plans?
A: The Joint Commission defines a leader as “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.” Unless specifically stated, the definition allows for the organization to define who the leaders are for an organization.
Q: We noticed our EMP does not include a process for an “active shooter” and training, mock event, etc. Does The Joint Commission have resources to get us started? Should “active shooter” situations be covered in EMPs?
A: Joint Commission Resources (JCR) provided articles in the April and August 2013 issues of The Joint Commisson’s EC News relative to the risks associated with an “active shooter.” Other useful resources for organizations to use are the local law enforcement to help develop strategies for safeguarding and response in addition to Homeland Security that provides suggestions. To determine if the risk should be addressed in the EMP, organizations should start with the HVA to determine the level of risk. If this issue ranks high up on an organization’s HVA risk level, the organization should take additional steps to develop plans to safeguard against the potential for an “active shooter.”
Q: Is there a recommendation on where to find the best HVA template or something that can be used to develop a really useful and comprehensive HVA?
A: The Joint Commission offers The Leading Practice LibraryTM to accredited customers that may offer a sample HVA form that organizations can use to develop their own form. Other sources to pursue that may be useful are in publications available through JCR relative to emergency management or asking nearby health care organizations for samples they may be willing to share.
Have more questions? Additional questions may be submitted to The Joint Commission Standards Interpretation Group by calling 630-792-5900, Option 6, then Option 2, or by submitting a standards question submission form.