Angela: This webinar focuses
on emergency operations communications plan,
the new standard at EM 12.2.1.
I'd like to take a moment to introduce myself
and my colleague.
My name is Angela Murray.
I'm a project director, healthcare standards development
in the department of standards and survey methods.
And with me as Marisa Voelkel,
she is a physical environment specialist
with the standards interpretation group.
Our disclaimer, these slides are current
as of April 8th, 2022.
The Joint Commission reserves the right
to change the content of the information as appropriate.
These slides are only meant to be cue points,
which were expounded upon verbally
by the original presenters and are not meant
to be comprehensive statements
of the standards interpretation
or represent all the content of the presentation.
Thus, care should be exercised
in interpreting Joint Commission requirements based solely
on the content of these slides.
These slides are copyrighted
and may not be further used, shared,
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Distribution of this presentation other than
in PDF format is expressly prohibited.
At the conclusion of this webinar,
you'll be able to understand the new
and revised emergency management chapter standards,
how to implement those new and revised standards,
and be provided with identifying new
versus old emergency management chapter standards.
The emergency operations communications plan, EM 12.2.1,
this new standard focuses
on hospital having a communications plan
that addresses how it will initiate
and maintain communications during an emergency.
And you'll note that the hospital
should use its prioritized hazards identified
as part of its hazards vulnerability analysis
when developing an emergency communications plan.
The communications plan describes how
and when it will communicate information to its staff
and others.
And the communications plan should account
for the rapid evolution of an emergency
or disaster, and the need
to consistently provide clear information regarding
the emergency and the hospital's ability
to provide services both internally and externally.
Now I will turn it over to Marisa
to talk about the elements of performance, Marisa.
Marisa: Thank you, Angie.
EM 12.2.1, EP1
is regarding the hospital maintaining a contact list
of individuals and entities
that need to be notified during an emergency.
There is a list in this element of performance
of entities and individuals that should be accounted for
in the emergency operations plan.
In order to implement EP1, the plan must be written.
This plan can be physical or it can be online
for your contact lists.
You can utilize a mass communication system.
You can utilize existing lists like departmental or on call.
Ensure that you are keeping your contact lists up to date
with names, titles, phone numbers, departments
or however you manage your list.
For entities such as your local emergency,
management agency, other healthcare organizations focus
on titles rather than names
so that you're reaching a department
and an emergency as positions can change over time.
EM 12.2.1, EP2.
This element of performance
for the communications plan describes how the organization
will establish and maintain communications
in order to deliver messages
and information during a disaster.
The point of this element of performance is making sure
that you are releasing critical information,
pertinent information to staff, volunteers, families,
community partners in real time,
so that if there's an area that should be avoided
or things have changed such as points of entry,
or there is a need to call in mass staff
that information gets out quickly and efficiently.
In order to implement EP2, this plan must be written
and the plan should focus
on how there is going to be communication
between the organization
and the other individuals or entities.
The communication process can be different for each group
and it can be accomplished in very different ways
whether it's with reaching the physicians,
or reaching the staff, reaching family members
of patients and so forth.
Focus on the process and the plan
for how it will be accomplished rather than getting
into the weeds of each minute detail.
Let's go through a few examples
of how this could be accomplished.
These are examples only and not intended
to be precisely what Joint Commission is looking for.
Staff is to be notified
and updated by their leaders if on duty.
And this will be accomplished by mass communication tech,
such as the software program in which one message is sent
to all the numbers enrolled in the program.
The plan may state communication with patients
and family members is the responsibility
of the nursing administration office.
And then the nursing administration office has procedures
for how they will accomplish this goal.
The plan may state communication
with community is the responsibility
of the director of emergency management
or the liaison in the incident command structure.
Communication with the community is the responsibility
of the director of emergency management,
or the liaison with an incident command.
Again, there would be a procedure or process
that could be retrieved from either of these physicians
that would demonstrate how that communication
will happen and with whom.
The plan might state communication
with relevant emergency management authorities
is the responsibility
of the emergency management coordinator.
It may state that communication
with relevant law enforcement authorities
is the responsibility of security.
Media and other stakeholders would be notified
by the media relations department.
And communication may occur via email, text, phone call,
website update, press release, radio, satellite phone,
internal instant messaging, mass communication platform,
depending on the need and what is available at the time.
So as you can see this example for a communication plan
divides up who will be contacted by whom during a disaster
leading to the procedures that each
of those relevant areas may have.
And it discusses that communication can occur
through several different modalities.
Again, this is only an example to demonstrate
that the plan can be very focused
on how information is disseminated.
EM 12.2.1, EP3.
This element of performance for the communication plan
describes how the hospital communicates with
and reports information about their needs
and their occupancy, and the assistance
that is either required or available.
Implementing this element
of performance requires a written plan
for how the information is shared.
There may be use of internal systems working
through a healthcare coalition system, through liaisons,
or many different structures that are dependent
on your organization, your location, your connections
and so forth.
Do you consider local guidelines regarding
the emergency department communication?
We don't wanna leave
that already established communication out,
but there should be some guideline for each ED
and how they communicate with other healthcare organizations
and emergency services.
Follow your state
and local authorities having jurisdiction guidelines
if there are any in place.
EM 12.2.1, EP4.
Element of performance four discusses
within the communication plan
how the hospital will provide warning
and notification alerts specific
to emergencies and disasters.
And what procedures to follow during those occurrences.
Implementation must be in written form.
You need to identify each alert or warning
and the procedures to follow when activated.
Keep it simple and manageable.
Focus on those that need an immediate response,
such as a fire or a missing person, code blue,
active shooter, severe weather.
It'll be up to your HBA and your committee decide
which items need an immediate response.
Other items you can plan for them such as impending flooding
and you have time to prepare or get a message out.
The initial alert should focus on an action has happened
or a situation has occurred and staff
and visitors need to do something immediately
to prepare for that situation or protect themselves.
Couple of examples to discuss; a code red or a fire alarm.
This could be an automatic fire alarm system
and it will close doors, it announces,
states the location of their fire alarm
so people know where not to go.
Staff will close all the doors in the area
and adjacent to the area to protect patients,
or they'll evacuate an area and so forth.
So when the fire alarm goes off when it's triggered
then staff know exactly what they need to do
to protect themselves and others.
Another example is a severe weather warning.
Perhaps there's an overhead announcement,
it's made by paging
that there's a severe weather warning followed by the type
of warning and the actions you need
to take such as seek shelter now.
Staff immediately pause or wrap up any patient care
that they have at the moment.
And they follow those procedures
to again protect the safety of all involved.
EM 12.2.1, EP5.
EP5 for the communications plan discusses the method
for sharing and releasing information,
and medical information about patients
that are under the care of the hospital.
This may include information to families, representatives,
or others involved with the care of the patient,
disaster relief organizations, other healthcare providers.
To appropriately implement this element of performance,
again, it must be written.
This should focus on a process
for sharing and releasing information.
Another where two or what department has the authority,
the ability and the mechanisms
for appropriately releasing protected information.
How it should be done or procedures,
and make sure that privacy compliance is maintained
throughout this process.
Normally, hospitals already have a mechanism
for sharing information with other entities
or with family but these processes may need
to be expedited during a disaster.
EM 12.2.1, EP6.
This element of performance discusses the primary
and alternate means for communicating with staff
and relevant authorities.
This should discuss your alternative,
and backup communication methods
and making sure that those methods are compatible
with other community partners,
as well as testing mechanisms.
This plan should also be written.
It should identify clearly the primary
and alternate communication methods.
For instance, primary methods may be through phone calls,
through instant message, through intranet, and so forth.
But an alternative method may be with walkie talkies
or personal cell phones, or a mass communication,
or a different form of paging.
Work with community partners basically means a statement
of who has compatible equipment.
So in working with them
or in the case of a healthcare coalition,
there may be certain tools, or radio receivers
that are disseminated among organizations
that are only used during disasters,
or only a certain frequently is used.
Those statements within your plan will assist
with showing the compatibility.
Regularly test your equipment to make sure
that it's functioning.
If you have walkie talkies, for instance,
that are always charging over time those batteries will die.
Or perhaps people don't know how to use the walkie talkies.
So regularly testing.
And that is not defined as to a timeframe
provide familiarity as well as ensure
that it is functioning when a disaster occurs.
You can work these tests into exercises.
It may include other partners.
It could be already established exercise.
Remember, communications is one of our six critical areas.
So this is a prime way to work communications
as one of the six critical areas into an exercise.
Also perform internal and external system tests
to ensure that whatever alternative communications
is chosen does work effectively.
Now I'm going to turn it over to Angie.
Angela: Thank you, Marisa.
As Marisa just described,
this reference guide demonstrates all of the current EPs,
all six EPs under the emergency operations
with regards to the communications plan.
The topics under that plan these are applicable
to critical access in hospitals.
And in the far right column, you will see the previous
or what I would call current EM standards
that have been combined or revised
with these new six elements
of performance again under EM 12.2.1.
This reference guide is now available to you.
You may print this off
so please visit jointcommission.org website
under the emergency management page.
There is a link to this that you can have access
to print off this new reference guide.
Thank you for watching this webinar.
If you have further questions or concerns,
feel free to reach out to dssminquiries.jointcommission.org
and submit your form, questions,
or concerns through that venue.
Again. Thank you.