Angela: This webinar will focus
on the emergency operations staffing plan.
This new standard is at EM.12.02.03,
for hospitals and critical access hospitals.
I'd like to welcome you to this webinar
and introduce the speakers.
My name is Angela Murray.
I'm a Project Director for Healthcare Standards Development
in the Department of Standards and Survey Methods.
With me is Marisa Voelkel, a Physical Environment Specialist
in the Standards Interpretation Group.
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as of April 8th, 2022.
The Joint Commission reserves the right
to change the content of the information as appropriate.
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or represent all the content of the presentation.
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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.
Let's discuss the Emergency Operations Staffing plan,
EM.12.02.03.
This new standard just requires the hospital
has a staffing plan for managing all staff
and volunteers during an emergency or disaster incident.
Again, the note focuses on those identified
prioritized hazards listed as part
of its hazards vulnerability analysis when considering
or when developing a staffing plan.
The rationale for EM.12.02.03,
the hospital's emergency staffing plan should be activated
in response to an emergency or disaster
when the hospital is unable to meet or maintain
the immediate or ongoing needs of its patients.
The plan should address or anticipate staffing shortages
and hospitals should stand ready to adjust their
staffing models to meet the needs of their staff.
For example, supporting staff's emotional
and mental health needs that may arise
during an emergency or disaster.
I will now turn it over to Marisa to discuss the elements
of performance for standard 12.02.03.
Marissa?
Marisa: Thank you, Angie.
EM.12.02.03 Element of Performance 1
is regarding a staffing plan for managing all staff
and volunteers to meet patient care needs
during the disaster.
This would include contacting off duty staff,
acquiring physicians or other licensed practitioners,
handling volunteers, and working with coalition support
and other agencies.
In order to implement this EP, it should be written.
It needs to include all the elements of performance,
so review them carefully.
It needs to focus on managing staff only during the disaster
and moving into recovery.
Consideration should be made for whether this is centralized
or decentralized in implementation.
EM.12.02.03, EP 2.
This EP on the staffing plan addresses the management
of all staff and volunteers such as reporting,
roles, responsibilities, and integrating staffing
from other agencies and volunteers.
This plan should be written.
It should identify reporting processes and the structure
and consideration should be made
for the use of incident command.
A structure such as a labor pool could be utilized
in order to manage your staff.
EM.12.02.03, EP 4.
Now we're gonna discuss EP 4.
There was an EP 3,
but through the vetting process, it was removed.
So you will notice that it jumps
from EP 2 straight to EP 4.
So let's discuss this element of performance.
EP 4 of the staffing plan describes in writing
how the organization will manage
volunteer licensed practitioners when the EOP is activated.
This would include verifying and documenting the identity
of volunteer licensed practitioners,
ensuring that the organization gets verification
of licensure within 72 hours, and provides oversight
for the care, treatment, and services provided.
In order to implement this plan should be in writing.
It should have a process or procedure
that verifies identification of any licensed practitioners.
All organizations have up to 72 hours
to verify the licensure.
That timeframe starts from the presentation
of an individual to the facility in order to volunteer
to help during a disaster.
You also need to have a process for any volunteers
that are not licensed practitioners
but are people perhaps from Red Cross
or the community that just want to assist
but are not providing patient care.
EM.12.02.03, EP 5.
This is regarding the hospital identifying
the individuals that are responsible for granting privileges
to volunteer physicians and other licensed practitioners
such as advanced practice registered nurses
and physician assistants.
This documentation should also be
in the medical staff bylaws, rules and regulations,
policies, and procedures as appropriate.
This plan needs to be in writing.
It should identify who will grant the disaster privileging.
Again, as we've said in many other videos,
this should be a title or a department, not an individual.
Whatever plan there is for disaster privileging
should be included in medical staff bylaws for physicians.
EM.12.02.03, EP 6.
This part of the plan describes how the organization
will provide employee assistance
and support for the duration of the disaster.
This should be in writing.
It needs to identify needs for the staff
during the emergency which could include housing,
transportation, food, supplies for resting
such as cots, blankets, pillows, et cetera.
It also needs to identify family support for the staff
such as childcare, elder care, pet care, and so forth.
The plan should also include mental health
and wellness needs for staff such as during
and post incident well checks, post trauma counseling,
and other mechanisms to ensure that staff have
the resources they need to deal with the crisis.
Now I'm going to turn it back over to Angie.
Angela: Thank you, Marisa.
I'm just gonna spend a minute or two discussing
the new versus the old
Emergency Management chapter standards.
As Marisa described, the new Emergency Management
chapter standards, EPs 1, 2,
there's not an Emergency Management standard for EP 3,
so it goes from four to five to six.
The elements of performance, the area of topic,
these are applicable to both critical access
and hospitals and to the far right column,
you will see the prior EM standards that are listed.
This reference guide is now available at jointcommission.org
under the Emergency Management section of this website.
It is available for you to print and refer
to the old standards versus the new chapter standards.
Thank you for watching this webinar.
If you require further information
regarding these standards, feel free to use the form
located at dssminquiries.jointcommission.org.
Again, thank you.