Angela: This webinar focuses on the new EM.13.01.01
Continuity of Operations Plan.
-: I'd like to take a moment to provide a welcome,
thank you for joining this webinar,
and to introduce the speakers.
My name is Angela Murray.
I am a project director
in the Department of Standards and Survey Methods,
and with me as Marisa Voelkel.
She's a physical environment specialist
in the Standards Interpretation Group.
These slides are current as of April 18th, 2022.
The Joint Commission reserves the right
to change the content of the information as appropriate.
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which were expounded upon verbally
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At the conclusion of this webinar,
participants will be able to describe
the new and revised Emergency Management chapter standards,
describe implementation of these standards,
and identify new versus old standards.
Continuity of Operations Plan EM.13.01.01.
The New Standard at EM.13.01.01,
the hospital has a continuity of operations plan.
The hospital considers its prioritized hazards
identified as part of its HVA
when developing its continuity of operations plan.
The rationale for this standard
is that the continuity of operations plan,
otherwise known as COOP,
provides guidance on how the organization
will continue to perform its essential business functions,
deliver essential services,
and provides delegations of authority and succession plans.
The executive leadership identifies
and prioritizes those essential services
that are deemed necessary to remain operational,
and makes certain that critical business functions
continue working during an emergency or disaster incident.
I'm now gonna turn it over to Marisa
to discuss the elements of performance.
Marisa?
Marisa: Thank you, Angie.
EM.13.01.01, EP 1.
This element of performance requires hospitals
to have a COOP that is developed
with the participation of key executive leaders,
business and finance leaders,
and other departments as determined by the organization.
To implement this element of performance,
the plan should be written.
For EP 1, the organization should develop a list
of essential business functions and critical services.
Consider administrative and vital roles,
information technology, financial services,
security systems, communications and telecommunications,
and building operations.
This list should focus on services and functions
that cannot be deferred during a crisis.
A good question to ask yourself is
what must we have in order to keep the doors open?
Some examples of things to consider
when developing your list of essential business functions
and critical services:
A hospital only has one backup server
for billing and payroll.
What happens if that server is compromised?
The hospital doors are tied
to the security and fire alarm system.
They need to remain operational
throughout the duration of a crisis.
Otherwise, people are locked out.
How are you going to ensure
that the doors remain functional?
In order to continue to receive necessary supplies,
someone needs to authorize payment and execute contracts.
Who would be responsible for that,
and how would they accomplish that goal?
Engineering has two people that know the electrical systems.
What happens if both of them are unavailable
or compromised during a disaster?
So these are just some example questions just to consider.
You may have many more other items to consider.
The key question is what must an organization have
to remain functional during the crisis?
EM.13.01.01, EP 2.
For this element of performance,
the continuity of operations plan identifies in writing
how and where it will continue to provide
essential business functions when the location
of these services and functions has been compromised.
Things to consider would include offsite locations,
spaces maintained by other organizations,
existing facilities and spaces,
remote working and telehealth.
To implement this element of performance,
it must be written.
The COOP provides guidance on how the hospital
will continue to perform the essential business function
or critical services.
It will also determine where the services will move
if the primary location is compromised.
And need to consider that the locations
are physically compromised,
in other words, they are inaccessible.
For example, for vital records or servers,
what is the organization going to do?
What is the plan to ensure
that their essential business functions remain operational?
EM.13.01.01, 3.
For this element of performance,
the organization has a succession plan
that identifies who is authorized
to assume particular leadership or management roles
when the main person is unable to fulfill their function.
This plan must be written, and keep in mind,
this succession plan is a plan that authorizes someone
to assume a particular leadership or management role
when the main person is unable to perform that function.
One example of how you can go through this process
to create a succession plan is identify the role.
In our example here, our role is going to be
the supply chain director.
Determine the skills and the access
that are necessary for that role,
so the director understands the policies and procedures
and has access to key vendors and critical information.
The next step would be to preposition
that access and authority,
so involve a chosen individual ahead of time,
or maybe more than one individual,
and have a letter of authority already created.
Develop successors.
Do you want to take the person that you've identified
and involve them in everyday activities
so they become familiar?
This would not be every day, every single activity,
but activities that would be required during a crisis.
You want to teach, train, and introduce them
so that the major event is not the first time
that they are introduced
as the person of authority in succession
or the first time that they are dealing with policies,
procedures, and access.
Again, this is just an example of how you can do it,
not a prescribed way from Joint Commission
on how you should do it.
EM.13.01.01, EP 4.
For this element of performance,
there is a written delegation of authority plan
that provides individuals with legal authorization
to act on behalf of the hospital for a specific purpose.
For this EP, it should also be in writing,
and the delegation authority
provides that legal authorization to act.
As we just discussed in EP 3 through succession planning,
that plan determines who is going to do certain actions.
This EP provides that authority to do those actions.
Let's take, for example, the financials.
You may identify who can grant authorization
for large expenditures.
You may assign required responsibilities to someone,
or more than someone to have this authorization.
You need to decide ahead of time
what will trigger this transfer of authority
and inform others, such as incident command and leadership,
who will have this authority
by announcing this authority to function during a crisis.
There should be some sort of accountability created
for when the main person returns,
and consideration should be made for any constraints
or boundaries that need to be in place.
In the case of the financials,
we may be discussing the chief financial officer,
that individual being compromised
or unable to perform duties during the crisis,
so who would be accessible and available
at that point in time to do a limited amount of duties,
just enough to keep the organization
functioning and moving forward?
Again, this is just an example and not a requirement
to go through these steps or processes for Joint Commission.
So, in summary, your Continuity of Operations Planning
should identify and prioritize essential business functions
and critical services,
and note that essential versus important difference.
There can be important services
that can be deferred during a crisis,
but essential functions are necessary
in order to keep the doors open
and maintain any kind of services.
The planning team should identify strategies
to support business continuation.
So, as you can see by the pyramid,
once the continuation of essential business functions
and operations is identified, then you put in a strategy
to protect those essential facilities,
equipment, records, or so forth.
You work through your service recovery
through your delegation of authority and succession plan,
and you mitigate the disruptions
as much as possible before the crisis hits.
Now I'll turn it back over to Angie.
Angela: Thanks, Marisa.
I'll just describe briefly some of the new
versus the old EM chapter standards.
As Marisa described, there are four elements of performance
under the standard EM.13.01.01
for the Continuity of Operations Plan,
and you will note the far right column,
the first two EPs that are listed under this new standard,
we did not have any previous EM standards for this.
But for written succession plans
and delegations of authority,
you will find those prior standards at EM.02.01.01, EP 12.
Thank you for watching this webinar.
If you have further questions regarding these standards,
please submit the form
using the dssminquiries.jointcommission.org.
Thank you.