Emergency Management Final Rule Impacts Specific Ambulatory Customers | Joint Commission
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Emergency Management Final Rule Impacts Specific Ambulatory Customers

Nov 01, 2017 | 1899 Views

17.BergeroBy Lynne Bergero
Project Director
Standards and Survey Methods

In September 2016, The Centers for Medicaid and Medicare Services (CMS) issued the Emergency Management Final Rule, a set of emergency preparedness and response regulations that applies to 17 health care settings, including ambulatory organizations.  

Ambulatory surgical centers (ASCs), Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) that are currently accredited by The Joint Commission are already substantially compliant with most of these CMS requirements.  

However, The Joint Commission has developed revisions to emergency management standards addressing deemed status programs, including ASCs. To support consistency in practice and preparedness across more accredited ambulatory settings subject to federal emergency management regulations, The Joint Commission has also included enhanced requirements for FQHCs and RHCs.  

Need for Better Emergency Planning

The purpose of the new regulations is to improve preparedness of ambulatory care organizations so that they can respond as effectively as possible to emergencies.  Disasters in the community can damage individual facilities and disrupt care to hundreds or thousands of patients for days, weeks, or months.  Recent disasters this summer in the US only reinforce this point.  Therefore, these regulations hold many health care organizations to a higher standard for communication and coordination across the continuum of care and including safety partners such as:

  • health departments

  • health care coalitions

  • fire department

  • utility providers

  • government agencies

These communication and coordination efforts can extend the capabilities of an ambulatory care organization to care for its own patients, facilitate its assistance to other health care organizations, and support situational awareness for decisions regarding maintaining services, closing the organization, re-opening post-disaster, and more.


The CMS Emergency Management Final Rule is structured to address key areas of preparedness and response: 

  • an emergency plan, including any supporting policies and procedures

  • a communication plan, which can be part of or separate from the Emergency Plan

  • training and testing within integrated healthcare systems, an optional requirement that applies to organizations that participate in a larger health system’s integrated emergency management program

New EPs – Effective Nov. 2017

The enhanced ambulatory care standards have been approved by CMS and will be effective for ambulatory care surveys beginning November 15, 2017.  These new elements of performance (EPs) are all contained in the Emergency Management (EM) chapter and are designed to address the more complex disaster planning environment. The new EPs require that the emergency management plan:

  • be reviewed and updated on an annual basis

  • address collaboration with local, tribal, regional, state, and federal emergency management officials

  • establish Continuity of Operations, with focus on succession planning, delegation of authority, and continuity of communications and facilities  

Of these areas, Continuity of Operations may present the most systemic change. It’s an essential component of emergency management planning with the general goal of recovery and restoration of the organization as a functioning entity following a disaster. Continuity of operations planning focuses on protecting the physical plant, information technology systems, business and financial operations, and other infrastructure from direct disruption or damage so that the ambulatory care provider can continue to function throughout or shortly after an emergency.  

Policies & Procedures

Existing Joint Commission Emergency Management and Leadership standards sufficiently cover the need for policies for ambulatory care providers, but new EPs for detailed CMS procedures were developed to address: 

  • communication with external sources of assistance for emergency response – applicable to ASCs  only

  • sheltering in place – applicable to ASCs only

  • federal waivers for declared disasters – applicable to ASCs only

  • role of volunteers and integration of federal health care workers

  • scope of responsibilities for evacuated patients

Communications Plan

The communications plan EPs list specific individuals and entities for which the ambulatory care provider must maintain contact information, including: 

  • patients and  families

  • staff, physicians, and other potential response partners or sources of assistance

  • contractors and vendors

  • relevant federal, state, tribal, regional, and local emergency preparedness staff 

In many cases, ongoing collaborative partnerships will be based on factors such as:  

  • the community and patient population served by the ASC, FQHC, or RHC organization

  • ways community partners can coordinate with the ambulatory care organization during disasters

  • the organization’s role in community response

In addition, back-up communication mechanisms are required so that if primary systems fail, the ambulatory care organization can continue to communicate information about coordination of staff, continuity of operations, closure, reopening, and so forth.

Training & Testing

The new EPs specify that the ambulatory care provider must train staff in emergency management procedures annually, and document the training. 

CMS expects organizations to reach out to the larger health care coalitions or health departments in their communities to participate in emergency management planning activities and community-wide disaster exercises. For some ambulatory care providers, there may be no relevant opportunities to participate in exercises. Regardless, ambulatory care providers must attempt to reach out to participate in community exercises, and document these attempts and their outcomes. 

Integrated Healthcare Systems Option

If the ASC, FQHC, or RHC organization is a member of a health care system that has an integrated emergency preparedness program for its members, and the organization chooses to participate in it, the organization must participate in planning, training, exercises, and other preparedness and response activities specified in the new EPs.  

Depending on the organization’s risks, services, and capabilities, some aspects of integration with the system may be at an early stage rather than an advanced stage. However, because disasters can occur at any time, the organization must be prepared to activate communication channels with the system to coordinate any essential patient care, safety, or continuity of operation processes.      

Web Resources

I encourage you to review the following resources for additional background information regarding the Emergency Management Final Rule: 

Professional associations also periodically post Emergency Management resources to support compliance with regulatory requirements. Follow the links below to a starting point for resources from the Ambulatory Surgery Center Association (ASCA) and National Association for Community Health Centers (NACHC):

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