Emergency Management chapter revised for Ambulatory Care, OBS Programs

Effective July 1, 2024, a fully revised Emergency Management (EM) chapter, including new and revised EM standards, has been approved for all Joint Commission-accredited ambulatory care organizations and office-based surgery practices. The Joint Commission thoroughly analyzed and rewrote the EM chapter, which resulted in the following:

• Reorganized requirements
• Renumbered standards
• Reduced elements of performance (EPs) by more than 40% for ambulatory care organizations
• Eliminated redundant requirements for office-based surgery practices

The goal of the rewrite was to help health care organizations to develop more comprehensive EM programs and to better prepare for the health, safety, and security needs of their facilities, staff, patient populations, and communities during emergencies or disasters (such as the COVID-19 pandemic). The new and revised EM requirements clarify and emphasize the following:

• Assessment, applicability, and incorporation of the hazard vulnerability analysis throughout the EM chapter
• Leadership involvement and oversight in all aspects of the EM program
• Staff education and training, with specific guidance for initial and ongoing EM training

As a result of the EM revisions, the following changes also apply:

• Information Management (IM) Standard IM.01.01.03, EPs 5 and 6, will be deleted from the ambulatory care requirements.
• There will no longer be requirements specific to Federally Qualified Health Centers (FQHCs). Those organizations will follow the EM requirements on the applicability grid for either medical centers or dental centers, as applicable.
• Rural health clinics (RHCs) accredited under the ambulatory care program will follow the EM requirements identified by the lead-in for RHCs, beginning at Standard EM.02.01.01 and ending at Standard EM.04.01.01, until further notice.

The program-specific R3 Report provides rationales for the requirements as well as references to the research and reports used to develop them. In addition to an extensive literature review, the new and revised requirements were developed based on voice-of-customer feedback resulting from the pandemic, public field review, and expert guidance from the standards review panel and an internal Joint Commission EM workgroup.

The new and revised standards will be posted on the Prepublication Standards page of The Joint Commission’s website and will publish online in the spring 2024 E-dition^® update to the Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) and the Comprehensive Accreditation Manual for Office-Based Surgery Practices (CAMOBS).

For more information, please contact the Department of Standards and Survey Methods.