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Emergency Management – Emergency Operations Plan Development and Participation

Are hospital leaders and medical staff required to participate in developing the Emergency Operations Plan?

Any examples are for illustrative purposes only.
The revised Emergency Management (EM) chapter for Hospitals and Critical Access Hospitals includes a new standard for EM leadership (EM.10.01.01).  Hospital leadership is expected to provide oversight and support of the Emergency Management Program.
A multidisciplinary committee that oversees the EM program should include medical staff or physician member as well as hospital executive leadership (e.g. individuals with decision-making authority).  The multidisciplinary committee, including medical staff and hospital leadership, will be directly involved in the preparation, development, implementation, evaluation, and maintenance of the EM program, the emergency operations plan, policies, and procedures.  Their input is essential to establish the expected capabilities and duties of these entities.
It is also important for medical staff and executive leadership to understand the duties and capabilities for the staff that will support the emergency operations plan, and the capabilities of community support entities. Many disaster scenarios involve patient care regarding management of current patients and managing influx of patients. Hospital leaders must understand the command structure and how it functions.
Manual: Critical Access Hospital
Chapter: Emergency Management EM
New or updated requirements last added: June 13, 2022. New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: June 13, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
This page was last updated on June 13, 2022 with update notes of: Reflects new or updated requirements Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.

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