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Emergency Management – Hazard Vulnerability Analysis

What are the requirements related to the hazard vulnerability analysis (HVA) for organizations and off-site facilities?

Any examples are for illustrative purposes only.
Organizations are expected to conduct a hazard vulnerability analysis (HVA) which identify potential emergencies, for locations within the organization/facility and the community (EM.11.01.01).  The potential emergencies could affect demand for services and/or the ability to provide services. The HVA should take into account the likelihood of those events occurring and the consequences of those events. The HVA is documented and reviewed at least every two years (EM.17.01.01, EP 3).    

The HVA should be reviewed and updated based on after-action reports or opportunities for improvements that have been identified following real events and/or exercises conducted. For instance, an organization with frequent severe winter weather (snowstorms or blizzards) on their HVA, due to activation of the Emergency Operations Plan (EOP) most winters, should improve their EM plans as they learn lessons and improve their response/recovery for severe winter weather. Therefore, as their plans and response improve, the risk rating of severe winter weather should decrease, allowing other risks and vulnerabilities to become a focus.    

The need for site-unique hazard vulnerability analysis (HVA) depends upon whether the off-site facility has different internal or external circumstances that would affect its ability to manage emergencies. If a site is in close proximity to the main facility, and participates in the main facility's emergency operations plan, then the organization may combine the off-site HVA with the main facility's HVA; the off-site facility must be identified. If the off-site facility has its own unique vulnerabilities in the context of its ability to provide services, then those vulnerabilities are to be assessed and an HVA performed for that site.
Although it is not uncommon for a unique hazard vulnerability to be identified for a remote facility, often the emergency operation plan is simply a documented process for temporarily stopping services since the off-site facility does not provide emergency services or any other care that cannot be deferred.    

Manual: Hospital and Hospital Clinics
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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