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Here’s a thought for you regarding emergency plan drills in 2009 and what The Joint Commission expects of you. Let’s look at EM.03.01.03, element of performance 16 (and I will quote it in its entirety):
The hospital modifies its emergency operations plan based on its evaluations of emergency response exercises and responses to actual emergencies.
So far, so good. But now we have this little dangling note:
Note: When modifications requiring substantive resources cannot be accomplished by the next emergency response exercise, interim measures are put into place until final modifications can be made.
Now I have to say that every time I see that lovely, little 15-letter phrase--"interim measures”--I start to get hives. I advise organizations to be succinct in identifying those interim measures.
I was recently asked whether organizations should create a policy to meet the requirements of EC.4.14. That Joint Commission (formerly JCAHO) standard requires hospitals to establish strategies to handle assets and resources during emergencies.
I don't know that I would necessarily recommend creating a policy to address all the elements of EC.4.14, as much because the individual elements carry across the whole operational continuum of an organization. In other words, there are pieces of EC.4.14 that "belong" to facilities, some to materials management, some to other department-level folks, etc.
I daresay that these should probably be addressed as a function of your response plan. This then folds up into your incident command structure for use during actual emergencies.
Managing assets and resource during an emergency needs to be "living" process and very fluid. My experience has been that once these things get to policy level, they lose a lot of flexibility in the process.
I read a story earlier this month in the St. Louis Post-Dispatch about a company with a new type of patient evacuation device called the Med Sled. The manufacturers noted in the story that using the sled-like device, a nurse weighing 100 pounds could take a 200-pount patient down flights of stairs during an evacuation.
I don’t know much about this product beyond what was in the newspaper article and what I’ve read on the company’s Web site, and customers seem satisfied based on online testimonials. But I will say that George Mills, senior engineer at The Joint Commission, is concerned in general about evacuation plans and how realistic they are when it comes to physically moving patients.
I remember at a session Mills spoke at during the National Fire Protection Association’s annual conference in June, he asked attendees if they’ve ever tried performing two-person evacuations of patients for any length of time.
"It’s a lot of work," he said, and specifically mentioned the difficulty of a nurse trying to move a 250–300-pound person.
I’ve never evacuated anyone during an emergency, but years ago HCPro filmed a nursing home evacuation video that I was an extra in. During one shot, three of us had to carry an actor portraying a patient down a flight of stairs, and I was sweating after the third or fourth take.
I guess ultimately, whatever devices your hospital uses to aid evacuations, make sure during drills that nurses and other unit staff members test their abilities to use those devices.
In 2009, disaster privileging will move from The Joint Commission’s medical staff chapter to the EM standards.
EM.02.02.13 allows hospitals to grant disaster privileges to volunteer licensed independent practitioners (generally speaking, physicians).
I’ve found that having a doc in the room can make a very big difference with the tone of surveyor interrogatories.
I’ve noticed a wee beastie under The Joint Commission’s upcoming 2009 emergency management standards, and it concerns licensed independent practitioners (LIPs).
Check out EM.02.02.07 (management of staff members during emergencies). EP #8 states:
The hospital communicates in writing with each of its licensed independent practitioners regarding his or her role(s) in emergency response and to whom he or she reports during an emergency.
This wording may be no big deal, but I’m thinking that any time we see an “each” in the standards it complicates compliance.
Also of note, The Joint Commission doesn’t even qualify the LIPs with “appropriate” or “applicable”, which I guess could mean you need to notify certain LIPs in writing to stay out of the way (and you know which ones they would be in your house).
I recently chatted with someone about items you need to monitor in the EC.
There are myriad activities, primarily represented through the "C" elements of performance (EPs) in the EC chapter, that revolve around the "care and feeding" of the care environment--medical equipment, life safety equipment, emergency power equipment, conduction of safety rounds, and the like.
A solid EC program is going to have a process for monitoring compliance with all these "have to" elements, just to ensure that the EC program’s baseline competencies, if you will, are in place and functioning appropriately.
Beyond the activities and processes that you "have to do," things get a whole lot grayer in very short order.
The key standard for the rest of the monitoring expectations is EC.9.10 (the hospital monitors conditions in the environment). These expectations are pretty much a function of the risk management process in the care environment. There are six EPs involved in EC.9.10, pretty much divided into constant activities and periodic (at least annually) evaluations of the whole kit and caboodle.
More on this topic in my next post . . .
Hi, it’s Scott Wallask signing in today. I just got back Tuesday night from the American Society for Healthcare Engineering (ASHE) conference.
Lots happening on The Joint Commission (formerly JCAHO) front, as you can imagine. We’ll be covering this in detail in upcoming issues of Briefings on Hospital Safety and Healthcare Life Safety Compliance.
One thing I did want to mention is that George Mills, senior engineer at The Joint Commission, said he was concerned about the lack of realistic utility contingencies in hospital emergency operations plans.
From Mills view, some utility contingency provisions read great on paper, but are never really tested and thus aren’t reliable.
Mills asked ASHE attendees this: “When was the last time [you] walked through to make sure these things are even operating?” In other words, if your utility contingency plans center of certain equipment working, check this equipment out during down time before a disaster strikes.
Mills would rather have a utility failure occur when hospitals are expecting it during testing than during an emergency when patient lives are at risk, he said.
By the way, if you need help with the 2009 emergency management, life safety, or EC standards and can spare a day away from the office, come to our Environment of Care for 2009 seminar September 5 in Boston.
Did you hear that great sighing sound earlier? In all candor, I have to tell you that I was one of those sighers.
(Is “sighers” a word? Probably not, but the blogosphere can’t rest on such formalities).
The other shoe has dropped, and The Joint Commission 2009 standards changes have (finally!) been posted on the Web.
The question then becomes: Celebration or commiseration? What do we do?
For the moment, it appears that a moderately restrained celebration will suffice. The key words indicating the disposition of the current standards I noted in reviewing the materials are the following:
- Retention--No change in the applicable EP, i.e., the song remains the same.
- Consolidation--A slight change, a blending, if you will, of risk management activities under a general umbrella. For instance, all the safety education elements are now living in one happy house, EC.03.01.01, and, perhaps most controversially, the safety and security standards have become one under EC.02.01.01.
- Split--EPs previously containing multiple component requirements are broken down into the individual components. For instance, EC.3.10, EP #3 under the 2008 standards speaks to the risk management of chemicals, which has been further broken out in the 2009 standards under EC.02.02.01 to reflect the risk management of hazardous chemicals, radiation equipment and lasers, and hazardous gases and vapors.
As near as I can tell (and this has pretty much been the indication as this initiative has rolled out), there are no new requirements, per se. What appears to be changing is more a function of how EPs could be scored during a survey, especially those (banana) splits.
In my client work, I have often compared the current survey process’ arrival at “jeopardy” as not so much death by a sucking chest wound, but more death by a thousand cuts--and the Swiss survey knife appears to have grown a couple more blades. While my obsessive-compulsive disorder has not yet resulted in my counting up the number of EPs in play, rest assured I will.
There is a fundamental constant that every time The Joint Commission deck gets shuffled, there is a likelihood of some resulting confusion, not only in the EC community at large, but also in the surveyor community.
Hi everyone --
It's Scott Wallask at HCPro logging in.
Just a quick FYI, The Joint Commission has posted its 2009 standards, including the revised EC and new life safety and emergency management chapters:
I'm sure Steve Mac will have more to say on this soon on the blog.
Meanwhile, I'd also like to mention that HCPro has an upcoming seminar on September 5 that will dig into all these new standard changes prior to January 1 effective date.
Thanks...Scott W.
Posted At : June 16, 2008 1:17 PM
| Posted By : Scott Wallask
Related Categories:
Emergency management
Hi everyone, it's Scott Wallask logging in today.
I've been reading quite a bit in the past few days about the floods in the central part of the country, some of which have outright closed hospitals. Reminds me a lot of what we saw after Hurricane Katrina in 2005.
Columbus (IN) Regional Hospital was particularly hard hit and looks to have its doors shuttered for six to eight weeks while staff members and contractors repair the facility.
Columbus Regional's CEO, Jim Bickel, held a series of meetings for his employees on June 13 at a local high school, during which he talked about recovery efforts the hospital was taking and how they affect workers. The facility posted his presentation online, and you may find it an interesting model to review for your own recovery planning in terms of communicating with staff members.
Just in case this one cruised in under the radar, the Hospital Safety Center is sponsoring an audioconference next Wednesday called “Steer Clear of the Top EC Citations.” It starts at 1 p.m. Eastern time.
While we all wait with bated breathe to see what the final EC standards and chapters and verses are going to look like, we noticed that folks are still facing some challenges with the current slate of Joint Commission expectations, and we thought that it might be a good time to talk about some hard-core compliance tips. I think it's a pretty safe bet that the 2009 revisions won't result in any shortcuts for the front-line safety pros, either.
And to sweeten the pot, we'll be introducing the newest member of our team, Brad Keyes. In his most recent former life, Brad worked as one of the original Life Safety Code surveyors for The Joint Commission, and he brings a wealth of practical knowledge to the table (as opposed to my rather post-practical yammerings).
That's right folks, you can ask questions of a genuine former Joint Commission surveyor--so don't delay, get yours today!
I was intrigued by a question posed on one of HCPro's talk groups about whether it was permissible for staff members to have emergency codes, such as RACE, on the back of their ID badges.
There is certainly no standards-based prohibition on them from The Joint Commission. However, there are surveyors that do not find this an appropriate practice, especially when it comes to your fire response plan. To be honest, I tend to agree that staff need to be able to respond to a fire without consulting their ID, but I digress.
Ultimately, the proof is in the practice. Using the fire response plan as the example, does someone monitor how often staff are consulting their badges during drills? EC.5.30 requires each organization to annually evaluate the effectiveness of fire response training. If staff are relying "too much" (again, for you to decide what that means) on the badge to walk through the process, it may well be representative of an improvement opportunity relative to education.
Posted At : May 13, 2008 9:20 AM
| Posted By : Steve MacArthur
Related Categories:
Emergency management
I was just looking over this week’s edition of our free e-newsletter, Emergency Management Alert, and was reading the item titled “Hospital ERs unprepared to handle terrorist attacks.” This elicited a number of thoughts, which I will now share.
First off, I recognize that there may have been a wee bit of hyperbole relative to the stance of “medical professionals” as they attempted to dissuade Capitol Hill lawmakers from enacting the Medicaid cuts scheduled to take effect on May 26. Certainly, this is not a time for healthcare organizations to be managing their corporate and civic responsibilities with increasingly limited resources, so I can applaud any efforts to stay the course when it comes to reimbursement.
That said, I can’t help but question playing the “terrorist card” as a means of convincing Congress to refrain from further reductions. In my travels around the country, I have encountered many instances in which reductions have resulted in hospitals facing significant challenges in managing the patients they already have, never mind some hypothetical surge as the result of a terrorist attack.
Anyone who has worked in healthcare for more than a nanosecond recognizes the universal truism: We don’t have enough space, resources, etc., to be able to manage our services without “trying”.
Having said that, what we do have is the practical application of critical thinking skills. I don’t know if I can call the existence of critical thinking skills in healthcare an abundance (cornucopia is certainly more alliterative), but it exists in reasonable supply.
A USA Today article cited a House Committee on Oversight and Government survey of 34 hospitals in seven major cities in which it was found that the hospitals had no space in their EDs to treat a sudden surge of patients. To which my initial response was, “No duh.”
I suppose it’s a valid point to make as it is, after all, accurate. However, authorities unfamiliar with all the work that’s been done relative to alternative care sites, continuity of operations planning, and the like? In order for hospitals to stay in business, they have to treat patients, and, strangely enough, those patients take up space in the ED, in the intensive care units, and on the med-surg units.
Does this mean the feds are going to subsidize hospitals to keep empty beds in the event of a catastrophic failure of homeland security? That hardly seems a useful or productive expenditure of tax dollars.
In discussing similar topics with clients over the past couple of years, my advice has always been that you need to prepare for those circumstances that are the most likely to occur in your community. Any expenditure in preparation for events that are not likely is a disservice to your organization and your community.
The development of real emergency response capacity is much more critical than chasing the “emergency du jour.” Just look at the news about cyclones, tornados, and earthquakes. Those are the real events, and it is most unlikely (at least I hope not) that nature is plotting these occurrences.
My experiences have been that while hospitals may not be completely prepared for every conceivable event (and never shall they be), they have made enormous strides over the last half-decade. I don’t think there is a responsible hospital leadership group in this country that do not understand the critical importance of emergency response.
But, in the absence of a level playing field in terms of reimbursement, expenditures, etc., the management of competing priorities varies from organization to organization, region to region. I’m not necessarily advocating an NFL-style salary cap leveling of the playing field (though maybe…).
It is all well and good to pronounce that hospital EDs are “unprepared,” which is extraordinarily hyperbolic. It is true that we don’t have the beds now, but we can shift things around to make them available because after all. Isn’t that what we do on an everyday basis? But I see no indication of anything in the way of solutions from our august Congress.
One of the most frustrating personalities I run into is that of the delegator, whose response when problems occur is, “I told them to do it, but they wouldn’t listen.” There is no room in this world for delegation. To my mind, it is way too passive. It is an imperative to “do” responsibility, not shift it. There’s a joke in here about shiftiness, but I’ll let you conjure that one up in your spare time, though I suppose one could consider that rather delegatory of me--so be it.
Hi, it’s Scott Wallask again here at the Hospital Safety Symposium. The Joint Commission’s move to soften its enforcement of certain EPs in the emergency management standards came up during a couple of our sessions today.
Here’s a link where The Joint Commission makes its official announcement about this.
This morning at the Hospital Safety Symposium, we were briefly discussing EC.4.19 in the emergency management standards. As you probably know, EC.4.19 doesn’t exist--the standards jump from EC.4.18 to EC.4.20 in the hospital accreditation manual.
While I don’t know any official reasons, I suspect EC.4.19 was kept "open" to leave room for expansion. But given that the emergency management standards will change their numbers (again) in 2009, I don’t suppose it really matters about EC.4.19 in the long run.
Hi folks – It’s Scott Wallask at HCPro checking in from our Hospital Safety Symposium, which kicked off this morning in Las Vegas.
Keynote speaker Dean Samet took the stage about 20 minutes ago and is talking to attendees about The Joint Commission’s 96-hour provisions under EC.4.12. He suggested a good way to evaluate your hospital’s ability to survive on its own for up to 96 hours is to hold a tabletop exercise immediately after one of your regular emergency management drills.
During the tabletop, ask various managers questions such as, "How long would our water supply have lasted during a prolonged emergency?" Samet suggested.
Watch for more blog postings from Steve Mac and me throughout the day.
I saw a question on HCPro’s Patient Safety Talk listserv last week asking about whether The Joint Commission requires fencing around exterior generators.
There is no specific requirement in the EC standards regarding the means by which you would secure your generator and any associated equipment, pipes, etc. That said, there are a number of ways that you could be cited if a surveyor believes your security measures for the generator are inadequate, including provisions under:
- The emergency power Sentinel Event Alert
- The maintenance and care of the generators as a function of your utility systems management program
- Safety and/or security risk assessments
My recommendation would be to conduct a security risk assessment, identify any applicable vulnerabilities to things like vandalism, and then carry out strategies for appropriately managing the identified risks.
It may be that your organization decides some strategies make good sense from an operational reliability standpoint and some may not. So long as you document the decision process (with a dash of ongoing monitoring to ensure the chosen strategies are indeed effective), then you should be in good stead during survey.
I’ve read with interest The Joint Commission’s announcement that it will pull back on the scoring of some EPs within the emergency management standards (see this prior blog entry for full details).
I think this is a very interesting development, and a good one for many hospitals. It makes me wonder what prompted this magnanimous gesture.
Could it be that the surveyors are "leaning" on this slate of standards with something less than a complete understanding of what is actually required? To be honest, I haven't heard of a lot of folks getting cited under the 2008 emergency management standards.
Some of the relaxed EPs deal with resources and assets during emergencies. The advice I've been giving to folks relative to managing their resources and assets inventory is that they need to maintain the inventory to the degree that they have enough reliable information to make good decisions once the poop has hit the poopdeck.
In other words, you need to be able to identify the point at which your organization needs to bring more “stuff” in, etc.
Also, I've run into a couple of organizations who have taken to establishing a requirement in their policies that they be able to sustain operations for 96 hours. In one instance, when I asked them why they did that, they told me it was a requirement of NIMS, which, interestingly enough, it is not.
While it is certainly appropriate to have the 96 hours as some sort of target, realize that it is not a Joint Commission requirement to do so. Rather, you must assess your ability to stand alone for 96 hours, and if you can’t, determine what steps you’ll take (such as evacuation).
Hi everyone, it’s Scott Wallask over at HCPro jumping in today.
We obtained an interesting e-mail from a Joint Commission official that seems to indicate the heat is being turned down in 2008 on some of The Joint Commission’s provisions within emergency management standards EC.4.11 through EC.4.18 after hospitals expressed concerns.
At a meeting on April 17, a Joint Commission committee “approved not counting noncompliance with [certain] new emergency management standards in accreditation decisions during 2008,” wrote Gail Weinberger, director of accreditation and certification policy and administration at The Joint Commission.
“This means although noncompliance with these requirements will continue to be cited in an organization’s report and will be required to be addressed in an evidence of standards compliance (ESC), they will not be included in the count of the requirements for improvement contributing towards a conditional accreditation or a preliminary denial of accreditation decision,” Weinberger wrote. Her e-mail went to a list of “corporate liaisons” who weren’t specified in the copy we obtained.
The decision applies to the following specific requirements, as listed by Weinberger:
- EC.4.11, EP 9 (documenting an inventory of assets and resources)
- EC.4.11, EP 10 (monitoring quantities of assets and resources)
- EC.4.12, EP 6 (meeting the 96-hour provisions)
- EC.4.13, EP 7 (communicating with vendors of essential supplies and services)
- EC.4.14, EP 8 (sharing of assets and resources with healthcare facilities outside the community))
- EC.4.14, EP 10 (transporting patients, medications, equipment, and staff members to alternate care sites)
- EC.4.15, EP 2 (coordinating security activities with outside agencies)
- EC.4.15, EP 3 (managing hazardous materials and wastes)
- EC.4.15, EP 5 (for long-term care facilities, identifying residents who might wander)
- EC.4.16, EP 2 (training staff members about their roles in emergency response)
- EC.4.16, EP 3 (communicating to licensed independent practitioners about their roles in emergency response)
- EC.4.17, EP.4 (determining alternative supplies of fuel for building operations or essential transport activities)
- EC.4.18, EP 4 (managing mental health needs of patients)
- EC.4.18, EP 5 (managing mortuary services)
- EC.4.18, EP 6 (documenting and tracking clinical information)
Steve Mac will share some of this thoughts about this development in the next day or two.
Thanks…Scott W.
Business continuity in general is a very organization-specific undertaking, and (like everything else) starts with the results of your hazard vulnerability analysis (HVA).
Focus on identifying a couple of different things:
- Those events or conditions that would result in something from which you would need to recover. For all intents and purposes, the depth of recovery is going to be fairly minimal for most events and conditions you're likely to encounter. Any event that can disrupt your organization is good fodder.
- Those key aspects of business that would be sufficiently impacted to require some sort of recovery. You can certainly start (and perhaps end, depending on what you find) with Joint Commission standards EC.4.13 through EC.4.18, a.k.a. the "six critical areas" of emergency management: communication, resources and assets, safety and security, staff responsibilities, utilities management; and patient clinical and support activities.
What you could do is develop a matrix (similar to the configuration for the HVA), but list the "heavy hitter" events along the left side of the matrix, the six critical areas across the top, and do an evaluation of what the disruptive impact of each event would be in each of the critical areas.
For the most part, different events and conditions are going to have varying levels of impact on each of the areas. Then you could establish a benchmark score above which you would need to have a concrete business continuity plan, and everything else becomes either a non-event or something to address later on in the process.
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