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Document community collaboration, succession plans for new EM standards


January 1, 2018

Go three deep or more in identifying staff positions to take over if key leadership can’t act in an emergency, consider ambulatory centers as alternate care sites even if they are not part of your health system, and document even unsuccessful attempts to coordinate community disaster planning.

Be prepared for surveyors, whether they work for CMS or The Joint Commission, to ask for documentation on these and other critical elements of your disaster plan now that new emergency preparedness Conditions of Participation (CoP) are in effect.

By law, the emergency preparedness CoP went into effect November 15, along with The Joint Commission’s recently published changes to its Emergency Management (EM) standards, revised to align with the new federal requirements.

Community planning and collaboration are at the heart of the new CoPs and are reflected in the revised EM standards, noted John Maurer, TJC’s acting director of engineering during the Chicago session of the commission’s annual Executive Briefings in September.

Most of the requirements in the new CoPs were already expected of hospitals as part of their emergency operations plan (EOP), said Maurer. Other providers had to expand their planning.

Evidence of community planning expected

For everyone now, the revisions to the EM standards specify that plans must include community-based risks as part of your annual hazard vulnerability analysis (HVA), details of continuity of operations and succession planning, and documentation of collaboration with local, regional, state, federal and tribal communities, depending on your location.

“You should involve the community and CMS is expecting the community to be involved. Part of the goal of having the community involved in assessing your risks is it could reduce duplicative efforts,” Maurer said.
Comprehensive community planning can also reveal opportunities, notes disaster planning expert Barbara B. Citarella, RN, BSN, MS, CHCE, NHDP-BC, president of RBC Limited Healthcare & Management Consultants in Staatsburg, NY.

She attended a recent tabletop emergency planning exercise with a regional coalition group in Florida, where hospital representatives and others were surprised when ambulatory care leaders said they could offer short-term surge capacity by rescheduling some surgeries and moving on-site dialysis to mornings only.

“There is that underlying brilliance in the federal regulations in forcing us as providers to look at each other differently,” says Citarella.

Those ambulatory care centers want to be taken seriously, she adds. “They want to be at the table, they want people to understand what they do.”

Be persistent and document it

Look for those types of opportunities during your planning, but remember to document all your efforts, even if they are not successful.

For facilities in urban areas or in states that have strong regional healthcare coalitions, which receive federal funding to facilitate emergency planning, working and training with local law enforcement, health departments and emergency services is often a regular practice.

But in areas where such services and resources are limited, or local often competing healthcare organizations are not cooperative, hospitals can face having to plan disaster responses alone or with little local input.

That’s a complaint Citarella has often heard.

“Document that you invite them and they don’t come,” advises Citarella. But keep inviting them.
Whether it’s the local emergency services or reluctant healthcare leadership, find a way to work with them. Ask “‘What do you need from me to make your job easier?’” she recommends.
“Collaborative leadership skills are very unique,” she says. “We don’t have a lot of leaders in healthcare that have that special skill set and that global vision.”
But it’s worth learning because it could help you in the end. One of the objectives of the collaboration is to identify surge capacity in case you need to send patients elsewhere, and to identify your own capacity for accepting patients from someone else.
Hospitals nationwide recently have responded to mass shootings, hurricanes, flooding and wildfires that required a coordinated response from several providers at once, noted Maurer.
“These are the things you need to plan for effectively. But what does that collaboration look like?”

CMS, Joint Commission will ask for documents

Documenting all of that work will be critical during your survey, Citarella notes in an assessment backed up by both Maurer and the revised EM standards.

The revised EM standards for hospitals, as well as ambulatory and home care centers, all include a requirement that the EOP must include how the organization prepares to communicate during an emergency, with an EP that specifically discusses documentation.

The healthcare provider is required to have documentation of attempts or actual contact with local, tribal, state, regional or federal officials within its area of service, with the intent of communicating and collaborating on a disaster response plan.

The contacts may be written, in email, in person, conference calls or other methods of communication and collaboration, says The Joint Commission.

Similar documentation is required by CMS, as noted throughout the new 73-page Appendix Z to Medicare’s State Operations Manual with interpretive guidelines for surveyors now enforcing the new emergency preparedness CoP.

For instance, under the new E-tags for emergency preparedness, E-0009 states that emergency plans must be reviewed and updated at least annually, and include “a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.”

Throughout Appendix Z, CMS surveyors are told to review written plans and ask for documentation.

“With the interpretive guidelines, I think what surprised me was the amount of documentation” required, says Citarella. CMS requirements are clearly “process driven rather than outcome driven.”

Maurer told healthcare leaders at Executive Briefings that policies and procedures developed as part of the EOP should be included in the plan or made readily available for surveyors.

That should include such policies on succession to replace key incident commanders in the event they cannot perform their duties and, if your facility chooses to be part of the emergency planning within an integrated health system, how that will be coordinated during planning, training and emergency response.
While surveyors will expect to be able to see those policies and procedures, there is no particular format expected, noted Maurer, “as long as the information can be provided to the surveyors in a timely fashion.”


The Joint Commission’s prepublished revisions to the hospital Emergency Management standards, effective Nov. 15: https://www.jointcommission.org/assets/1/6/Prepub_HAP_EM_Revisions_20171018.pdf

CMS emergency preparedness webpage, including link to State Operations Manual, Appendix Z: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

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