The Joint Commission – Emergency Management 2010 & Beyond Yusuf A. Rahman, BA, RRT, CHEC Georgia Hospital Association
Objectives <ul><li>Overview of changes to 2009 & 2010 JC standards </li></ul><ul><li>Primary stumbling blocks for most hos...
Primary Focus Areas <ul><li>Life Safety (LS) </li></ul><ul><li>Environment of Care (EC) </li></ul><ul><li>Emergency Manage...
GENERAL CHANGES <ul><li>2008 </li></ul><ul><ul><li>Joint Commission involvement in aftermath of recent disasters </li></ul...
EM.01.01.01 <ul><li>“The organization engages in planning activities prior to developing its written Emergency Operations ...
COMMUNITY PARTNERS <ul><li>Determine critical community partners </li></ul><ul><li>HVA reviewed & prioritized with communi...
HAZARD  VULNERABILITY  ANALYSIS <ul><li>Consider possibility of cascading events </li></ul><ul><li>Worst-case scenarios </...
Rationale <ul><li>Emphasize a “scalable” approach to help manage the variety, intensity, and duration of the disasters tha...
STAND ALONE CAPABILITY <ul><li>Identifies capabilities & establishes response efforts when organization cannot be supporte...
POTENTIAL RESPONSES <ul><li>Maintaining or expanding services </li></ul><ul><li>Conserving resources </li></ul><ul><li>Cur...
EM.03.01.03 <ul><li>“The organization evaluates the effectiveness of its EOP.” </li></ul><ul><ul><li>Emergency exercises <...
REQUIREMENTS <ul><li>Twice annually (unchanged) </li></ul><ul><ul><li>FSE/FE vs. tabletops </li></ul></ul><ul><li>Influx o...
The “Critical Six”  Functions <ul><li>Communications </li></ul><ul><li>Resources and Assets </li></ul><ul><li>Safety & Sec...
Most Problematic Standards <ul><li>Published in November 2009 Perspectives </li></ul><ul><ul><li>% of hospitals that recei...
Most Problematic Standards <ul><li>LS.02.01.20 (45%)  The hospital maintains the </li></ul><ul><li>integrity of the means ...
<ul><li>LS.02.01.10 (43%)  Building and fire protection </li></ul><ul><li>features are designed and maintained to minimize...
<ul><li>Egress includes corridors, stairways, and doors so avoid blocking hallways with carts, x-ray machines, laundry car...
Resources
Resources
Resources <ul><li>Standards questions can also be submitted by phone, mail or fax </li></ul><ul><li>Standards Interpretati...
Resources <ul><li>http://blogs.hcpro.com/accreditationcenter/   </li></ul><ul><li>www.jointcommission.org/Standards/FAQs/ ...
DISCUSSION
QUESTIONS
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Emag conf jc 2010 050410

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  • Because our interests lie primarily in the EM arena, and because these topics have the most significant impact on the healthcare physical environment emergency management, life safety, and environment of care, these are the primary areas we’ll focus on
  • Move from a “silo’ed” EM strategy to a community-wide, all hazards approach. Stresses interoperability of everything from communications infrastructure to command structure
  • Figure out who critical community partners are, share and review plans/HVAs with them to highlight real-world capabilities. e.g. RN homes planning to send patients to hospitals
  • Recognize that some disasters might be low intensity but sustained e.g. pan flu vs. others that are higher intensity but relatively short in duration, e.g. Atlanta tornado. Each type of scenario has unique challenges.  Lessons learned from Hurricane Katrina
  • Emag conf jc 2010 050410

    1. 1. The Joint Commission – Emergency Management 2010 & Beyond Yusuf A. Rahman, BA, RRT, CHEC Georgia Hospital Association
    2. 2. Objectives <ul><li>Overview of changes to 2009 & 2010 JC standards </li></ul><ul><li>Primary stumbling blocks for most hospitals </li></ul><ul><li>Provide tools and resources to help with future JC reviews </li></ul><ul><li>Share experiences and best practices </li></ul>
    3. 3. Primary Focus Areas <ul><li>Life Safety (LS) </li></ul><ul><li>Environment of Care (EC) </li></ul><ul><li>Emergency Management (EM) </li></ul>
    4. 4. GENERAL CHANGES <ul><li>2008 </li></ul><ul><ul><li>Joint Commission involvement in aftermath of recent disasters </li></ul></ul><ul><ul><ul><li>Katrina  Focus on sustainability </li></ul></ul></ul><ul><ul><ul><li>Identification of opportunities for improvement </li></ul></ul></ul><ul><li>2009 </li></ul><ul><ul><li>Emergency Management & Life Safety Code become stand alone chapters </li></ul></ul><ul><ul><li>Emphasis on documentation </li></ul></ul>
    5. 5. EM.01.01.01 <ul><li>“The organization engages in planning activities prior to developing its written Emergency Operations Plan.” </li></ul><ul><ul><li>HVA </li></ul></ul><ul><ul><li>Community partners </li></ul></ul><ul><ul><li>Community communication </li></ul></ul><ul><ul><li>Mitigation & preparedness </li></ul></ul><ul><ul><li>Incident command </li></ul></ul><ul><ul><li>Inventory </li></ul></ul>
    6. 6. COMMUNITY PARTNERS <ul><li>Determine critical community partners </li></ul><ul><li>HVA reviewed & prioritized with community </li></ul><ul><li>Communicate needs & vulnerabilities </li></ul><ul><li>At annual review of plan & when needs change </li></ul>
    7. 7. HAZARD VULNERABILITY ANALYSIS <ul><li>Consider possibility of cascading events </li></ul><ul><li>Worst-case scenarios </li></ul><ul><ul><li>Surge of infectious patients </li></ul></ul><ul><ul><li>IT vulnerabilities / failures </li></ul></ul><ul><ul><li>Loss of utilities or other critical infrastructure </li></ul></ul><ul><li> Define mitigation & preparedness </li></ul>
    8. 8. Rationale <ul><li>Emphasize a “scalable” approach to help manage the variety, intensity, and duration of the disasters that can affect a single organization, multiple organizations, an entire community, or region </li></ul><ul><li>Importance of planning for emergencies in which the local community cannot support the healthcare organization </li></ul>
    9. 9. STAND ALONE CAPABILITY <ul><li>Identifies capabilities & establishes response efforts when organization cannot be supported by community for </li></ul><ul><li>> 96 hours </li></ul><ul><ul><ul><li>does NOT require stockpiles </li></ul></ul></ul><ul><ul><ul><li>does NOT require the ability to stand alone for 96 hours </li></ul></ul></ul>
    10. 10. POTENTIAL RESPONSES <ul><li>Maintaining or expanding services </li></ul><ul><li>Conserving resources </li></ul><ul><li>Curtailing services </li></ul><ul><li>Supplementing resources from outside community </li></ul><ul><li>Closing hospital to new patients </li></ul><ul><li>Staged or total evacuation </li></ul>
    11. 11. EM.03.01.03 <ul><li>“The organization evaluates the effectiveness of its EOP.” </li></ul><ul><ul><li>Emergency exercises </li></ul></ul><ul><ul><li>Stress capabilities </li></ul></ul><ul><ul><li>Realistic & relevant </li></ul></ul><ul><ul><li>Identify lessons learned and opportunities for improvement </li></ul></ul><ul><ul><li>Implement corrective actions </li></ul></ul>
    12. 12. REQUIREMENTS <ul><li>Twice annually (unchanged) </li></ul><ul><ul><li>FSE/FE vs. tabletops </li></ul></ul><ul><li>Influx of patients (unchanged) </li></ul><ul><li>One exercise annually to evaluate ability to stand alone without community support </li></ul><ul><ul><li>Community portion can be tabletop </li></ul></ul><ul><li>One community-wide exercise annually </li></ul>
    13. 13. The “Critical Six” Functions <ul><li>Communications </li></ul><ul><li>Resources and Assets </li></ul><ul><li>Safety & Security </li></ul><ul><li>Staff Responsibilities </li></ul><ul><li>Utilities Management </li></ul><ul><li>Patient Clinical & Support Activities </li></ul>
    14. 14. Most Problematic Standards <ul><li>Published in November 2009 Perspectives </li></ul><ul><ul><li>% of hospitals that received a Requirement for Improvement (RFI) </li></ul></ul>
    15. 15. Most Problematic Standards <ul><li>LS.02.01.20 (45%) The hospital maintains the </li></ul><ul><li>integrity of the means of egress </li></ul>
    16. 16. <ul><li>LS.02.01.10 (43%) Building and fire protection </li></ul><ul><li>features are designed and maintained to minimize </li></ul><ul><li>the effects of fire, smoke, and heat </li></ul><ul><li>EC.02.03.05 (38%) The hospital maintains fire </li></ul><ul><li>safety equipment and fire safety building features </li></ul><ul><li>LS.02.01.30 (36%) The hospital provides and maintains building features to protect individuals </li></ul><ul><li>from the hazards of fire and smoke </li></ul>Most Problematic Standards
    17. 17. <ul><li>Egress includes corridors, stairways, and doors so avoid blocking hallways with carts, x-ray machines, laundry carts, equipment, or supplies </li></ul><ul><ul><li>Surgery areas particularly susceptible </li></ul></ul><ul><li>WOWS/COWS should only be in hallways when in use </li></ul><ul><ul><li>Not unattended while charging </li></ul></ul>Most Problematic Standards
    18. 18. Resources
    19. 19. Resources
    20. 20. Resources <ul><li>Standards questions can also be submitted by phone, mail or fax </li></ul><ul><li>Standards Interpretation Group (SIG) </li></ul><ul><ul><li>630 792-5900 </li></ul></ul><ul><li>Fax questions to 630 792-5942 </li></ul><ul><li>By mail: </li></ul><ul><ul><li>SIG, The Joint Commission </li></ul></ul><ul><ul><li>One Renaissance Blvd </li></ul></ul><ul><ul><li>Oakbrook Terrace, IL 60181 </li></ul></ul>
    21. 21. Resources <ul><li>http://blogs.hcpro.com/accreditationcenter/ </li></ul><ul><li>www.jointcommission.org/Standards/FAQs/ </li></ul><ul><li>GHA911 </li></ul><ul><li>LiveProcess JC standards crosswalks </li></ul>
    22. 22. DISCUSSION
    23. 23. QUESTIONS
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