TJC Final Emergency Management Standards Effective November 15, 2017

Standard EM.01.01.01
Element(s) of Performance for EM.01.01.01
The hospital engages in planning activities prior to developing its written Emergency Operations Plan.  Note: An emergency is an unexpected or sudden event that significantly disrupts the organization’s ability to provide care, or the environment of care itself, or that results in a sudden, significantly changed or increased demand for the organization’s services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity. A disaster is a type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions.
The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

The hospital conducts a hazard vulnerability analysis (HVA) to identify potential emergencies within the organization and the community that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events. The findings of this analysis are documented. (See also EM.03.01.01, EP 1; IC.01.06.01, EP 4)  Note 1: Hospitals have flexibility in creating either a single HVA that accurately reflects all sites of the hospital, or multiple HVAs. Some remote sites may be significantly different from the main site (for example, in terms of hazards, location, and population served); in such situations a separate HVA is appropriate. Note 2: If the hospital identifies a surge in infectious patients as a potential emergency, this issue is addressed in the “Infection Prevention and Control” (IC) chapter.

Standard EM.02.01.01
Element(s) of Performance for EM.02.01.01
The hospital has an Emergency Operations Plan.  Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This “all hazards” approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan includes a continuity of operations strategy that covers the following: – A succession plan that lists who replaces key leaders during an emergency if a leader is not available to carry out his or her duties – A delegation of authority plan that describes the decisions and policies that can be implemented by authorized successors during an emergency and criteria or triggers that initiate this delegation Note: A continuity of operations strategy is an essential component of emergency management planning. The goal of emergency management planning is to provide care to individuals who are incapacitated by emergencies in the community or in the organization. A continuity of operations strategy focuses on the organization, with the goal of protecting the organization’s physical plant, information technology systems, business and financial operations, and other infrastructure from direct disruption or damage so that it can continue to function throughout or shortly after an emergency. When the organization itself becomes, or is at risk of becoming, a victim of an emergency (power failure, fire, flood, bomb threat, and so forth), it is the continuity of operations strategy that provides the resilience to respond and recover.

For hospitals that use Joint Commission accreditation for deemed status purposes: If a hospital has one or more transplant centers (see Glossary), the following must occur: – A representative from each transplant center must be included in the development and maintenance of the hospital’s emergency preparedness program – The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant center, and the organ procurement organization (OPO) for the donation service area where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure for requesting an 1135 waiver for care and treatment at an alternative care site.  Note: During disasters, organizations may need to request 1135 waivers to address care and treatment at an alternate care site identified by emergency management officials. The 1135 waivers are granted by the federal government during declared public health emergencies; these waivers authorize modification of certain federal regulatory requirements (for example, Medicare, Medicaid, Children’s Health Insurance Program, Health Insurance Portability and Accountability Act) for a defined time period during response and recovery.

The Emergency Operations Plan describes a means to shelter patients, staff, and volunteers on site who remain in the facility.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has one or more emergency management policies based on the emergency plan, risk assessment, and communication plan. Procedures guiding implementation are defined in the emergency management plan, continuity of operations plan, and other preparedness and response protocols. Policy and procedure documents are reviewed and updated on an annual basis; the format of these documents is at the discretion of the hospital.

Standard EM.02.02.01
Element(s) of Performance for EM.02.02.01
As part of its Emergency Operations Plan, the hospital prepares for how it will communicate during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: As part of its communication plan, the hospital maintains the names and contact information of the following: – Staff – Physicians – Other hospitals and CAHs – Volunteers – Entities providing services under arrangement – Relevant federal, state, tribal, regional, and local emergency preparedness staff – Other sources of assistance

For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the following: – Process for communicating information about the general condition and location of patients under the organization’s care to public and private entities assisting with disaster relief – Process, in the event of an evacuation, to release patient information to family, patient representative, or others responsible for the care of the patient Note: These processes are consistent with privacy and disclosure requirements specified under 45 CFR 164.510(b)(1)(ii) and 45 CFR 164.510(b)(4).

For hospitals that use Joint Commission accreditation for deemed status purposes:  The organization maintains documentation of completed and attempted contact with the local, state, tribal, regional, and federal emergency preparedness officials in its service area. This contact is made for the purpose of communication, and where possible collaboration, on coordinated response planning for a disaster or emergency situation. Note: Examples of these contacts may be written or email correspondence; in-person meetings or conference calls; regular participation in health care coalitions, working groups, boards, and committees; or educational events sponsored by a third party (such as a local or state health department).

Standard EM.02.02.03
Element(s) of Performance for EM.02.02.03
As part of its Emergency Operations Plan, the hospital prepares for how it will manage resources and assets during emergencies.
The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies that will be required throughout the response and recovery phases of an emergency.

The Emergency Operations Plan describes the following: How the hospital will obtain and replenish nonmedical supplies (including food, bedding, and other provisions consistent with the hospital’s plan for sheltering on site) that will be required throughout the response and recovery phases of an emergency.

Standard EM.02.02.07
Element(s) of Performance for EM.02.02.07
As part of its Emergency Operations Plan, the hospital prepares for how it will manage staff during an emergency.
The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management during an emergency.

The Emergency Operations Plan describes the following: The roles and responsibilities of staff for communications, resources and assets, safety and security, utilities, and patient management and evacuation during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of on-duty staff during an emergency.

For hospitals that use Joint Commission accreditation for deemed status purposes: Initial and ongoing training relevant to their emergency response roles is provided to staff, volunteers, and individuals providing on-site services under arrangement. This training is documented and then reviewed and updated annually and when these roles change. Staff demonstrate knowledge of emergency procedures through participation in drills and exercises, as well as post-training tests, participation in instructor-led feedback (for example, questions and answers), or other methods determined and documented by the organization.
For hospitals that use Joint Commission accreditation for deemed status purposes: The Emergency Operations Plan describes the use of volunteers in an emergency, including emergency staffing strategies, such as the role and process for integration of state or federally designated health care professionals to address surge needs during an emergency.

Standard EM.02.02.09
Element(s) of Performance for EM.02.02.09
As part of its Emergency Operations Plan, the hospital prepares for how it will manage utilities during an emergency.
As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Electricity and lighting.

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization).

As part of its Emergency Operations Plan, the hospital identifies alternative means of providing the following: Utility systems that the hospital defines as essential (for example, vertical and horizontal transport, heating and cooling systems, and steam for sterilization). Note: The essential utility systems include mechanisms for maintaining temperatures at a level that protect patient health and safety and the safe and sanitary storage of provisions.

For hospitals that use Joint Commission accreditation for deemed status purposes: The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, TIA 12-6); Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, TIA 12-4); and NFPA 110, when a new structure is built or when an existing structure or building is renovated.

Standard EM.02.02.11
Element(s) of Performance for EM.02.02.11
As part of its Emergency Operations Plan, the hospital prepares for how it will manage patients during emergencies.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a system to track the location of patients sheltered on site during an emergency. This system includes documentation of the name and location of the receiving facility or alternate site in the event a patient is relocated during the emergency. Note: The name and location of receiving facilities or alternate sites may be defined in the emergency management plan, formal transfer agreements, or other accessible documents.

Standard EM.04.01.01
Element(s) of Performance for EM.04.01.01
For hospitals that use Joint Commission accreditation for deemed status purposes: If the hospital is part of a health care system that has an integrated emergency preparedness program, and it chooses to participate in the integrated emergency preparedness program, the hospital participates in planning, preparedness, and response activities with the system.
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital demonstrates its participation in the development of its system’s integrated emergency preparedness program through the following: – Designation of a staff member(s) who will collaborate with the system in developing the program – Documentation that the hospital has reviewed the community-based risk assessment developed by the system’s integrated all-hazards emergency management program – Documentation that the hospital’s individual risk assessment is incorporated into the system’s integrated program – Documentation that the hospital’s patient population, services offered, and any unique circumstances of the hospital are reflected in the system’s integrated program – Documentation of an integrated communication plan, including information on key contacts in the system’s integrated program – Documentation that the hospital participates in the annual review of the system’s integrated program

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has implemented communication procedures for emergency planning and response activities in coordination with the system’s integrated emergency preparedness program.

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital’s integrated emergency management policies, procedures, or plans address the following: – Identification of the hospital’s emergency preparedness, response, and recovery activities that can be coordinated with the system’s integrated program (for example, acquiring or storing clinical supplies, assigning staff to the local health care coalition to create joint training protocols, and so forth) – The hospital’s communication and/or collaboration with local, tribal, regional, state, or federal emergency preparedness officials through the system’s integrated program – Coordination of continuity of operations planning with the system’s integrated program – Plans and procedures for integrated training and exercise activities with the system’s integrated program.

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