EMERGENCY MANAGEMENT UPDATE

Transcription

1 2017 EMERGENCY MANAGEMENT UPDATE John Maurer, SASHE, CHFM, CHSP Engineering Department The Joint Commission Department of Engineering

2 DISCLOSURE STATEMENT Disclosure Statement The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: John Maurer Leslie LaBelle George Riccio Steve Chinn The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. Department of Engineering

3 PUBLICATIONS AND RECORD RESTRICTIONS The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. Department of Engineering

4 PUBLICATIONS AND RECORD RESTRICTIONS Copyright 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22 nd Street Suite 1300W, Oak Brook, Illinois Department of Engineering

5 OBJECTIVES Upon completion of this program, participants will be able to: 1) Understand the Emergency Management standards changes 2) Understand the Emergency Management most challenging standards Department of Engineering

6 CMS EMERGENCY MANAGEMENT FINAL RULE Joint Commission focus on deemed settings: Deemed Home Health Agencies Deemed Hospices Deemed Hospitals Deemed Critical Access Hospitals Deemed Ambulatory Surgical Centers Plus: Rural Health Clinics and Federally Qualified Health Centers Department of Engineering

7 CMS EMERGENCY MANAGEMENT FINAL RULE Structure Emergency Plan Policies & Procedures Communication Plan Training and Testing Integrated Healthcare Systems (option) Department of Engineering

8 CMS EMERGENCY MANAGEMENT FINAL RULE Applies to all hospital and critical access hospitals. In most cases, a new EP was developed rather than revision of an existing EP All new/revised content is indicated in red and is in draft status Department of Engineering

9 SURVEY FUNDAMENTALS APPLY New content, but usual approach applies; confirm that: HVA was performed and is relevant to organization and community EOP covers critical areas and supports response to prioritized risks Staff training aligns with response plans Exercises test & stress the plan & surface gaps, weaknesses, opportunities for improvement Exercises and responses to actual emergencies are reviewed and inform improvements to plan Department of Engineering

10 EMERGENCY OPERATIONS PLAN Continuity of Operations (COOP) The plan must address continuity of operations, including delegations of authority and succession plans (Source: CMS) The health care organization s COOP may be an annex to the organization s EOP, and during a response should be addressed under the ICS (Source: ASPR) Department of Engineering

11 EMERGENCY OPERATIONS PLAN EM , EP 12 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 the key leader(s) during an emergency if the 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 Department of Engineering

12 EMERGENCY OPERATIONS PLAN EM , EP 13 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 must be included in the development and maintenance of the emergency preparedness program - 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 Department of Engineering

13 EMERGENCY OPERATIONS PLAN EM , EP 14 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a procedure to request 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. Department of Engineering

14 COMMUNICATIONS PLAN EM , EP 20 For hospitals that use Joint Commission accreditation for deemed status purposes: As part of it communications plan, the hospital maintains the names and contact information of the following: - Staff - Physicians - Other HAPs and CAHs - Volunteers - Entities provided arranged services - Relevant fed, state, tribal, regional and local EM - Other sources of assistance Department of Engineering

15 COMMUNICATIONS PLAN EM , EP 22 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. Department of Engineering

16 COMMUNICATIONS PLAN EM , EP 22 - continued Note: Examples of these contacts may be written or 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). Department of Engineering

17 COMMUNICATIONS PLAN Incident Command Structure - Essential structure flexes to size of organization & type of emergency Department of Engineering

18 POLICIES & PROCEDURES Current key requirement addressing organization policy: LD , EP 1 Leaders review and approve policies and procedures that guide and support patient care, treatment, or services. Department of Engineering

19 POLICIES & PROCEDURES Survey: During document review evaluate EM plan for annual review and update. Existing EM and LD requirements sufficiently cover the need for policies To avoid possible redundancy or conflict with plans / procedures required in EM, EC, COOP & ICS, no additional policy EPs were added. Department of Engineering

20 TRAINING EM , EP 13 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 onsite services under arrangement. This training is documented and then reviewed and updated annually and when these roles change. Department of Engineering

21 TRAINING EM , EP13 - continued 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. Department of Engineering

22 TESTING -EXERCISES One of the two annual exercises must be operations based with community or as individual organization CMS requires documentation of attempt to participate in community exercise An actual emergency response can suffice Other annual exercise must be operations based tabletop will not count toward this requirement Department of Engineering

23 INTEGRATED SYSTEM EM PROGRAM Optional requirement for all settings Applies to organizations that choose to be members of their systems integrated EM program. Department of Engineering

24 INTEGRATED SYSTEM EM PROGRAM New Standard EM 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. Department of Engineering

25 INTEGRATED SYSTEM EM PROGRAM EM , EP 1 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 Department of Engineering

26 INTEGRATED SYSTEM EM PROGRAM EM , EP 1 continued - Documentation that the hospital has reviewed the community-based risk assessment developed by the system s integrated program - Documentation that the hospital s individual risk assessment is incorporated into the system s integrated program Department of Engineering

27 INTEGRATED SYSTEM EM PROGRAM EM , EP 1 continued - 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 Department of Engineering

28 INTEGRATED SYSTEM EM PROGRAM EM , EP 2 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. Department of Engineering

29 INTEGRATED SYSTEM EM PROGRAM EM , EP 3 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital s integrated emergency management policies, procedures, or plans address the following: Department of Engineering

30 INTEGRATED SYSTEM EM PROGRAM EM , EP 3 - continued - 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 Department of Engineering

31 INTEGRATED SYSTEM EM PROGRAM EM , EP 3 - continued - 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 Department of Engineering

32 CMS EMERGENCY MANAGEMENT FINAL RULE WEB INFORMATION CMS sponsored portal Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html ASPR TRACIE Joint Commission Emergency Management Portal spx Department of Engineering

33 Most Cited EM Standards 2017 YTD 2016 EM EM EM EM EM EM EM EM EM EM Department of Engineering

34 #1 - EM : EVALUATION Hospital evaluates effectiveness of EOP Two drills annually, activate the EOP at each site Actual events may apply One required for business occupancies Likely scenarios to evaluate the 6 critical areas Escalating event Department of Engineering

35 #2 - EM : DISASTER VOLUNTEERS LIPS Hospital may grant disaster privileges to volunteer Licensed Independent Practitioners (LIP) Identifies in bylaws responsibility for granting disaster privileges Prior to eligibility, obtains 2 forms of ID Grants privileges when EOP is activated Determines how volunteer LIPs are distinguished Department of Engineering

36 #3 - EM : PLAN REQUIREMENTS Hospital has an EOP Identify capabilities for 96 hours Leaders, including medical staff participate in development Develops and maintains EOP Process for initiating and terminating response and recovery Department of Engineering

37 #4 - EM FOUNDATION Hospital engages in planning activities prior to developing the EOP Documented inventory of resources and assets Conducts HVA Works with and prioritizes HVA with community Department of Engineering

38 #5 - EM EVALUATION Hospital evaluates the effectiveness of the EOP Annual review of inventory Annual review of the EOP s objectives and scope Annual review of the HVA Department of Engineering

39 SURVEY PROCESS Pre-Session Documents Emergency Operations Plan All hazards approach Addresses the six critical areas Inventory of resources and assets Identification of Potential Emergencies..(aka, HVA) Mitigation and preparedness activities for the identified risks Disaster drill and real event evaluations Monitors and evaluates the six critical areas Department of Engineering

40 SURVEY PROCESS Emergency Management topics are addressed in Leadership, Individual Tracers, and System Tracers Scenarios not used Focus on all-hazards planning to sustain six critical capabilities Department of Engineering

41 SURVEY PROCESS Emergency Management Session Focus on mitigation and preparedness No disaster scenarios Use disaster critiques Data collection Focused discussion on six critical areas Look at resources and assets inventory, if present Appropriate storage Expirations Training Department of Engineering

42 DEPARTMENT OF ENGINEERING John Maurer, SASHE, CHFM, CHSP Acting Director Andrea Browne, PhD., DABR Medical Physicist Kathy Tolomeo, CHEM, CHSP Engineer Herman McKenzie, MBA, CHSP Engineer James Woodson, P.E., CHFM Engineer Kate Dolezal, MA, CRC, LPC Technical Coordinator Department of Engineering

43 THE JOINT COMMISSION DISCLAIMER These slides are current as of 10/9/2017. The Joint Commission reserves the right to change the content of the information, as appropriate These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission Department of Engineering