The Joint Commission and Joint Commission Resources 2018 Emergency Preparedness Conference

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and Joint Commission Resources 2018 Emergency Preparedness Conference April 18 19, 2018 Lake Buena Vista, FL JCR Events Are Paperless. All learning materials will be digitally available. AGENDA 7:00 8:00 am Registration & Continental Breakfast 8:00 8:15 am Opening/Welcome Welcome: Diane Sosovec, RN, MS Program Manager Global Education and Technology Joint Commission Resources Conference Moderator: Kenneth A. Monroe, PE, MBA, CHC, PMP Department of Engineering 8:15 9:45 am Northern California Wild Fires Within minutes of each other, two of California s largest healthcare systems, Kaiser Permanente and Sutter Health Systems, evacuated hospitals during the North Bay Fires on October 9th, 2017. Both organizations use an organization wide approach to emergency management, from the clinic to the corporate offices. Hear each system s story and lessons learned regarding hospital evacuation, event response, recovery, and full restoration of healthcare services in the community of Santa Rosa and the North San Francisco Bay Area. Moderator: Lynne Bergero, MHSA Project Department of Standards and Survey Methods John Fannin, MBA, CHSP Support Services Administrator Kaiser Permanente Santa Rosa Santa Rosa, CA Donald Stevens, CHFM, CHC Executive Regional Support Services Kaiser Permanente Northern California Oakland, CA Mark Shirley Environmental Risk Consultant Sutter Health System Office Santa Rosa, CA 9:45 10:00 am BREAK

10:00 11:15 am Common Thread, Uncommon Strength: HCA Gulf Coast Galvanizes in the Shadow of Harvey This health systems leadership and staff were faced with one of the greatest risks and challenges that exists, making the decision on sheltering in place or evacuating patients and staff ahead of an intense storm Hurricane Harvey. This presentation will discuss the challenges presented, factors of consideration, triggers for execution and the intense operation that occurred to ensure the safest operations for patients, staff and community. Presenters will share insights into the HCA strategic clinical de risking model that was integral to its facilities safer operating conditions. Additional topics include, cooperation with other regional hospitals and coalitions members to ensure community readiness and safe clinical operations, multiagency coordination in a tiered healthcare system, caring for the physical and emotion health of staff, and more. Erin Erb, MHSA, RHIA, CPHQ Division Vice President of Quality HCA Gulf Coast Division Kelli Nations, MHA, BSN, RN, NE BC Chief Nurse Executive HCA Gulf Coast Division Jenn Bowman, RN, BSN, MBA, Transfer Center HCA Gulf Coast Division Zachary Oatis, BA Coordinator Enterprise Preparedness & Emergency Operations HCA Clinical Services Group 11:15 am 12:15 pm Preparedness, Response and Recovery 1 October Las Vegas Incident On the night of Sunday, October 1, 2017, a gunman opened fire on a crowd of concertgoers at the Route 91 Harvest music festival on the Las Vegas Strip in Nevada, leaving 58 people dead and 851 injured. How does a hospital prepare for an incident of this magnitude? An overview of the incident, lessons learned and panel discussion on how to prepare for a no notice critical incident will be presented. Michael Wargo RN, BSN, MBA, PHRN, CMTE Assistant Vice President HCA Clinical Services Group Enterprise Preparedness & Emergency Operations Nashville, TN Kevin Menes, MD Police SWAT Physician Emergency Medicine Department Sunrise Trauma Center Las Vegas, NV Jeff Murawsky, MD Chief Medical Office & Hospital Incident Commander Sunrise Trauma Center Las Vegas, NV 12:15 1:30 pm Lunch and Networking Exhibit Hall and Poster Presentations Sponsored by Yale New Haven Health System Center for Emergency Preparedness and Disaster Response 1:30 2:30 pm Joint Commission Updates and CMS Emergency Management Final Rule CMS Emergency Management Final Rule Overview of rule requirements across settings Joint Commission s onsite evaluation of rule requirements Preparedness, Response and Recovery for Large Scale Disasters Lynne Bergero, MHSA Project Department of Standards and Survey Methods

2:30 2:50 pm BREAK 2:50 4:30 pm Joint Commission Survey Readiness This session will provide guidance to a successful survey relative to emergency management. Included will be information focused on the survey process, frequently cited standards, and surveyor insights that will assist Joint Commission accredited organizations with their preparedness and response activity. Kenneth A. Monroe, PE, MBA, CHC, PMP Department of Engineering David Dagenais, BS, FASHE, CHFM, CHSP, Plant Operations and Security Wentworth Douglas Hospital Dover, NH Surveyor 4:30 pm ADJOURN 4:30 5:00 pm Exhibits, Networking, and Reception

Thursday, April 19, 2018 7:00 8:00 am Continental Breakfast TRACK A Moderator: Kenneth A. Monroe, PE, MBA, CHC, PMP, Department of Engineering 8:00 9:00 am The NICS: A System Wide Approach to Emergency Response Utilizing the components of NIMS, ICS, CMS and Joint Commission requirements, the creation of a system wide Incident Command System was established known as NICS. This presentation will demonstrate effective methods creating a comprehensive system wide emergency preparedness network Jared Shapiro, DRPH(c), PhD(c), MPH, NRP, CHEP, CHSP System, Environmental Health and Safety Montefiore Health System New York, New York Ed Tangredi, CEM of Emergency Management White Plains Hospital White Plains, NY TRACK B Moderator: Lynne Bergero, MHSA Project, Department of Standards and Survey Methods Something from Nothing? Building on Emergency Management Program for Ambulatory Care Networks Hospitals and other inpatient facilities have long had requirements for emergency management program planning, including those for Joint Commission accreditation. Now, with new requirements from CMS relative to 17 provider types, including ambulatory care, many organizations are faced with the daunting challenge of developing a program where one never existed. This session explores the journey of the municipal ambulatory care system in New York City as it built its ambulatory care emergency management program almost from scratch, and lessons learned along the way. Daniel E. Meisels, MPA, EMTP, CHSP, CHFM, CEM Sr. Associate Safety Security & Emergency Management NYC Health + Hospitals New York, New York 9:10 10:10 am Defining Performance Metrics for Emergency Management Programs Organizations continue to struggle with determining the effectiveness of their emergency operations plans. BIDMC has developed a performance metric that has been utilized for more than five years. The presentation will describe the development of a corrective action tool, data captured and how it drives mitigation and continued improvements. Meg S. Femino, HEM Senior, Emergency Management Beth Israel Deaconess Medical Center Boston, MA Planning for Evacuation: A 7 Step Approach A hospital evacuation plan is no longer just an accreditation requirement, it is indispensable. Successful evacuation planning integrates multidisciplinary team members focused on the unique population needs and supporting activities of the hospital. Challenges created by unfunded mandates, time, resources and priorities can all be overcome with a robust project management plan. The 7 Step Plan, lessons learned and next steps will be discussed. Lisa Yahle Dunbar MPH, BSN, RN, CIC, PMP Senior Quality Manager & Emergency Preparedness Committee Chair. James Emergency Department The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute Columbus, OH

TRACK A TRACK B 10:30 11:30 am Putting Practice to Action: Responding to Hurricane Harvey Hurricane Harvey affected every aspect of the hospital, from the janitorial crews, to the cooking team, to all specialties of nursing and doctors, and public safety. The presentation will focus on how the public safety team was able to assist with preparations and the response to the most devastating natural disaster is Houston s history. The primary successes, lessons learned, and areas for improvement that were realized before, during and after the Hurricane Harvey event will be discussed. This will be viewed through the lens of a large hospital setting as well as that of a higher education entity. Takeaways will include: best practices, planning criteria, and operational workflow strategies. Vicki King Assistant Chief of Police University of Texas Police at Houston at The University of Texas MD Anderson Cancer Center Andrew Dasher, BS, MBA, PhD Metrics Analyst, Emergency Response University of Texas Police at Houston at The University of Texas MD Anderson Cancer Center and The University of Texas Health Science Center What do I do: Developing No Notice Drills to Maximize Disaster Response Training Opportunities A critical aspect of planning efforts at MGH has been the facilitation of no notice drills in the Emergency Department to increase staff comfort with their role in a disaster. This session will provide practical and achievable recommendations to enhance a hospital s ability to implement immediate response actions when a disaster occurs, including: 1. Best practices developed to guide the implementation of 15 minute no notice drills in Emergency Departments and other key areas of the hospital to reinforced key actions via ongoing training. 2. A comprehensive curriculum to guide the develop of institution specific programs based on the unique needs of a facility 3. Specific action items identified in MCI related no notice exercises. Paul Biddinger, MD Massachusetts General Hospital Center for Disaster Medicine Boston, MA 11:30 12:45 pm Lunch and Networking Exhibit Hall and Poster Presentations Sponsored by Yale New Haven Health System Center for Emergency Preparedness and Disaster Response

12:45 1:45 pm Integration of the Needs of Individuals with Disabilities and Access and Functional Needs, Into Hospital Emergency Management Planning 1:45 2:00 pm BREAK TRACK A TRACK B Approximately 20 percent of Americans have a registered disability, and at least another 30 percent have an Access and Functional Need (AFN). This population has an incredibly diverse and unique set of needs particularly so in a disaster. Panelists will offer techniques and resources for integrating AFNs into your plans, including a sample AFN Liaison Officer Job Action Sheet for use in HICS. Participants will be provided with a comprehensive, adaptable tool for assessing risk to the AFN community, and identifying the hospital s current capability to respond. Steven Storbakken, MBA, CHEP, CHSP, CHEM, CHPA, HACP, CHPP, Emergency Preparedness & Environmental Safety Pomona Valley Hospital Medical Center Pomona, CA L. Vance Taylor Chief, Office of Access and Functional Need California Governor s Office of Emergency Services Mather, CA Kevin G. Muszynski Project Manager, Support Services Pomona Valley Hospital Medical Center Pomona, CA When You Can t Log On: Planning for Information Systems Downtime Healthcare s increasing reliance on Information Technology expands beyond the support of direct patient care activities, it commonly encompasses nearly every aspect of daily operations, from supply chain management to nutrition services to finance and beyond. Each instance creates new vulnerabilities to cyberattack. When IS services fail, creating unplanned downtime events, each of the putative benefits of IS systems (such as improvements in speed and efficiency, integration of information, reduction of errors, and communication), can become an area of major vulnerability for an organization. The process of working across the organization to develop a rapid response team for IS downtime events, including the specific roles and responsibilities that support downtime response and the best practices established when implementing this response to outside attacks on IS systems will be presented. Paul Biddinger, MD Massachusetts General Hospital Center for Disaster Medicine Boston, MA

TRACK A TRACK B 2:00 3:00 pm Reuniting Children and Families Following Disasters: Planning and Best Practices When disasters occur, the risk of children experiencing the physical and psychological impacts of trauma increases the longer they are separated from their families. The Western Region Homeland Security Council (WRHSAC) has developed a ready to use family reunification plan template and checklist and training and exercise schedule based on nation wide best practice models. This plan is intended to support schools, hospitals, and other organizations that deal with children regularly, and emphasizes the importance of those organizations collaborating with healthcare organizations, first responders, community stakeholders, and other support agencies. Ann M. Shea, BA, MS, CHSP Emergency Preparedness/Environment of Care Coordinator Mercy Medical Center Springfield, MA Happily, Ever After a beautiful relationship in Unified Command Theory and application are often different. When they collide, there is rarely a happy ending. Unified Command can either be a beautiful relationship leaving you signing hi ho hi ho or leave you wondering how the evil step mother joined your family. In this case study, the application of Unified Command in an evacuation of an ambulatory clinic, learn a way it can work well and things to watch out for, so everyone can have a happy ending to the crisis. Marisa Bartlett, RN, BSN, CHSP, CHEP, CHEC III, Safety and Emergency Management University of Wisconsin Health Madison, WI 3:00 pm ADJOURN Patricia A. Smith Senior Land Use Planner Franklin Regional Council of Governments Greenfield, MA