ED Accreditation Update

Is your department prepared to make changes to your emergency management exercises?

Surveyors will expect communitywide focus

As of July 1, 2006, hospitals are required to improve the planning and evaluation of emergency management exercises under revised standard EC 4.20. This change is being made to help ensure that providers are conducting emergency management exercises, formerly called drills, rigorously and thoroughly, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Officials with the agency believe there have been missed opportunities by ED managers and others to identify and improve weaknesses.

When it comes to emergency management exercises, the ED is "home base," says Jerry Gervais, CHFM, CHSP, engineer with the Joint Commission. "So they're right at the heart of the matter, right at the point of sword in receiving victims, whether it's an internal or external disaster," he says.

Compliance with the revised standard will be challenging for EDs, says Marianne Klaas, RN, MN, director of accreditation and safety at Swedish Medical Center in Seattle. "There is a temptation to knee-jerk national events and expect hospitals to turn their emergency management plans around on a dime, when in fact, these are issues we have been grappling with for a long time and in many cases, need local and regional government support and financial support," she says.

Exercises must be based on the hospital's hazard vulnerability analysis, Gervais says. Other changes to the elements of performance for EC 4.20 include:

Hospitals are required to designate a formal observer, internal or external, to critique the exercise. That person can't have any other responsibilities during the exercise, Gervais emphasizes. "The key is that whoever it is, that person needs to be intimate with that organization's emergency management plan," he says.

St Joseph's Hospital of Atlanta experience evaluators through its participation in two drills with the Metropolitan Atlanta Rapid Transit Authority (MARTA), which hired a company, Alexandria, VA-based Community Research Associates that puts on large-scale emergency exercises. "It's a really good opportunity for them to see how you perform, and also to give you some ideas about where you can improve or things you can work on," says Joe Nedley, RRT, coordinator for emergency preparedness and director of respiratory therapy at St. Joseph's. In the MARTA exercises, the hospital and other participants learned that there were opportunities to improve communication, which is "always an issue," he says.

Under the revised standard, administrators, clinical staff, and specifically physicians must be involved in giving input for the critique, Gervais says.

Strengths and weakness identified in the critique must be shared with all levels of the organization.

In the past, post-exercise reports often went to administration and committees, but the results weren't often communicated beyond those groups, Gervais says. "Employees participated but never get any information back as far as how we did overall, what worked well and didn't," he says.

The facility modifies its emergency management plan in response to critiques.

"People were identifying issues, but they were not modifying their plans to alter them to expand on what they've learned," Gervais says. When the critique indicates opportunities for improvement, those opportunities need to be tied into future exercises, he says. You must test and retest to validate changes, he adds.

Klaas says, "It's a good idea to close the loop on improvements, but the timing and methodology will need to be explored." Gervais acknowledges that not every issue applies to every disaster, but notes that many needed improvements will be universal regardless of the specific scenario.

Facilities will be judged on how effectively they communicate within the hospital and with groups outside the hospitals such as the local government, police, and fire department.

The focus will be much more on community drills and community activities, Nedley says. "So from the ED standpoint, I think this is kind of a more complex version than what we've had in the past," he says. "I think we're seeing an evolution away from emergency management activities at an individual facility and moving more toward community."

Lesson from Hurricane Katrina

One of the most powerful lessons that came out of the Hurricane Katrina disaster response was that when you have complete failure of your infrastructure and the scope of the disaster exceeds what the hospital can handle by itself, you need to be able to formally communicate and integrate with the community, Gervais says.

Consider the example of a bioterrorism situation that require inoculation of citizens, Gervais says. "The last thing you want is thousands of people showing up at your ED trying to get an inoculation of Cipro," he says. You may want to designate a civic center, company warehouse, or airport hanger for such an event, he says. "Each community needs to be creative in their own context," Gervais adds. "No matter your size, even the larger hospitals are not prepared to deal with that kind of response."

Swedish Medical Center focused on integration with its community by obtaining input for its hazard vulnerability analysis, Klaas says. "We have always had a very close working relationship with our public health emergency operations center [EOC], King County EOC, and various Homeland Security committees [for the state]," she says. "We also get together with key businesses surrounding our hospital campuses in order to incorporate possible risks into our overall planning."

Key members of the hospital's Safety Team and Hospital Emergency Incident Command System (HEICS) are completing training requirements from the Department of Homeland for Security for Incident Command Systems courses and National Incident Management Services courses. "This will enable us the theoretical knowledge to link our HEICS with community incident command structures and support a unified incident command system," Klaas says.

Swedish Medical puts hospital representative on key local, regional, and state committees for the National Disaster Medical Systems program to ensure coordination of drill requests, so they aren't inundated with requests to participate from various leaders.

Staff must 'walk and talk' roles

To successfully met the revised standard, staff must be able to "walk and talk" their roles as defined by the hospital incident command system and understand they are obligated to carry out the expectations of their hospitals, Gervais says. "It starts with solid communication to the staff as to what expectations are, followed with education for them to carry out responsibilities," he says.

Exercises are an opportunity to make an assessment of your staff's ability and preparedness to do that, he says. "Hopefully, by the time JCAHO comes through on its triennial cycle, we will validate what's already in place," Gervais says.


For more information on the revised standard, contact:

  • Marianne Klaas, RN, MN, Director of Accreditation and Safety, Swedish Medical Center, Seattle, WA. E-mail: Marianne.Klaas@swedish.org.
  • Joe Nedley, RRT, Coordinator for Emergency Preparedness, Director of Respiratory Therapy, St Joseph's Hospital of Atlanta. E-mail: jnedley@sjha.org.