JCAHO changes focus on disaster preparedness

Use of volunteers, review of plans clearly defined

Same-day surgery managers and staff members will have more direction and some flexibility if they face a disaster that requires the use of health care volunteers or if they choose to stay open during a pandemic situation with new standards in the Joint Commission on Accreditation of Healthcare Organizations’ hospital, ambulatory care, and office-based surgery standards that are effective July 1, 2006.

"Changes to the standards that relate to disaster situations have been in the works for several years, but the disasters of the past two summers have illustrated the challenges faced by health care organizations and the need to define different roles and expectations," says Michael Kulczycki, executive director of the Ambulatory Accreditation Program at the Joint Commission.

One of the challenges faced by health care organizations that needed extra help and health care workers from other parts of the country that wanted to volunteer was the requirement that providers be credentialed by the organization for which they were volunteering, says Kulczycki. New standards for both nonlicensed independent contractors and licensed independent contractors allow organizations to grant disaster responsibilities or disaster privileges, in the case of physicians, to those who want to volunteer. "Volunteers who are members of the Medical Reserve Corps or the Emergency System for Advance Registration of Volunteer Health Professionals are already pre-registered and credentialed to assist in a professional capacity in a disaster, but not all health care workers are members of these or similar organizations," he points out.

The new standards (H.R. 1.2.5 and H.R. 4.3.5) allow organizations to assign emergency responsibilities or privileges to volunteers who show verification of their licensure, certification, or registration to practice their profession until the immediate situation is under control and primary source verification of credentials can begin, says Kulczycki. Primary source verification must be completed within 72 hours of the time the volunteer appeared for assignment, or the organization must document reasons for not completing this step in this timeframe, he adds.

Not only does this standard more clearly define the process that organizations should follow to use volunteers in a disaster, but it provides some flexibility so that a volunteer can immediately begin helping, says Kulczycki. The standard also specifies that disaster privileges can be granted only when the disaster plan is implemented and the organization cannot meet immediate patient needs without volunteer assistance, he adds. Another component of the standard requires the organization to have a written protocol that may include observation, mentoring, and clinical record review of volunteers to ensure that the volunteer is competent to handle the assigned duties and to assure patient safety, Kulczycki explains.

Lou Warmijak, administrator of Kissimmee (FL) Surgery Center, says it would be rare for a surgery center that performs elective procedures to continue operating during a disaster, "but I can see that in some situations we might be opened as a triage center or other type of health facility," he says. "We’ve not experienced the long-term recovery period following a disaster that Louisiana and Mississippi health care organizations have experienced, so we have not had to deal with professionals offering to volunteer." Warmijak points out that the flexibility of the disaster volunteer standards is helpful for everyone because staff members at his and other surgery centers owned by his general partner are able to volunteer through the larger organization for work in disaster areas.

Evaluate all disaster drills

Other Joint Commission standards changes that relate to disaster preparedness for ambulatory care organizations require that organizations not only develop a disaster plan that addresses a variety of situations, but also that the organization conduct a variety of disaster drills and that the organization conducts an evaluation of these drills, says Kulczycki. Prior standards manuals did not clearly state the expectation that organizations critique each drill to identify deficiencies and implement changes to improve the plan, he explains.

The evaluating of each drill does not need to be in writing, but it must be in practice, says Kulczycki. "If a surveyor asks a staff member what happens after a disaster drill, the surveyor wants to hear that a multidisciplinary team looks at how the plan was implemented and if everything went as planned," he says. "I expect that most same-day surgery programs already perform an evaluation, but some may have to formalize the process and include a variety of staff members in the evaluation."

Warmijak’s experiences with hurricanes in the past couple of years have changed the way his facility plans and prepares for disasters, he says. "It’s very hard to completely prepare for a disaster when you’re sitting behind a desk with electricity working," Warmijak points out. "It wasn’t until we experienced a storm that cut power for many days that we discovered flaws in our plan."

Testing of emergency plans for office-based surgery programs does not require as much evaluation because the staff size is not as large as a surgery center, Kulczycki says. "Office-based surgery staffs do have to test their plans and do have to address realistic scenarios," he says.

One editorial change to the office-based surgery manual’s infection control standard specifies that if an office-based program chooses to treat patients during a pandemic situation, the program must have a plan to segregate infectious patients from noninfectious patients, says Kulczycki. The previous standard’s wording did not make it clear that an organization does not have to treat patients if there is a pandemic-type situation but if the organization chooses to do so, there must be a plan, he explains.

With medication management being such an important issue for patient safety, a requirement that the organization develop a policy that addresses medication storage between the receipt of medication and the administration of the medication is a key addition to the ambulatory care and the office-based surgery standards, says Kulczycki. "If a same-day surgery program is using compounded drugs from outside the organization, they must get assurance that the medication was stored and transported safely," he says.

Don’t forget your anesthesiologists either, especially if you contract with another organization for anesthesiology services, suggests Kulczycki. If you allow the anesthesiologist to bring in medications, make sure you can identify how the medication was stored and at what temperature, if that is a safety factor," he says.


For more information on accreditation standards or emergency preparedness, contact:

  • Michael Kulczycki, Executive Director, Ambulatory Accreditation Program, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5290. E-mail: kulczycki@jcaho.org.
  • Lou Warmijack, Administrator, Kissimmee Surgery Center, 2275 N. Central Ave., Kissimmee, FL 34741. Telephone: (407) 870-0573. Fax: (407) 870-1859. E-mail: lou.warmijak@hcahealthcare.com.