New requirements for emergency management oversight

Focus on need for leadership, accountability

The accrediting agency is also specifying that annual emergency management planning reviews need to be forwarded to hospital leaders for review. In addition, TJC states that hospitals need to evaluate the effectiveness of their emergency operations plans with "relevant input from all levels of staff affected."

Further, any deficiencies or opportunities for improvement identified during the evaluation of emergencies and emergency response exercises must be communicated to the improvement teams responsible for monitoring environment of care issues as well as senior hospital leaders.

The new requirements specify that senior hospital leaders need to direct the implementation of any hospital-wide improvements in emergency management that are based on reviews.

Jeannie Kelly, RN, MHA, LHRM, an expert on risk management and quality assurance at Soyring Consulting in St. Petersburg, FL, suggests that the new requirements underscore the importance of leadership in any emergency management situation. The way hospital administrators handled the crisis following the bombing at the Boston Marathon earlier this year is a good example of what is involved, she says. "You have to spring to attention at a second’s notice in a hospital. Someone has to take charge," she says. "You can’t say you don’t know, and you can’t be negotiating or debating authority in a crisis."

For these reasons, Kelly notes that it is important to establish the power and authority up front so that there is buy-in from the staff. "Then you test the culture, you have trial runs and you have mock drills," she says. "People do that so that they know what to do, and they know who to look to for leadership."

A common problem in hospitals is that people tend to operate in siloes, explains Kelly. "People are all doing their jobs, but they don’t understand how what they do can affect other people," she says. "Trying to get all these people to work as a team toward a common goal is a real challenge of leadership, and that is a big issue."

• Jeannie Kelly, RN, MHA, LHRM, Health Care Consultant, Soyring Consulting, St. Petersburg, FL. Phone: 866-345-3887.

Hospital and ED administrators need to familiarize themselves with new requirements for emergency management oversight that have been unveiled by The Joint Commission (TJC). The standards, which go into effect on January 1, 2014, state that leaders need to identify individuals to be accountable for:

  • staff implementation of the four phases of emergency management, including mitigation, preparedness, response, and recovery;
  • staff implementation of emergency management across six critical areas, including communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities;
  • collaboration across clinical and operational areas to implement emergency management;
  • identification of, and collaboration with, community response partners.