What the survey process expects of your organization: Questions to ask yourself

Excerpt from Joint Commission Perspectives

Assessing your emergency management plan on site

The modified 2001 environment of care (EC) standards for emergency management planning have not changed fundamentally, but the events of Sept. 11, 2001, have necessitated a greater focus on this planning and an increased flexibility and applicability of the emergency management plan. EC standards continue to require hospital, ambulatory care, behavioral health care, home care, and long-term care organizations to design, implement, and test a plan that ensures the organization is prepared to respond to a disaster. Although the current climate does not require organizations to start from scratch with a new emergency plan, organizations need to look closely at their plan, as will surveyors, to ensure that it applies to a variety of disasters on many different scales and that it considers all-important elements of emergency management. During various functional interviews in an accreditation survey, Joint Commission on Accreditation of Healthcare Organizations surveyors assess how an organization plans, designs, implements, and improves its emergency management plan; how that plan applies to a variety of possible events; and whether staff at all levels has been trained in their roles and responsibilities in the plan. The surveyors look to see that your plan addresses all key aspects related to emergency management.

Questions to ask yourself

The rest of this article presents some probing questions to help you assess your emergency management plan in a new light, organized by the point in a survey in which the issue may arise. Some questions may not apply in all health care settings.

Leadership. This interview addresses, among other topics, the collaboration of senior leaders in planning, designing, implementing, and improving the emergency management plan. All leaders need to work together to create, support, and communicate an emergency management plan that meets the changing circumstances and needs of the organization and its community. The following questions will help you determine if leaders have been successful in this endeavor:

(LD.1.1.1) How have leaders determined the scope and resources for your emergency management plan (that is, hazards vulnerability analysis [HVA], command structure, and community integration) and implementing the plan?
(consultation
under EC.1.4)
How have leaders planned to rapidly expand clinical and nonclinical staff in the event of a disaster?
(EC.1.4) Who is involved in the HVA? Is the emergency management plan flexible enough to allow response to a variety of disasters? To what types of disasters is your plan capable of responding?
(EC.1.4) What is your command structure? How have staff members been oriented in their roles and responsibilities within this structure? How does your internal command structure integrate into the community’s structure? 
(EC.1.4, EC.2.4) How will critical supplies (such as medical supplies, water, pharmaceuticals, ventilators, and so forth) be obtained and allocated?

Unit visits. Surveyors visit various care units in the organization to determine whether staff understand the emergency management plan and applies it to the activities of that unit. During visits to care units, surveyors ask staff how they are involved in planning, designing, and implementing the emergency management plan.

(EC.2.4) What education have you received about recognizing hazards identified in the emergency management plan?
(HR.4, HR.4.2, EC.2.4) What type of orientation, training, and education have you received about your roles and responsibilities in the emergency management plan? What types of emergencies were addressed in the education?
(HR.4, HR.4.2, EC.1.4) Has a command center been identified to coordinate community response?
(EC.2.9.1) Does the unit participate in emergency-preparedness drills regularly? What was your role in the most recent drill? 
(EC.1.4, EC.2.4) How will critical supplies (such as medical supplies, water, pharmaceuticals, ventilators, and so forth) be obtained and allocated?

Clinical leadership. This interview addresses the role of clinical leadership (for example, nursing or medical staff leaders), including their participation in planning, designing, implementing, and improving the emergency management plan. Involving clinical staff in implementing the emergency management plan is key because they directly affect the safety and care of patients through the plan’s use.

(EC.1.4) How is clinical leadership involved in developing the emergency management plan, including the command structure and its specific roles? Who from the clinical staff was involved in its development?
(EC.1.4) What was the clinical staff’s contributions to the development of the emergency management plan, including command structure? Who from the clinical staff is included in the command structure?
(consultation
under MS.5.14.4, EC.1.4)
How has the clinical staff planned to rapidly expand the number of physicians and other licensed independent practitioners (LIPs) in the event of a disaster? Has clinical leadership considered how it will quickly credential volunteer physicians and other LIPs?
(HR.4, HR.4.2, EC.1.4) How are clinical staff members trained in emergency management? 
(HR.4, HR.4.2, EC.2.4) What education is provided to clinical staff to recognize symptoms of and/or manage hazards or treat conditions identified in the emergency management plan? When was the training conducted? Who attended?
(HR.4, HR.4.2, EC.2.4) What type of orientation and education is provided to clinical staff about their roles and responsibilities in the plan?

Environment of care interview. During this interview, surveyors address how the emergency management plan is integrated with other EC-related functions. The most intensive assessment of an organization’s emergency management plan occurs at this time.

(EC.1.4) Does your plan address the four phases of emergency management planning: mitigation, preparedness, response, and recovery? How does it address them?
(EC.1.4) Does an HVA exist? Is it consistent with the community analysis? How was the HVA used to develop the emergency management plan?
(EC.1.4) Can you provide evidence that the HVA is shared with the key leaders/staff and the emergency management program committee (if one exists) and that they are knowledgeable about its content?
(EC.1.4) How are the hazards identified in the HVA linked to mitigation, preparedness, response, and recovery activities?
(EC.1.4) Are there clearly defined staff roles for external emergencies? How does your emergency response plan address your organization’s mission in terms of its role in community disaster response?
(EC.1.4) Are there clearly defined staff roles for internal emergencies? Does your response plan identify the expected roles that community response agencies/organizations will assume?
(EC.1.4) Does your plan identify key response agencies or institutions in the community with which your organization will interact during a disaster (such as police and fire departments, public health agencies, laboratories, other hospitals, and the National Disaster Medical System)?
(EC.1.4) Does your plan list whom to contact specifically within each community response agency and institution (including telephone numbers, e-mail addresses, and so forth) and the process for updating this information?
(EC.1.4) Does your plan identify how to contact each community response agency or institution during a disaster (such as through the use of two-way radio, cell phones, and so forth)?
(EC.1.4) Does your plan identify a command center where community response will be coordinated?
(EC.1.4) What are the details regarding your evacuation/alternative care site?
(EC.1.4) Does your plan describe processes to identify an alternative care site and how it will be used?
(EC.1.4) Does your plan describe how a reporting or command structure is to be used during a disaster?
(EC.1.4) Does your plan include a command structure consistent with that used by the local community? Have you reviewed the community’s emergency management plan?
(EC.1.4) During an incident, can your organization quickly identify whether someone is an employee, a visitor, or a patient?
(EC.1.4) How will you identify certain individuals in charge of managing the incident?
(EC.2.9.1) Can you provide evidence that your external emergency management plan has been implemented in the past 12 months?
(EC.2.9.1) Has your organization participated with community response agencies’ or institutions’ occurrences or drills as described in your emergency management plan? Was the drill in which you "actively participated" led by your organization or the community?
(EC.1.4, EC.2.4, note to EC.2.9.1) Have you verified that the contact individual (for both participating and nonparticipating community response agencies/institutions) and the method for communicating with that individual during a disaster specifically identified in your plan is current? 

Source: Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Perspectives 2001; 21:(12)6. Reprinted with permission.