Emergency management: What JCAHO expects

Standard EC.1.4 A plan addresses emergency management.

Intent of EC.1.4

The emergency management plan describes how the hospital will establish and maintain a program to ensure effective response to disasters or emergencies affecting the environment of care. The plan should address four phases of emergency management activities: mitigation, preparedness, response, and recovery.

The plan provides processes for:

A. Identifying specific procedures in response to a variety of disasters based on a hazard vulnerability analysis performed by the hospital.

B. Initiating the plan (including a description of how, when, and by whom the plan is activated);

C. Defining and, when appropriate, integrating the hospital’s role with communitywide emergency response agencies (including the identification of who is in charge of what activities and when they are in charge) to promote interoperability between the hospital and the community.

D. Notifying external authorities of emergencies.

E. Notifying personnel when emergency response measures are initiated.

F. Identifying personnel during emergencies.

G. Assigning available personnel in emergencies to cover all necessary staff positions.

H. Managing the following during emergencies and disasters:

  • patients’ activities including scheduling, modifying, or discontinuing services, control of patient information, and patient transportation;
  • staff activities (for example, housing, transportation, and incident stress debriefing);
  • staff-family support activities;
  • logistics of critical supplies (for example, pharmaceuticals, medical supplies, food supplies, linen supplies, water supplies);
  • security (for example, access, crowd control, traffic control);
  • interaction with the news media.

I. Evacuating the entire facility (both horizontally and, when applicable, vertically) when the environment cannot support adequate patient care and treatment.

J. Establishing an alternative care site(s) that has the capabilities to meet the clinical needs of patients when the environment cannot support adequate patient care including processes that address, when appropriate, management of patient necessities (for example, medications, medical records) to and from the alternative care site; patient tracking to and from the alternative care site, interfacility communication between the hospital and the alternative care site, or transportation of patients, staff, and equipment to the alternative care site.

K. Continuing and/or re-establishing operations following a disaster.

The plan identifies:

L. An alternative means of meeting essential building utility needs (for example, electricity, water, ventilation, fuel sources, medical gas/vacuum systems) when the hospital is designated by its emergency plan to provide continuous service during a disaster or emergency.

M. Backup internal and external communication systems in the event of failure during disasters and emergencies.

N. Facilities for radioactive or chemical isolation and decontamination.

O. Alternate roles and responsibilities of personnel during emergencies, including who they report to within a command structure that is consistent with that used by the local community.

The plan establishes:

P. An orientation and education program for personnel who participate in implementing the emergency management plan. Education addresses specific roles and responsibilities during emergencies, the information and skills required to perform duties during emergencies, the backup communication system used during disasters and emergencies, and how supplies and equipment are obtained during disasters or emergencies.

Q. Ongoing monitoring of performance regarding actual or potential risk related to one or more of the following:

  • staff knowledge and skills;
  • level of staff participation;
  • monitoring and inspection activities;
  • emergency and incident reporting;
  • inspection, preventive maintenance, and testing of equipment.

R. How an annual evaluation of the emergency management plan’s objectives, scope, performance, and effectiveness will occur.

[For more information, contact: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. The standard is available on-line at www.jcaho.org/standard/ecer.html.]