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Proposed changes will align EM standards with new CoPs


December 1, 2017

Identify who the backup leadership will be in the event your command incident officer isn’t available during an emergency, start putting together contact information on staff, physicians, suppliers, volunteers and others who you might need to communicate with, and ensure you can legally keep operating off site if that becomes necessary.

Those are among the new requirements The Joint Commission (TJC) hoped to add to its Emergency Management standards by November 15, pending approval by CMS.

The accreditor released prepublication standards at press time, but on September 29, Joint Commission acting Director of Engineering John Maurer provided an update on the standards at TJC’s Chicago session of its annual Executive Briefings.

New CoPs took effect November 15

The changes are necessary to bring the EM standards in alignment with the new Medicare Conditions of Participation (CoP) on emergency preparedness, which went into effect on November15.

In proposing the new CoPs, CMS noted that it relied heavily on TJC standards. And so far a draft copy of the changes shows only six new EPs under existing EM standards and three under a new standard requiring hospitals that are part of a healthcare system to plan and prepare with the system if it chooses to work under a system-wide integrated emergency program.

A copy of the draft proposal is available to hospitals through their TJC extranet system. Once approved, the standards will be published on TJC’s public website, as it has other prepublished standards.

TJC’s standards emphasize the importance of hospitals having a continuity of operations and a leadership succession plan, and also working within its health system, if there is one, and with the community at large. (For more on continuity of operations, see p. x.)

When working with the community and holding exercises, Maurer noted that CMS requirements are different from TJC requirements, in that TJC’s are more stringent.

Two full-size exercises still required

Both require at least two exercises of the emergency operations plan (EOP) per year, but CMS says only one should be a full-size, community-inclusive test of the EOP. The second test can be a functional or tabletop exercise, according to CMS.

TJC requires now and will continue to require that both times the EOP is activated, either as an exercise or in real-time events, must be full-scale exercises.

Tabletop exercises may be used as an escalation tool, Maurer noted, to analyze how the hospital would handle an emergency on top of an emergency. But it can’t be one of the two required annual exercises, he said.

To learn more about CMS expectations, Maurer recommended hospital managers go through the online training for providers that CMS has created to go alongside the online courses it created for its own surveyors as they learn how to implement the new CoPs. (For a link to the course and a quick quiz on the new CoPs, see below.)

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