© SMS, Inc., 2010 1

“The Joint Commission®’s Standards related to

Emergency Preparedness”

Presented by: William M. Wagner, ScD CHCM CHSP CHEP

Vice President & Director of Education, Research & Development SAFETY MANAGEMENT SERVICES, INC.

(877) 577-6550 ** info@safemgt.com(877) 577-6550 ** info@safemgt.com

APIC Annual ConferenceNew Orleans

July 12, 2010

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Ready for any emergency?

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• Provide for patients

• Protect the staff

• Preserve the facility

Initial Emergency Response

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Physical Event ModelEmergency

• Infrastructure intact• Sustainable services

Disaster• Infrastructure damaged• Sustainable services

Catastrophe• Infrastructure damaged• Not sustainable services

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Patient Care Event Model

Emergency• Standard care• Response capability high

Disaster• Sufficient care• Staff shortage• Able to sustain for 96 hours

Catastrophe• Basic/primitive care• Evacuation maybe necessary

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Joint Commission Standards

Emergency Management (EM.01.01.01 – EM.03.01.03)

Infection Control (IC.01.06.01)

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EM Standards

Planning (EM.01.01.01)• Identifying & planning for emergencies

Implementation (EM.02.01.01-.15)

• Developing emergency response

Evaluation (EM.03.01.01-03) • Testing & analysis of the Plan

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EM Components

• Hazard Vulnerability Analysis (HVA)

• Emergency Operations Plan (EOP)

• Emergency Response Plans (ERP)

• Incident Command Structure (ICS)

• Staff Training & Exercises

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Infection Control Standards

Planning (IC.01.01.01-.01.06.01)

• Responsibilities, resources, plans, & assessments

Implementation (IC.02.01.01-.02.04.01)

• Developing prevention & control activities

Evaluation and Improvements (IC.03.01.01) • Effectiveness of Program

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Prepares to Respond to Influx (IC.01.06.01)

• Information about infections that can cause influx

• Clinical & epidemiological information on new infections

• Methods for communicating information• Plan to respond to influx, or not!• Methods for managing influx patients• Activities to respond to influx

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Planning:Hazard Vulnerability Analysis

(HVA)

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Conducting the HVA

• Involvement of Leadership, including medical staff

• Identify “potential” hazards, threats & events

• Evaluate likelihoods & consequences

• Assess effect on hospital or community

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Organizational HVA

• Develop one, overall HVA • Develop a separate HVA for

each site:• Ambulatory Surgery Center• Emergency Clinic• Home Health• Hospice• Hospital

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Hazard Vulnerability Analysis

13131111112222222222Severe WeatherSevere Weather

13131111112222222222Mass CasualtyMass Casualty

18184422223311223311Ice and SnowIce and Snow

10101111111111112222Hazmat InternalHazmat Internal

18185511331111223322Generator FailureGenerator Failure

11111111111111114411Electrical FailureElectrical Failure

12121111111111223322Contaminated VictimContaminated Victim

13131111111111333322PandemicPandemic

16162233221111223322Communications FailureCommunications Failure

Capabilities and Capabilities and Consequences Consequences

(Add the Scores)(Add the Scores)

Staff and Staff and Patient Patient Family Family

MembersMembers

Commercial Commercial ResourcesResources

Public Public ServicesServices

Utility Utility ServicesServices

Structure Structure StaffingStaffingSupport Support ServicesServices

Patient Patient Care Care

ServicesServicesEVENTEVENT

ScoringScoringConsequences on External Consequences on External

ServicesServicesAbility and Consequences to Provide ServicesAbility and Consequences to Provide Services  

1= 100% prepared or insignificant

2= 75% prepared or minor

3= 50% prepared or moderate

4= 25% prepared or serious

5= 0% prepared or very serious

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Hazard Vulnerability Analysis(Likelihood))

EVENTLikelihood of Occurrence

Scoring of Capabilities and Consequences

(Table 2)

Total Score

Communications Failure 2 16 32

Pandemic 3 13 39

Contaminated Victim 1 12 12

Electrical Failure 1 11 11

Hazmat Internal 1 10 10

Generator Failure 1 18 18

Ice and Snow 3 18 54

Mass Casualty 2 13 26

Severe Weather 1 13 13

Scoring Criteria

1= Minimal or slight probability

2= Moderate probability  

3= High probability  

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Infection Control Standards

Response to Influx (IC.01.06.01)• Information about infections that can

cause influx• Clinical and epidemiological information

on new infection• Methods for communication information• Plan to respond to influx (could be no)• Methods for managing influx patients• Activities to respond influx

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Influx vs. Surge

• Influx = managing patients waiting to receive care at a rate higher than normal– Triage– Registration

• Surge = managing patients within the organization at a greater rate than its current/normal resources can manage– Capacity– Capability

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Surge Capacity & Capability

• Capacity = having the physical resources & manpower abilities to manage a sudden influx of patients

• Capability = having specialized competencies & resource capabilities to treat specific groups of patients, infectious patients from a pandemic event

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Implementing:Emergency Operations

& Response Plans

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Six Critical Functions (EM.02.02.01-.02.02.11)

• Communication Management • Resources & Assets Management• Security & Safety Management• Staff Role & Responsibility • Utility Systems Management• Patient Management

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Six Critical Functions

Events CommunicationRes

AssetsSafety

SecurityStaff Roles

Utility Systems

Patient Care

Severe Weather            

EpidemicDOH NumbersPoints of Control Pages, cell, etc

PPEReuseAllocation

 Lockdown  HICS Negative Air Systems

Screening  Triage Isolation

Contaminated Victim            

Electrical Failure            

Mass Casualty            

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Emergency Plans

Emergency Operations Plan (EOP)– Overall Plan

Emergency Response Plan (ERP)– Event Specific Emergency Plan

Incident Action Plan (IAP)– A “To Do List” developed during

the eventJob Action Sheet (JAS)

– Guide for Specific Role

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Emergency Operations

Plan

“A process to respond to any emergency”

Revised 2/2010

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Emergency Operations Plan

• Blueprint for responding to any emergency

• Information that can be used for any event

• Easy reference with tabbed sections

• Include information requested by The Joint Commission

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Emergency Initiation Process

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Emergency Influx

Response Plan

“Receiving patients at an increased rate”

Revised 6/2010

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Plans to respond to emergencies

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Four Key Elements in theEmergency Response Plans

• Mitigation• Preparedness• Response• Recovery

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Four Key Elements in theEmergency Response Plan

• Mitigation - actions taken before event to limit impact– Provide appropriate Airborne Infectious Isolation

Rooms– Purchase appropriate PPE

• Preparedness - actions taken to ensure organization is prepared– Train staff to manage “concerned” patients– Provide security procedures

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Four Key Elements in theEmergency Response Plan

• Response - actions taken during event

– Active EOP & ERP– Initiate infection prevention measures

• Recovery - actions taken to re-establish organization’s response capacity– Evaluate response– Update plans based on the evaluation– Resupply consumables– Service equipment used during the event

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Incident Action Plan (IAP)

• Outline initial response activities (“back of the envelope”)

• Utilize information in ERP

• Identify specific objectives based on current events

• Formulate into current “Response Plan” for organization

• Review & revise periodically

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Influx Response Plan1. Response Plan: Immediate (Operational Period 0-2 Hours) A. Goal To manage an increase number of patients with serious conditions

B. Operational Time-Frame IAP review: within 2 hours of ICS Activation Operational Shift: 12 hours Planned Duration of Self Sustained Operations: 96 hours

C. Objectives * To ensure essential patient security and services are maintained * To prepare the facility for increase patients in ER * To process individuals in an expeditious and organized manner

D. Resources

Personnel: Staff retained until next operation period or event is over Food: Refrigeration is required for food supplies Clinical Supplies: Refrigeration is required for blood and drugs. Sufficient supplies on hand for most items for short term (less than 24 hours). Inventory, planning and re-supply efforts will be considered for longer term events. Non-clinical Supplies: Re-supply will be considered for longer term events. Utilities (Assets) Support: Support lighting for night time events, electrical support for additional data entry equipment

E. Tasks

* Open Emergency Operations Center (EOC) - fill essential posts * Obtain appropriate PPE and supplies. * Ensure emergency room is secure * Surge existing ER patients * Obtain additional PPE supplies for ER * Take out Emergency Power Distribution System Chart

F. Security Institute lockdown procedure if necessary

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Incident Action Plan(0-2 Hours)

Objectives & Task (0-2 Hrs)1. Clear snow from ER entrance

2. Provide security at ER entrance

3. Surge current ER patients to other locations

4. Obtain additional respirators & PPE

5. Identify common symptoms

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Job Action Sheets (JAS)

• Information tool • Radio “contact” title• Purpose • Reporting structure• Critical action

considerations• Prompts actions

related to their roles & responsibilities

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IncidentCommand Structure

(HICS)

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HICS Management Functions

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OperationsSection Chief

Medical Care Branch Director

Infrastructure Branch Director

HAZMAT Branch Director

Security Branch Director

Casualty CareLeader

Building/GroundsLeader

Casualty CareDecon Leader

Access ControlLeader

Clinical SupportLeader

Environmental Services Leader

Detection/MonitoringLeader

Crowd ControlLeader

Business ContinuityBranch Director

InpatientLeader

Mental HealthLeader

OutpatientLeader

Patient RegistrationLeader

Food Services Leader

Medical GasLeader

Medical DevicesLeader

HVACLeader

Power/LightingLeader

Water/SewerLeader

Business RelocationLeader

Information TechnologyLeader

VictimDecon Leader

Traffic ControlLeader

Staging Manager

Equipment/SupplyStaging Leader

MedicationStaging Leader

Records PreservationLeader

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PlanningSection Chief

Resources Leader

SituationLeader

Documentation Leader

DemobilizationLeader

Patient TrackingManager

Bed TrackingManager

Personnel TrackingManager

Material TrackingManager

Staff PersonnelTracking Manager

Physician TrackingManager

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LogisticsLogisticsSection ChiefSection Chief

ServiceServiceBranch DirectorBranch Director

SupportSupportBranch DirectorBranch Director

CommunicationsCommunicationsLeaderLeader

IT/ISIT/ISLeaderLeader

Staff Food & SleepStaff Food & SleepLeaderLeader

Employee HealthEmployee HealthLeaderLeader

Family CareFamily Care LeaderLeader

SupplySupplyLeaderLeader

FacilitiesFacilities LeaderLeader

TransportationTransportation

LeaderLeader

Labor Pool &Labor Pool &Credentialing Credentialing

LeaderLeader

Alternate CareAlternate Care

Site LeaderSite Leader

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FinanceFinanceSection ChiefSection Chief

ProcurementProcurementLeaderLeader

CostCostLeaderLeader

Compensation/ClaimsCompensation/ClaimsLeaderLeader

TimeTimeLeaderLeader

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• Develop process for monitoring resources needed during an emergency

• Determine sustainability with existing resources

• Identify consumption adjustments

• Plan for evacuation if things get worse

Resources & Assets

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Evaluation

EM.03.01.03: Testing & Exercise

● Communication internal & Communication internal & externalexternal

● Resources mobilization & Resources mobilization & allocationallocation

● Safety & security activitiesSafety & security activities● Staff roles & responsibilityStaff roles & responsibility● Utility systemsUtility systems● Patient clinical & support Patient clinical & support

activitiesactivities

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Critique of Critical Functions

Critical FunctionsCritical Functions Good FairOpportunities for

ImprovementComments

Communication

Resource Mobilization & Allocation

Safety & Security

Roles & Responsibilities

Utility Systems

Patient Management

Monitor(s)

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Improvement Process

HVA

Preparation

Implementation

TrainingEvaluation

CommitteeReview Planning

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Survey Preparation Summary

• Evaluate emergencies with HVA• Plan response through EOP• Develop specific ERPs • Participate in HICS• Identify resources and assets• Evaluate response to events• Improve with committee review

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Contact Information

SAFETY MANAGEMENT SERVICES, INC.

(877) 577-6550 info@safemgt.com

www.safemgt.com