Emag conf jc 2010 050410
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Transcript of Emag conf jc 2010 050410
The Joint Commission – Emergency Management 2010 & Beyond
Yusuf A. Rahman, BA, RRT, CHECGeorgia Hospital Association
Objectives
Overview of changes to 2009 & 2010 JC standards
Primary stumbling blocks for most hospitals
Provide tools and resources to help with future JC reviews
Share experiences and best practices
Primary Focus AreasLife Safety (LS)
Environment of Care (EC)
Emergency Management (EM)
GENERAL CHANGES
2008– Joint Commission involvement in aftermath of
recent disasters–Katrina Focus on sustainability–Identification of opportunities for
improvement
2009– Emergency Management & Life Safety Code
become stand alone chapters– Emphasis on documentation
EM.01.01.01
“The organization engages in planning activities prior to developing its written Emergency Operations Plan.”– HVA– Community partners– Community communication– Mitigation & preparedness– Incident command– Inventory
COMMUNITY PARTNERS
Determine critical community partnersHVA reviewed & prioritized with communityCommunicate needs & vulnerabilitiesAt annual review of plan & when needs
change
HAZARD VULNERABILITY ANALYSIS
Consider possibility of cascading eventsWorst-case scenarios
– Surge of infectious patients– IT vulnerabilities / failures– Loss of utilities or other critical
infrastructure
Define mitigation & preparedness
Rationale
Emphasize a “scalable” approach to help manage the variety, intensity, and duration of the disasters that can affect a single organization, multiple organizations, an entire community, or region
Importance of planning for emergencies in which the local community cannot support the healthcare organization
STAND ALONE CAPABILITY
Identifies capabilities & establishes response efforts when organization cannot be supported by community for
> 96 hours– does NOT require stockpiles– does NOT require the ability to stand
alone for 96 hours
POTENTIAL RESPONSES
Maintaining or expanding servicesConserving resourcesCurtailing servicesSupplementing resources from outside
communityClosing hospital to new patientsStaged or total evacuation
EM.03.01.03
“The organization evaluates the effectiveness of its EOP.”– Emergency exercises– Stress capabilities– Realistic & relevant– Identify lessons learned and opportunities
for improvement– Implement corrective actions
REQUIREMENTS
Twice annually (unchanged)– FSE/FE vs. tabletops
Influx of patients (unchanged)One exercise annually to evaluate ability
to stand alone without community support– Community portion can be tabletop
One community-wide exercise annually
The “Critical Six” Functions
CommunicationsResources and AssetsSafety & SecurityStaff ResponsibilitiesUtilities Management Patient Clinical & Support Activities
Most Problematic StandardsPublished in
November 2009 Perspectives– % of hospitals
that received a Requirement for Improvement (RFI)
Most Problematic StandardsLS.02.01.20 (45%) The hospital
maintains the
integrity of the means of egress
LS.02.01.10 (43%) Building and fire protectionfeatures are designed and maintained to minimizethe effects of fire, smoke, and heat
EC.02.03.05 (38%) The hospital maintains firesafety equipment and fire safety building features
LS.02.01.30 (36%) The hospital provides and maintains building features to protect individualsfrom the hazards of fire and smoke
Most Problematic Standards
Egress includes corridors, stairways, and doors so avoid blocking hallways with carts, x-ray machines, laundry carts, equipment, or supplies– Surgery areas particularly susceptible
WOWS/COWS should only be in hallways when in use– Not unattended while charging
Most Problematic Standards
Resources
Resources
ResourcesStandards questions can also be submitted
by phone, mail or fax
Standards Interpretation Group (SIG) – 630 792-5900
Fax questions to 630 792-5942By mail:
SIG, The Joint Commission
One Renaissance Blvd
Oakbrook Terrace, IL 60181
Resources
http://blogs.hcpro.com/accreditationcenter/
www.jointcommission.org/Standards/FAQs/
GHA911LiveProcess JC standards crosswalks
DISCUSSION
QUESTIONS