Download - Emag conf jc 2010 050410
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The Joint Commission – Emergency Management 2010 & Beyond
Yusuf A. Rahman, BA, RRT, CHECGeorgia Hospital Association
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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
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Primary Focus AreasLife Safety (LS)
Environment of Care (EC)
Emergency Management (EM)
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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
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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
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COMMUNITY PARTNERS
Determine critical community partnersHVA reviewed & prioritized with communityCommunicate needs & vulnerabilitiesAt annual review of plan & when needs
change
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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
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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
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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
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POTENTIAL RESPONSES
Maintaining or expanding servicesConserving resourcesCurtailing servicesSupplementing resources from outside
communityClosing hospital to new patientsStaged or total evacuation
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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
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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
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The “Critical Six” Functions
CommunicationsResources and AssetsSafety & SecurityStaff ResponsibilitiesUtilities Management Patient Clinical & Support Activities
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Most Problematic StandardsPublished in
November 2009 Perspectives– % of hospitals
that received a Requirement for Improvement (RFI)
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Most Problematic StandardsLS.02.01.20 (45%) The hospital
maintains the
integrity of the means of egress
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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
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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
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Resources
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Resources
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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
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Resources
http://blogs.hcpro.com/accreditationcenter/
www.jointcommission.org/Standards/FAQs/
GHA911LiveProcess JC standards crosswalks
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DISCUSSION
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QUESTIONS