Compliance standards for emergency managers in hospitals and other healthcare facilities have been getting more comprehensive and stringent over the past few years, particularly since the 9/11 attacks.

Indeed, major catastrophic events and the threat of terrorist attacks exposed the vulnerabilities of our nation’s healthcare emergency preparedness and response systems. Over the years, mounting public pressures and increased regulatory scrutiny have led to an unprecedented movement in compliance circles to ensure that the nation’s emergency management infrastructure will be able to meet large-scale and unforeseen disasters and emergencies, both natural and man-made.

This year, the Joint Commission, the Oak Brook, Ill.–based organization that accredits the nation’s hospitals, created a separate chapter for emergency management, a rare occurrence for an organization known for its consistency and rigor. This new chapter of standards becomes effective Jan. 1, 2009.

These standards will be assembled under one chapter, rather than being scattered through all of the other standards, and many will address new areas in hospital emergency management. Overall, the changes indicate the importance of maintaining an effective healthcare response capability that is intimately linked with response agencies to provide care and services to the community.

The current batch of compliance standards for 2008 gave us a glimpse of things to come for hospital emergency managers. The Joint Commission has instituted some new and significantly revised provisions among the 45 Elements of Performance (EPs) in its “Environment of Care” rules.

The Joint Commission notes that emergency management standards for hospitals, critical-access hospitals and long-term-care facilities have been revised to reflect an “all-hazards” approach to emergency preparedness that permits appropriately flexible and effective responses, and to emphasize a scalable approach that can help manage the variety, intensity and duration of the disasters that can affect a single organization, multiple organizations or an entire community. The standards also stress the importance of planning and testing response plans for emergencies during conditions when other parts of the community, such as the fire and/or police department, are unable to respond.

While most hospitals agree with the standards, many are having a difficult time coming into compliance quickly enough. Some of the standards the Joint Commission introduced in 2008, in fact, were postponed to help healthcare organizations come into compliance and therefore won’t go into effect till next year. While these standards will still be cited during surveys, they will not impact accreditation status until Jan. 1, 2009.

Meanwhile, the following standards fall under this extended timeline:

• EC.4.11.9, 10 — Inventories of assets and resources, and monitoring asset and resource quantities, respectively (see below).
• EC.4.12.6 — Stand-alone capability (see below).
• EC.4.13.7 — Vendor communication.
• EC.4.14.8, 10 — Sharing of resources and assets within and outside community, and evacuation, respectively.
• EC.4.15.2, 3, 5 — Role of community security agencies, hazardous materials and waste and identifying patients who may wander.
• EC.4.16.2, 3 — Staff and physician training.
• EC.4.17.4 — Fuel for building operations and essential transport.
• EC.4.18.4, 5, 6 — Mental health, mortuary services and patient clinical information.

Current problematic standards
There are two problematic Elements of Performance for emergency managers in 2008. One, the so-called “96-hour” rule (EP 4.12.6), identifies an organization’s capabilities and establishes response efforts when the organization cannot be supported by the local community for at least 96 hours in six critical areas: 

1. Communications,
2. Resources and assets,
3. Safety and security,
4. Staffing,
5. Utilities, and
6. Clinical activities.

While the rule does not specifically require a facility to be self-sustaining for that period of time, it does require the facility to measure its ability to remain operational and to identify "trigger points" for implementing strategies to remain viable, such as:

• Conserving resources: Rationing current resources to safely extend services;
• Curtailing services: Limiting or postponing specific services;
• Supplementing resources from outside the local community or impact area: Using Memorandums of Understanding, supplier agreements or contracts to replenish supplies; and
• Conducting staged evacuation or, if needed, implementing a total facility evacuation.

Another current problem area is the so-called "response asset list" provisions, included in EC 4.11.9 and EC 4.11.10, which require an organization to keep a documented inventory of on-site assets and resources needed during an emergency (at a minimum, personal protective equipment, water, fuel, staffing, medical, and pharmaceuticals resources and assets) and to establish methods for monitoring quantities of assets and resources during an emergency. Following this additional EP will enable hospitals to make better and more strategic decisions in their response activities. This is particularly true when an incident affects the facility for an extended period of time.

Looking ahead to 2009
In 2009, all emergency management–related standards, including those that emergency managers have been given a little extra time to implement, will be combined into a stand-alone chapter separate from the Joint Commission's Environment of Care standards. While this will certainly help organizations better meet Joint Commission rules, it will put additional challenges on the individual currently responsible for maintaining a hospital’s emergency management program.

For one, the Joint Commission may implement an entirely new scoring system, as well as more specific and demanding requirements, for a broad range of entities, from acute-care hospitals to psychiatric hospitals, critical-access hospitals, ambulatory care, behavioral health, home care, and nursing homes.

Changes to emergency management guidelines, standards and regulations have become more difficult to track, let alone manage. In addition, many hospitals are already stretched to maintain current requirements. In most cases, these changes will require additional resources, including, but not limited to, implementing new programs, more broadly delegating program responsibilities, or adding staff to effectively support the program.