Comparison of the Joint Commission’s 2007 and 2008 Emergency Management Standards
Effective January 1, 2008
2007 Standards / Key Issues for 2008Standard EC.4.10
The organization addresses emergency management.
Elements of Performance
1. The hospital conducts aHazard Vulnerability Analysis.
2. The hospital established the following with the community:
- Priorities identified in the HVA
- The hospital’s role in relation to a community-wide emergency management program
- An “all hazards” command structure
4. The emergency management plan is developed with the involvement of the hospital’s leaders including those of the medical staff.
5. The plan identifies and describes mitigation, preparedness, response, and recovery strategies, actions and responsibilities for each priority emergency.
6. The plan provides processes for initiating the response and recovery phases, including a description of how, when, and by whom.
7. The plan provides processesfor notifying staff whenemergency response measures are initiated.
8. The plan provides processes for notifying external authorities of emergencies.
9. The plan provides processes for identifying and assigning staff to cover all essential staff functions under emergency conditions.
10. The plan provides processes for managing the following:
- Activities related to care, treatment and services
- Staff support activities (housing, transportation, incident stress debriefing)
- Staff family support activities
- Logistics related to critical supplies
- Security
- Communication with news media
12. The plan provides processes for evacuating the entire building both vertically and horizontally when the environment cannot support adequate care, treatment, and services
13. The plan providesprocesses for establishing an alternate care site(s) With capabilities to meet the needs of patients including processes for the following:
- Transporting patients, staff, and equipment to alternate care site(s)
- Transferring to and from the alternate care site(s) the necessities of patients
- Tracking of patients
- Interfacility communication between the hospital and the alternate care site(s)
15. The plan provides processes for cooperative planning with health care organizations providing services to a contiguous geographic area ( for examples, hospitals serving a town or borough) to facilitate timely sharing of the following:
- Essential elements of their command structures and control centers
- Names and roles of individuals in their command structure and command center phone numbers
- Resources and assets that could potentially be shared in an emergency response
- Names of patients and deceased individuals brought to their hospitals to facilitate identifying and locating victims
18. The plan identifies backup internal and external communication systems in the event of failure during emergencies.
19. The plan identifies alternate roles and responsibilities of staff during emergencies, including to whom they report in the hospital’s command structure, and when activated, the community’s command structure.
20. The plan identifies an alternative means of meeting essential building utility needs when the hospital is designated by its emergency management plan to provide continuous services during an emergency.
21. The plan identifies means for radioactive, biological, and chemical isolation and decontamination. / Standard EC.4.10 has been replaced with
EC.4.11 - EC4.18.
EC.4.11speaks to managing the consequences of the emergencies.
The expected outcomes of a Hazard Vulnerability Analysis are more specific in the 2008 standards.
Reference to “all hazards” moved to EC.4.12 EP1
The emergency management plan name has been changed to the Emergency Operations Plan (EOP) to keep in line with the National Incident Management System (NIMS) terminology.
Reference to leadership involvement moved to EC.4.11 EP 1.
Mitigation, preparedness, response, and recovery moved to EC.4.11 EPs 5-8
Notifying staff moved to EC.4.13 EPs 1 and 2
Notifying external authorities was clarified and moved to EC.4.13 EPs 3 and 4
Processes for identifying and assigning staff was clarified and moved to EC.4.12 EP 3
Managing activities related to care, treatment, and services was moved underEC.4.18 EP
1- 4 and is greatly expanded. Includes NIMS expectations for special needs populations.
Staff and family support activities now under EC.4.14 EPs 5 and 6
Logistics related to critical supplies now falls under EC.4.14 EPs 1-4
Security is expanded and found under EC.4.15 EPs 1- 8
Communication with news media moved under EC. 4.13 EP 6
Evacuatingvertically and horizontallyis now under EC.4.14 EP 9
Alternate sites of care moved under EC.4.12 EP 7 for 2008
The transporting of patients and theirnecessities was expanded and moved to EC.4.14 EPs 10 and 11
Tracking of patients to communicate with family is under EC.4.13 EP 5. Tracking of patient’s clinical information is under EC.4.18 EP6
Communication with alternate care site(s) is now under EC.4.13 EP 13
Now underEC.4.16 EP 4
Located under EC.4.13 EPs 8-11 for 2008
Backup for communications has been expanded and moved under EC.4.13 EP 14
Staff roles are located under EC.4.16 and now include the roles of licensed independent practitioners.
The requirements for alternative means of supplying utilities has been expanded is now located under EC.4.17 EPs 1-5
Moved to EC 4.15 EP 4
Standard EC.4.20
The organization regularly tests its emergency operation plan.
Elements of Performance
1. The hospital tests its Emergency Operations Plan twice a year, either in response to an actual emergency or in a planned exercise.
2. Hospitals that offer emergency services or are community-designated disaster receiving stations conduct at least one exercise a year that includes an influx of actual or simulated patients.
3. Hospitals that have a defined role in the community-wide emergency managementprogram participate in at least one community-wide exercise a year.
4. Not Applicable
5. Planned exercise scenarios are realistic and related to the priority emergencies identified in the hospital’s Hazard Vulnerability Analysis.
6. Not Applicable
7. During planned exercises, an individual whose sole responsibility is to monitor performanceand who is knowledgeable in the goals and expectations of the exercise, documents opportunities for improvement.
8. During planned exercises the hospital monitors at least the following core performance areas: Event notification including processes related to activation of the emergency management all hazards command structure, notification of staff, and notification of external authorities.
9. During planned exercises the hospital monitors at least the following core performance areas: Communication, including the effectiveness of communication both within the hospital as well as with response entities outside of the hospital, such as local governmental leadership, police, fire, public health, and other health care organizations within the community.
10. During planned exercises the hospital monitors at least the following core performance areas: Resource mobilization and allocation, including responders, equipment, supplies, personal protective equipment, transportation, and security.
11. During planned exercises the hospital monitors at least the following core performance areas: Patient management including provision of both clinical and support care activities, processes related to triage activities, patient identification and tracking processes.
12. All exercises are critiqued to identifydeficiencies and opportunities for improvement based upon monitoring activities and observations during the exercise.
13. Completed exercises are critiquedthrough a multi- disciplinary process that includes administration,clinical, (including physicians), and supportstaff.
14. The hospital modifies its emergency operations plan in response to critiques of exercises.
15. Planned exercises evaluate the effectiveness of improvements that were made in response to critiques of the previous exercise.
16. The strengths and weaknesses identifiedduring exercises are communicated to the multidisciplinary
improvement team responsible for monitoring environment of care issues. / Very little has changed under EC.4.20for 2008. EPs 3, 11,12, and 13 are new; therefore the numbering of the EPs has changed. Certain aspects of the standards, such as security and clinical and support staff activities, were relocated under separate Elements of Performance (11, 12 and 13).
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