Compliance News: Emergency Management - Exercises

By Susan McLaughlin, MBA, FASHE, CHSP

The Joint Commission requirements for emergency exercises have been relatively static over the past several years. But there have been several minor changes, primarily in the notes to ele­ments of performance in EC.03.01.03, that merit taking a closer look at what is needed.

First the schedule, which hasn’t changed in and of itself. Hospi­tals must do two “live” exercises per year (as opposed to tabletops) to include the following three scenarios: Influx of patients (EP 2), Sustainability (EP 3), and Community integration (EP 4).

The twice a year requirement comes out of EM.03.01.03, EP 1, which contains Note 2, “Staff in freestanding buildings classified as a business occupancy (as defined by the Life Safety Code®) that do not offer emergency services nor are community designated as disaster receiving stations need to conduct only one emergency exercise annually.” Conversely, if there are business occupancies that DO offer emergency services and/or ARE disaster receiving stations, the implication is that these facilities are under the same exercise requirements as a hospital.

This makes it essential that the role(s) of business occupancies be defined within the Emergency Operations Plan. Typically the business occupancy roles in an emergency are one of the following:

• Close and staff goes home
• Continue to offer routine service
• Close and staff goes to the hospital to assist
• Offer emergency services and/or serve as a disaster receiving station

Once this is understood and defined, the business occupancies must be exercised according to that role.

A new Note 4 was recently added to EM.03.01.03 EP 1. “In order to satisfy the twice a year requirement, the hospital must first evaluate the performance of the previous exercise and make any needed modifications to its EOP before conducting the subse­quent exercise in accordance with EPs 13-17.” This will be effec­tive July 1, 2011.

The change was in response to CMS requirements, and will likely be difficult to comply with. The good news is that it encour­ages prompt post-exercise evaluation. The bad news is that it will frequently be difficult to complete all identified changes prior to the subsequent exercises. Hospitals should develop action plans as soon as possible following an exercise or event. The plans should include ownership of the action and expected completion dates. Progress should be documented through to completion, whether or not that takes place prior to the next exercise. Assessment of this in practice will need to be seen.